When do you really need to prescribe a fluoride complement for your patients?
The following question was submitted by a general dentist: Our patients can no longer purchase Oral B Fluorinse. Does anybody have an alternative daily and weekly fluoride rinse they can recommend?
This initial quick response is presented by Dr. Getulio Nogueira, from the Faculty of Dentistry at the University of Toronto in collaboration with experts: Dr. Walter Siqueira (Western University, Canada) and Dr. Jaime Cury (Faculty of Dentistry, UNICAMP, Brazil)
Clinical Question
When do you really need to prescribe a fluoride complement for your patients?
The Fact
It has been confirmed that Oral B Fluorinse is no longer available in Canada. Since Proctor & Gamble bought Gillette/Oral-B a few years back, Crest/Oral-B is now a division of P&G. Here is the website for Crest Canada: http://www.crest.com/en-CA/. Note that Fluorinse is not listed under “Products”- “Rinses”. They removed the Oral B Rinses from the market and the only available OCT is the Crest Complete Rinse that contains 0.022% NaF for daily rinse (but no longer 0.2% NaF weekly rinse). Other fluoride rinses can still be found in the Canadian market.
Brief Review of the Rationale to Use Fluoride Rinses
1. The Fluoride rinses mechanism of action is very similar to fluoridated toothpastes, but obviously without the biofilm mechanical removal promoted by additional tooth brushing action. After using a fluoride rinse, the concentration of F in saliva and biofilm increases and stays elevated for about 1-2 hours. F will stay available in the oral cavity and will help with the demineralization/re-mineralization processes on tooth surface (Benson et al., 2004).
2. There is evidence that rinse concentrations, of 0.05% NaF (225 ppm F) for daily use or 0.2% NaF (900 ppm F) for weekly use, are equally efficient to prevent dental caries (Marinho et al., 2003). However, when considering the individual patient’s caries prevention, the use of daily fluoride rinses is preferred in order to increase patient’s compliance, on the basis that weekly rinses could easily be forgotten! Nevertheless, 0.2% NaF rinses are still used for caries control in community dental programs.
3. There is also evidence suggesting that the combined effect of fluoride rinses and fluoride toothpastes is very minimal with no added benefits to low-risk caries patients. Therefore, fluoride rinses would be beneficial only to high-risk caries patients with evidence indicating the combination of 0.05% NaF rinses with fluoride toothpastes for patients undergoing orthodontic treatment.
4. There was no evidence in controlled studies indicating the effectiveness of other fluoride formulations (e.g. 0.02% NaF) in controlling caries. Although fluoride rinses at 0.02% NaF have only 99ppm NaF and may seem like a very low concentration for daily use, studies did not show a difference between them and the 225 ppm of NaF found in the 0.05% rinses (Yu et al., 2004).
5. It is still very common to use of fluoride complements (i.e. topic fluoride varnishes, gels and foams, and fluoride toothpastes and rinses) to prevent and treat caries in high-risk caries patients in Canada and worldwide. And, although Duraphat® Fluoride varnish has also been removed from the Canadian market, one can still find the brand Duraflor® used for varnish applications in office. However, there is no evidence that the use of these fluoride complements has any additional effects on caries control! For example, if a patient receives a topic fluoride in-office, there is no reason to prescribe any extra fluoride rinse. Considering that high-risk caries patients (i.e. patients who are controlling caries by other means than tooth brushing with fluoride toothpastes) have a low compliance rate with fluoride rinses daily use, it is advisable to propose an individualized maintenance program with frequent recalls. The patient will then receive in-office fluoride applications, which evidence shows are effective in combating caries.
6. Finally, the sole exposure to fluoride neither prevents the occurrence of caries nor improves caries control. Fluoride will not interfere with the major etiologic factors for caries, such as biofilm formation and sugar-rich diet (=low pH). Nevertheless, fluoride plays an important role in controlling caries progression and its use should be based on the best evidence available, including a patient’s individualized caries assessment.
Alternatives
Check your local pharmacy or drugstores for available fluoride rinses OTC or ask the pharmacist for help. Also, search the WorldWide Web, you will find other alternatives of OTC daily fluoride rinses in Canadian pharmacies and drugstores. Here in Toronto, we can find rinses OCT at 0.021% NaF, 0.022% NaF, and 0.05% NaF. The available online “tick in the box” fluoride rinse products are marketed as “direct Fluorinse® replacements.” I did not find any 0.2% NaF in Toronto’s pharmacies and drugstores. You may order it online or request a special order in specialized pharmacies.
Conclusion
The most important clinical message here is that your patients MUST be treated on an individual basis and based on their individual caries-risk assessments because fluoride complements alone will not prevent caries occurrence. Develop and implement an efficient caries-risk assessment program in your practice which will allow you to effectively evaluate your patients’ needs for caries treatment and/or prevention. A sensible approach is to spend additional time with your patient, emphasizing two main aspects:
- The importance of dental recall appointments (using your available motivational tools for better patient retention practice).
- Reinforcing your patients’ oral hygiene practices (proper and effective tooth brushing and flossing).
References
- Benson PE, Parkin N, Millett DT, Dyer FE, Vine S, Shah A. Fluorides for the prevention of white spots on teeth during fixed brace treatment. Cochrane Database Syst Rev. 2004;(3):CD003809.
- Marinho VC, Higgins JP, Logan S, Sheiham A. Fluoride mouthrinses for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2003;(3):CD002284.
- Yu D, Sipos T, Wu MM, Bilbault T, Lynch MC, Naleway C. Effect of fluoride/essential oils-containing mouthrinse on the microhardness of demineralized bovine enamel. Am J Dent. 2004;17(3):216-8.
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A very nice synopsis – thank you. The only thing I might want to add to the individualized care for all patients is that in an oncology setting, where I work, we have patients on daily neutral pH sodium fluoride gels in custom mouth guard style trays for life or until such a time as they get some (usually minimal) salivary recovery. I guess my point is beware the xerostomic patient. Those people need to be provided aggressive preventive care up front including fluoride gel applications with possible weaning from fluoride later on in the course of their management. And even in the era of anatomically contoured CT assisted radiation treatment we have not seen post radiation caries fall in the 500 patients we see each year.
Bob, Do you advise any bicarbonate rinses to help neutralize the intraoral pH?
What role does high F toothpaste such as Prevident have as well as remineralization toothpastes like 3Ms Clinpro? Patients home care, diet, habits, salivary flow rate, saliva buffering capacity all have a major influence on caries development.
Can you please discuss the difference between use of Stannous and Neutral Sodium Fluorides? I am partial to the latter and do use it in gel delivery format along with in-office rinses.
Thanks.
This very curious article in response to a question about fluoride rinse strays over to disparage fluoride varnish. Although the writing is quite direct “However, there is no evidence that the use of these fluoride complements has any additional effects on caries control! ” I must be misreading the info. Azarpazhooh A, Main PA Fluoride varnish in the prevention of dental caries in children and adolescents – a systematic review – JCDA 2008 found: “There is good evidence of the complementary efficacy of preventive strategies such as sealants and varnish, as well as toothbrushing and nutritional counselling; oral health care programs should therefore include as many complementary strategies as possible.
How about fluoride rinse in decreasing teeth sensitivities ?
I appreciate this well represented information about fluoride. As someone who is trying to learn about this to understand my own experience with fluorosis it is helpful to have as much information as possible. If anyone knows a reliable way to reverse fluorosis please do comment