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Restorative Dentistry

For the frail elderly, how often should fluoride varnish be applied and in what doses?

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The following question was submitted by a practising dentist: I am working in a residential care centre with mostly frail elderly. I am looking for information on Fluoride varnish application and dental caries. How often should it be applied and in what doses?

JCDA Editorial Consultants Drs. Michael MacEntee of Vancouver, Michael Wiseman and Rita Hurley of Montreal and Mary McNally of Halifax provided this initial discussion for consideration:

Dr. McEntee opened the discussion: Management of caries requires a multifaceted approach (which includes applying fluoride varnish periodically), the primary objective of which is to stabilize the normal sequence of demineralization and remineralization of teeth consequent on the changing environment of the mouth and dental biofilm.

Effective management involves recognition of the disease process for what it is, diet control, daily use of fluoridated toothpaste and a mouth rinse at appropriate concentrations based on disease severity, periodic applications of fluoride varnish, restorations as appropriate and regular monitoring.

Dr. Wiseman responded: There was a study published in 2010 in which the authors applied fluoride varnish every 3 months. Their findings were that a 5% fluoride varnish or CHX varnish + oral hygiene decreased root caries significantly better than oral hygiene alone.

The key point is the provision of oral hygiene. The study did not evaluate the use of fluoride without oral hygiene. Too often in long-term centres, oral care does not exist. As Michael stated, diet analysis, and medications usage must be evaluated.

Dr. McNally added some specifics through some slides from one of her lectures. She also commented, regarding mouth rinse, that the 0.2% concentration is usually marketed for “weekly” use and that MacEntee and Wyatt had found a caries reducing affect on institutionalized elders when this concentration was used daily.

Dr. McEntee responded with an update about one of the products: Unfortunately Fluorinse is now off the market. We have yet to find a comparable replacement. So we recommend high fluoride toothpaste e.g. PreviDent® 5000 Plus (1.1% Sodium Fluoride) Prescription Toothpaste (Rx only).

Dr. Hurley rounded out the conversation with these observations: My experience is that the frail elderly in facilities are just that, frail with a compromised immune system, challenges with psycho-motor skills and limited cognitive ability.  Couple this with institutions (private or public) that have high staff burn-out/turnover due to the burden of care, limited financial resources and poor compliance by patient, family as well as staff; it is difficult to imagine any preventive treatment suggested being successful.

In spite of this I have tried various regimes of fluoride varnish, PreviDent® toothpaste and even daily Fluoride mouth rinsing with 0.2% (questioned each time I prescribed by the pharmacist) with the elderly.

Follow-up: Readers are invited to comment on this initial response and provide further insights by posting in the comment box which you will find by clicking on “Leave a reply“ below. Comments come directly to me for approval prior to posting. You are welcome to remain anonymous. We will never post your email address in any response. John

 

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