General
Clinical recommendations for
professionally applied topical fluoride
Dr. Ayesha Taha
MDS, Paediatric and Preventive Dentist
D ental caries is one of the
most common chronic
dental diseases in all countries
and all populations with
varying degree of severity[1]
International data on caries
epidemiology confirm that
dental caries remains
a significant disease of
childhood in both developing
and developed countries.[2]
Treatment of dental caries,
especially in children, may
require advanced skills of
clinicians and sometimes high
cost of general anaesthesia for
patient management.[1]
Based on preventive dentistry,
use of topical fluoride may be a
useful measure to arrest caries
lesions because fluoride used in
various forms have been proven
to be effective in dental caries
prevention.[3]
Due to the characteristics of
deciduous teeth enamel (half
as thick as that of permanent
teeth,[4] lower mineral content
and higher organic content,[5]
and more susceptibility to
caries), use of fluoride to
control the development and
progression of carious lesions
is so important in primary
dentition.[4] Topical application
of fluoride has been proven to
be the most important method
in combating carious lesions.
[6],[7],[8],[9]
Fluoride has been a major
factor in the decline in
prevalence and severity of
dental caries in the U.S. and
other economically developed
countries. It has several caries-
protective mechanisms of
action. Topically, low levels of
fluoride in plaque and saliva
inhibit the demineralization
of sound enamel and enhance
the remineralization of
demineralized enamel. Fluoride
also inhibits dental caries by
affecting the metabolic activity
of cariogenic bacteria.[10] High
levels of fluoride, such as those
attained with the use of topical
gels or varnishes, produce a
temporary layer of calcium
fluoridelike material on the
enamel surface. The fluoride
is released when the pH drops
in response to acid production
and becomes available to
remineralize enamel or affect
bacterial metabolism.[11]
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The IDA Times_November_2019.indd 20
Professionally-applied topical
fluoride treatments are
efficacious in reducing
prevalence of dental caries. The
most commonly used agents for
professionally-applied fluoride
treatments are five percent
sodium fluoride varnish
[(NaFV) 2.26 percent F,
22,600 ppm F] and acidulated
phosphate fluoride (APF; 1.23
percent F, 12,300 ppm F).[2]
Clinical Recommendations
for the use of professionally
applied Topical Fluoride.
The clinical recommendations
are a resource for dentists
to use. These clinical
recommendations must be
balanced with the practitioner’s
professional judgment and
the individual patient’s
preferences.
(i) Younger than 6 years:
Fig. 1 - Topical fluoride gel in a foam tray
Fig. 2 - Fluoride tray placement procedure
Patients whose caries risk
is lower, as defined in this
document, may not receive
additional benefit from
professional topical fluoride
application. Fluoridated water
and fluoride toothpastes
may provide adequate caries
prevention in this risk
category. Whether or not to
apply topical fluoride in such
cases is a decision that should
balance this consideration with
the practitioner’s professional
judgment and the individual
patient’s preferences.
The IDA Times Mumbai November 2019
Moderate-risk patients should
receive fluoride varnish
applications at six-month
intervals. Fluoride varnish
contains a smaller quantity of
fluoride compared to fluoride
gels; and, therefore, its use
reduces the risk of inadvertent
ingestion in children younger
than 6 years.
Higher-risk patients should
receive fluoride varnish
applications at three to six-
month intervals.
(ii) 6 to 18 years of age:
Patients whose caries risk
is lower, as defined in this
document, may not receive
additional benefit from
professional topical fluoride
application. Fluoridated water
and fluoride toothpastes
may provide adequate caries
prevention in this risk category.
Whether or not to apply topical
fluoride in such cases is a
decision that should balance
this consideration with the
practitioner’s professional
judgment and the individual
patient’s preferences.
Moderate-risk patients should
receive fluoride varnish or
Patient Education brochures
gel applications at six-month
intervals.
Higher-risk patients should
receive fluoride varnish or
gel application at six-month
intervals. Fluoride varnish
applications at three-month
intervals or fluoride gels at
three-month intervals may
provide additional caries
prevention benefit.
(iii) Older than 18 years
Patients whose caries risk
is lower, as defined in this
document, may not receive
additional benefit from
professional topical fluoride
application. Fluoridated water
and fluoride toothpastes
may provide adequate caries
prevention in this risk category.
Whether or not to apply topical
fluoride in such cases is a
decision that should balance
this consideration with the
practitioner’s professional
judgment and the individual
patient’s preferences.
Moderate-risk patients should
receive fluoride varnish or
gel applications at six-month
intervals.





Higher-risk patients should
receive fluoride varnish or gel
applications at three- to six-
month intervals.[12],[13]
All ages application time:
Fluoride gel and foam should
be four minutes. A one-minute
fluoride application is not
endorsed.
Guidelines for topical
application of High-Potency
Fluoride Products:
(1) No more than 2 g of gel
per tray or approximately
40% of tray capacity should
be dispensed. Even more
conservative amounts
should be considered for
small children.
(2) Because patients may
have the need to swallow
during a four-minute topical
application procedure,
the use of a saliva ejector
during the procedure is
recommended.
(3) Following the four-minute
application procedure, the
patient should be instructed
to expectorate thoroughly
for from 30 sec to one min,
regardless of whether high-
10/18/2019 11:31:33 AM
 General

speed suction is utilized.
Expectoration is probably
the single most effective way
of reducing orally retained
fluoride.
3. Patients
(4) When utilizing custom
individually fitted trays for
patients requiring daily or
weekly application of a high-
F-concentration product,
utilize only 5 to 10 drops of
product per tray.[14]
4. Overdoses greater than 15
Fluoride Toxicity
Fluoride combines with
hydrochloric acid in the stomach
to form hydrofluoric acid (HF).
The corrosive effect of HF on
the gastric mucosa accounts
for gastrointestinal symptoms
such as nausea, vomiting,
diarrhoea, and abdominal pain.
A more serious consequence
of fluoride overdose is
hypocalcaemia caused by the
affinity of fluoride to cat ions
in the serum associated with
symptoms such as; paresthesia,
paresis, muscle fibrillation,
tetany, convulsions, decreased
myocardial contractility,
and possibly cardiovascular
collapse.
Acute fluoride intoxication
has also been associated with
hyperkalemia leading to
ventricular arrythmias and
cardiac arrest. The exact toxic
and lethal doses of fluoride
vary considerably in the
literature. In general, mild
gastrointestinal symptoms
are usually associated with
doses up to 5 mg/kg, and more
serious systemic toxicity with
those greater than 5 mg/kg.
The estimated ‘‘certainly lethal
dose” of fluoride is 71-142 mg/
kg; however, a death has been
reported after an estimated
dose of 16 mg/kg.
should be administered
orally as these combine with
fluoride to form more poorly
absorbed fluoride salts.
who have
swallowed more than 5
mg/kg fluoride should be
admitted to the hospital
and observed for further
symptoms even if they
appear asymptomatic.
mg/kg require immediate
stomach emptying,
gastric lavage, and slow
intravenous administration
of 10 ml of 10% calcium
gluconate solution. If
clinical signs of tetany
develop, or if a prolongation
of the Q-T interval is seen on
an electrocardiogram, then
further doses of 10% calcium
gluconate should be given
until symptoms disappear.
The patient should be
observed for secondary
neurologic symptoms
such as muscle twitching,
paresthesia, convulsions, or
stupor. The neuromuscular
manifestations may
occur immediately,
depending on the dosage
of fluoride ingested, but
these symptoms are
usually delayed for a
few hours. Death from
cardiorespiratory arrest
can occur hours after the
gastrointestinal symptoms
have subsided. Because the
elimination of fluoride is
almost exclusively renal,
adequate urine output
should be maintained with
use of diuretics. Dialysis
can decrease fluoride levels,
but may be of benefit only in
patients with compromised
renal function.[15]
A review. Oral Health Prev
Dent 2008;6:315-21.
3) Hiiri A, Ahovuo-
Saloranta A, Nordblad A,
Mäkelä M. Pit and fissure
sealants versus fluoride
varnishes for preventing
dental decay in children
and adolescents. Cochrane
Database Syst Rev
2006;17:CD003067.
4) Mortimer KV. The
relationship of deciduous
enamel structure to
dental disease. Caries Res
1970;4:206-23.
5) Brown LJ, Wall TP, Lazar
V. Trends in total caries
experience: Permanent and
primary teeth. J Am Dent
Assoc 2000;131:223-31.
6) Chedid S. Evaluation of
the amount of fluoride
dentifrice or 0.02% NaF in
the development of caries
in deciduous teeth: an in
vitro study using pH cycling
model [Doctoral Thesis]. São
Paulo: Faculty of Dentistry,
University of São Paulo;
1999.
7) Hicks J, Wild T, Flaitz
CM, Seybold S. Fluoride
varnishes and caries
development in primary
tooth enamel: An in vitro
study. ASDC J Dent Child
2001;68:304-10, 300.
8) ten Cate JM. Current
concepts on the theories of
the mechanism of action of
fluoride. ActaOdontolScand
1999;57:325-9.
9) Rølla G, Saxegaard E.
Critical evaluation of the
composition and use of
topical fluorides, with
emphasis on the role of
calcium fluoride in caries
inhibition. J Dent Res
1990;69:780-5.
10) Buzalaf MA, Pessan JP,
Honório HM, ten Cate JM.
Mechanism of action of
fluoride for caries control.
Monogr Oral Sci 2011;22:97-
114.
11) Center for Disease
Control and Prevention.
Recommendations for
using fluoride to prevent
and control dental caries in
the United States. MMWR
Recomm Rep 2001;50(RR-
14):1-42.
12) Marinho VC, Higgins
JP, Logan S, Sheiham A.
Fluoride gels for preventing
dental caries in children
and adolescents. Cochrane
Database Syst Rev
2002(2):CD002280.
13) Marinho VC, Higgins
JP, Logan S, Sheiham A.
Fluoride varnishes for
preventing dental caries in
children and adolescents.
Cochrane Database Syst
Rev 2002(3):CD002279.
14) Lecompte EJ. Clinical
application of topical fluoride
products-risks, benefits, and
recommendations. Journal
of dental research. 1987
May;66(5):1066-71.
15) Bayless JM, Tinanoff N.
Diagnosis and treatment
of acute fluoride toxicity.
Journal of the American
Dental Association (1939).
1985 Feb;110(2):209-11.

Smiles for Life

Management and
Guideline:
1. At levels less than 5 mg/
kg, the treatment for
fluoride toxicity is to give
calcium orally to relieve
gastrointestinal symptoms.
(Milk or even ice cream
may be less traumatic
to a frightened child.)
Inducing vomiting is not
recommended as the side
effects of an emetic are
greater than the effects of
fluoride at levels of less
than 5 mg/kg.
2. Fluoride ingestion above
5 mg/kg can produce more
severe symptoms. The
stomach should first be
emptied by administration
of an emetic. It must be
remembered that patients
with a depressed or absent
gag reflex (infants younger
than 6 months or patients
who have a severe mental
handicap) should receive
immediate nasotracheal
intubation and gastric
lavage. Calcium salts,
such as calcium gluconate,
and other salts, such as
magnesium sulphate and
aluminium hydroxide,
Summary
The literature has shown
overwhelmingly that fluoride
used for dental prophylaxis
presents minimal risks if used
appropriately. However, there
is an increasing potential
for ingestion of toxic doses
of fluoride because of the
increasing use of pleasant-
tasting fluoride products. The
ADA has recommended that IDA life membership at
no more than 120 mg fluoride
(264 mg NaF) be dispensed INR 26,491 INR 15,000 only
at any one time. Health
professionals should be aware
of the potential toxic effects Couple registration at INR 26,500
of fluoride in addition to the
well-known caries preventive
effects. It is necessary to
know how to calculate the
amount of fluoride ingested
and the emergency treatment
recommended to prevent toxic
effects in suspected overdose
cases.
Whatsapp ‘LIFE’ to 7304705201 to Register
References:
1) Chu CH. Treatment of early
childhood caries: A review
and case report. Gen Dent
2000;48:142-8.
2) Chu CH, Lo EC. Promoting
Fees excludes admission fees & National Social Security Scheme
caries arrest in children
with silver diamine fluoride:

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