By DIANNE GLASSCOE WATTERSON, RDH, BS, MBA
Dear Dianne,
My boss went to a meeting and heard a speaker say that we should be applying topical fluoride on all patients. Now he wants me to push fluoride and recommend it for all of my patients. Of course, having been a dental hygienist for 20 years, I know the benefits of fluoride. But I have patients who come in every six months who have not had any caries or other dental problems for many years. I can't really see how fluoride would be helpful for those patients.
Truthfully, I think the extra production is the motivating factor for him. Since I am not convinced that every patient needs fluoride, what am I supposed to say when patients ask why they need it? Is fluoride truly helpful for every patient?
-Skeptical RDH
Dear Skeptical,
Profit is not a "bad" thing since every business has to be profitable in order to survive. But when a company touts a product as a "profit center," it can seem unethical. When the math is presented-that X treatments equals Y dollars to the practice-the buyer has to figure out how to integrate the treatment into the current protocol. It might be a good treatment, but whether patients actually benefit from the treatment is sometimes not even considered if profit is the primary motivator.
I think we have to be careful about how we justify certain treatments or adjuncts. Is the decision based on a speaker's zealous presentation, a profit motivation, or evidence-based science? The proper motivation would be that the treatment, whatever it is, is supported by unbiased scientific evidence that clearly shows its efficacy and its benefit to the patient.
To guide the decision-making process, the American Dental Association (ADA) published a document, titled "Professionally Applied Topical Fluoride: Executive Summary of Evidence-Based Clinical Recommendations," in 2006. To my knowledge, no new breakthroughs concerning topical fluoride have been offered since that time, so the information is still relevant. An expert panel of dental professionals "evaluated the collective body of scientific evidence on the effectiveness of professionally applied topical fluoride for caries prevention." Here is a summary of the panel's conclusions, based on the evidence:
- Fluoride gel is effective in preventing caries in school-aged children.
- Patients whose caries risk is low, as defined in the document, may not receive additional benefit from professional topical fluoride application.
- There are considerable data on caries reduction for professionally applied topical fluoride gel treatments of four minutes or more. In contrast, there is laboratory data on the effectiveness of one-minute fluoride gel applications (but no clinical equivalency).
- Fluoride varnish applied every six months is effective in preventing caries in the primary and permanent dentitions of children and adolescents.
- Two or more applications of fluoride varnish per year are effective in preventing caries in high-risk populations.
- Fluoride varnish applications take less time, create less patient discomfort, and achieve greater patient acceptability than fluoride gel, especially in preschool-aged children.
- Four-minute fluoride foam applications, every six months, are effective in caries prevention in the primary dentition and newly erupted permanent first molars.
- There is insufficient evidence to address whether a difference exists in the efficacy of sodium fluoride versus acidulated phosphate fluoride gels.
From the evidence examined by the panel, it was determined that people over the age of six with low caries risk most likely will not benefit from topical fluoride adjuncts. Low risk is defined as "No incipient or cavitated primary or secondary carious lesions during the last three years and no factors that may increase caries risk."
The panel defined moderate risk as "One or two incipient or cavitated primary or secondary carious lesions in the last three years. No incipient or cavitated primary or secondary carious lesions in the last three years but presence of at least one factor that may increase caries risk."
High risk was defined as "Three or more incipient or cavitated primary or secondary carious lesions in the last three years. Presence of multiple factors that may increase caries risk. Suboptimal fluoride exposure. Xerostomia."
All three classifications mention risk factors that should be assessed. What are those risks that increase an individual's propensity to develop caries? The panel listed these risk factors:
"Factors increasing risk of developing caries also may include, but are not limited to, high titers of cariogenic bacteria, poor oral hygiene, prolonged nursing (bottle or breast), poor family dental health, developmental or acquired enamel defects, genetic abnormality of teeth, many multisurface restorations, chemotherapy or radiation therapy, eating disorders, drug or alcohol abuse, irregular dental care, cariogenic diet, active orthodontic treatment, presence of exposed root surfaces, restoration overhangs and open margins, and physical or mental disability with inability or unavailability of performing proper oral health care. On the basis of findings from population studies, groups with low socioeconomic status have been found to have an increased risk of developing caries. In children too young for their risk to be based on caries history, low socioeconomic status should be considered as a caries risk factor. Medication-, radiation- or disease-induced xerostomia."
Every practice has patients that fall into the moderate to high risk category. According to the science, it is these-and only these-patients who will benefit from topically applied fluoride. Patients with low caries risk should not be given fluoride adjuncts, as the benefit is negligible.
When patients present with moderate to high risk, you should be able to tell the patient why fluoride would be beneficial based on the risk factors. If the risk is low, fluoride should not be offered.
Topical fluoride applications to treat hypersensitivity are helpful to some patients, especially when large calculus deposits are removed from exposed root surfaces. However, the panel did not discuss fluoride for treating sensitivity.
One other consideration about fluoride varnish is that patients leave with a rough, unpleasant film on their teeth following the application. The vast majority of patients enjoy that nice, clean, slick feeling after visiting their hygienists. Hygienists have reported that patients complain about the unpleasant feeling of fluoride varnish. I don't think we benefit when patients leave the office unhappy.
The bottom line in deciding whether topical fluoride is a beneficial adjunct is to look at the patient's risk factors. Clearly, blanket mandates of fluoride for everyone are not appropriate.
All the best,
DIANE RDH
DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is an awards winning speaker, author, and consultant. She has published hundreds of articles, numerous textbook chapters, an instructional video on instrument sharpening, and two books. For information about upcoming speaking engagements or products, visit her website atwww.professionaldentalmgmt.com. Dianne may be contacted at (336)472-3515 or by email [email protected].
