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Caries Management by Risk

Assessment (CAMBRA):

Week 4Part 1

Fluoride in the Dental Office and byPrescription

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Office-Applied Fluoride ProductsGel (> 5,000 ppm F)

and Fluoride VarnishDo not require continuing patient

compliance

Forms slowly soluble calcium fluoride-likedeposits in lesions and the plaque

Gives slow release fluoride for several

weeksThree times a year for high risk patients

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Evidence-based Clinical Recommendations:Professionally Applied Topical FluorideThe Council on Scientific Affairs, AmericanDental AssociationMay, 2006

Fluoride gel applied for 4 minutes or more is

effective Fluoride varnish applied every 6 months is effective

Two or more applications of fluoride varnish peryear are effective in high caries risk individuals

Office topical applications no added benefit for lowrisk individuals

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Protective Factors

Weintraub et al, J Dent Res, 2006. Fluoridevarnish in infants (approx 2 years old at start)

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Fluoride Varnish for High Risk of All Ages

White Vanish Varnish3M ESPE Prev Care

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501 Children, 9.1 years old, China, using fluoride

toothpaste Four groups: a) sealant, b) F varnish 6 mths,

c) Silver Diamine F, d) placebo control (water)

Pit/fissure sites with dentin caries at 24 months

Sealant 1.6 % NaF varnish 2.4 %

Silver DF 2.2 %

Control 4.6 % - significantly different

J Dent Res 91:753-758, 2012

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5000 ppm F vs 1450 ppm F (as NaF) toothpaste

Caries incidence and caries progression

Compliance assessed Prevented fraction 40%: 5,000 ppm versus 1450 ppm Caries still progressed in many, even with high

concentration fluoride

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High concentration fluoride products for highrisk patients. Proven effective for root caries.

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Clinpro 5000 1.1% NaF Dentifrice

3M ESPEContains Tri-calcium phosphate

i i i

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High concentration fluoride (5,000 ppmF)toothpaste not available in some countries.

Can use high concentration gel instead.

In Italy, for exmple, you could use ElmexGelee, 12,500 ppm F Once a day

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Conclusions - Fluoride

The anti-caries effects of fluoride areprimarily topical (surface) in plaque

The systemic benefits of fluoride areminimal

Therapeutic levels of F can be achievedfrom drinking water and fluoride products

Fluoride therapy may not overcome a highbacterial challenge

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Calcium Phosphopeptide:

CPP/ACP

Laboratory studies: Three decades

Clinical Studies: clinical evidence

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Representation of a proposedCPP-ACP complex

Cross et al.2007 Curr PharmDe

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MI Paste PlusHas Fluoride

Marketed Alsoas ToothMousse

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The Caries Balance

Protective FactorsSaliva flow and componentsFluoride, calcium, phosphatremineralization

Antibacterials:- chlorhexidinxylitol, new?

No CariesCaries

Pathological Factors

Acid-producing bacteria

Frequent eating/drinkingof fermentable carbohydrates

Sub-normal saliva flow andfunction

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Why would we prescribe a 5,000ppm fluoride toothpaste rather than

a 1,000 ppm or 1450 ppm one?

5,000 ppm F toothpaste has been proven

clinically superior for high caries risk It is likely that 5000 ppm F will work better

based on laboratory experiments

The 5000 ppm F toothpaste most likely hasantibacterial properties

All of the above

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Why would we prescribe a 5,000ppm fluoride toothpaste rather than

a 1,000 ppm or 1450 ppm one?

5,000 ppm F toothpaste has been proven

clinically superior for high caries risk It is likely that 5000 ppm F will work better

based on laboratory experiments

The 5000 ppm F toothpaste most likely hasantibacterial properties

All of the above