See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/340998347

Evidence-based clinical practice guidelines for topical fluoride application

Article · April 2020

CITATIONS READS

0 1,810

5 authors, including:

Kengadaran Shivashankar Anusha Divvi

Indira Gandhi Institute of Dental Sciences, Pondicherry Indira Gandhi Institute of Dental Sciences
50 PUBLICATIONS 91 CITATIONS 40 PUBLICATIONS 62 CITATIONS

SEE PROFILE SEE PROFILE

Senthil Murugappan
Indira Gandhi Institute of Dental Sciences
28 PUBLICATIONS 14 CITATIONS

SEE PROFILE

All content following this page was uploaded by Kengadaran Shivashankar on 11 June 2020.

The user has requested enhancement of the downloaded file.

 Research Article

Evidence-based clinical practice guidelines for topical

fluoride application
Shivashankar Kengadaran*, Divvi Anusha, M. Senthil, M. Vikneshan, G. Vidhya

ABSTRACT

Introduction: Dental caries is a global oral health problem which has a distinctive variation. Prevention of dental caries in
children and adolescents is generally regarded as a priority for dental services and considered more cost-effective than its
treatment. Fluoride is the primary agent available for caries prevention. It can be taken both systemically and topically. The
aim of this report is to update the evidence at the 5-year interval according to American Dental Association (ADA) policy and
address additional questions related to the use of prescription-strength, home-use topical fluorides. Materials and Methods: A
systematic search was conducted in databases such as PubMed, Cochrane, and Google Scholar. A group of six examiners
was involved in the process identifying the clinical problems which were then converted to research questions for which the
committee aimed at providing evidence-based recommendations. The same set of examiners was involved in the selection of
articles and all the examiners graded each article based on the evidence. Results: The systematic search revealed a total of
27 publications from PubMed and Google Scholar which were scrutinized based on pre-set inclusion and exclusion criteria.
Fluoride induced faster remineralization than other remineralizing agents. Appropriate use of fluorides may help in the
prevention of dental caries. Conclusion: With the evidence available, it can be concluded that all age and risk groups must
use an appropriate amount of fluoride toothpaste when brushing twice a day. Fluorides irrespective of forms and methods of
application are effective in preventing dental caries.

KEY WORDS: Dental caries, Fluoride, Primary prevention, Systematic review

INTRODUCTION dental fluorosis levels in some countries, and

Dental caries is a global oral health problem which
has a distinctive variation.[1] Dental caries is the most
common oral disease that affects a significant number
of Indian population. The prevalence of caries in
India is reported 31.5–89%.[2-8] Dental caries is widely
recognized as a multifactorial infectious disease.[9] The
main etiology of dental caries is (a) cariogenic bacteria,
(b) fermentable carbohydrates, (c) a susceptible tooth
and host, and (d) time.
Prevention of dental caries in children and
adolescents is generally regarded as a priority for
dental services and considered more cost-effective
than its treatment.[10] Fluoride is the primary agent
available for caries prevention which can be taken
both systemically and topically. In the past 30
years, with the substantial decline in dental caries
rates in many western countries, an increase in
Access this article online
Website: jprsolutions.info ISSN: 0975-7619
Department of Public Heath Dentistry, Indira Gandhi Institute of Dental Sciences, Sri Balaji Vidyapeeth, Pondicherry, India
intensive research on the mechanism of action of
fluoride highlighting the primary importance of
its topical effect, greater attention has been paid
to the appropriate use of other fluoride-based
interventions.[11] The most important anticaries
effect of fluoride is considered to result from its
local action.
Local availability of fluoride to the tooth surface
has been shown to prevent caries by primarily
three mechanisms. (1) Inhibiting demineralization
of tooth enamel by acting on the tooth/plaque
interface, through the promotion of remineralization
of early caries lesions and by reducing tooth enamel
solubility;[12] (2) enhancing remineralization of
tooth enamel before lesion progression by diffusing
with the acid from plaque into the enamel and
acting at the crystal surface to reduce mineral loss.
When the pH rises following demineralization,
fluoride combines with dissolved calcium and
phosphate ions to precipitate or grow fluorapatite
like crystalline material within the tooth. Fluoride
enhances this mineral gain and provides a material

*Corresponding author: Dr. Shivashankar Kengadaran, Department of Public Heath Dentistry, Indira Gandhi Institute of
Dental Sciences, Sri Balaji Vidyapeeth, Pondicherry - 607 402, India. Phone: +91 9003949330. E-mail: shiva.freee@gmail.com

Received on: 20-07-2019; Revised on: 20-08-2019; Accepted on: 02-11-2019

Drug Invention Today | Vol 14 • Issue 3 • 2020 451

 Shivashankar Kengadaran, et al.
which is more resistant to subsequent acid attack;[13]
and (3) inhibiting the enzyme activity (enolase) of
cariogenic bacteria.[14] This occurs with all forms
and concentrations of topical fluoride, although to a
variable extent.
Regular use of fluoride toothpaste or mouth rinse
results in sustained elevated fluoride concentrations
in the oral fluids during the demineralization/
remineralization cycle, but with higher concentration
topical fluoride vehicles (such as varnishes and gels),
calcium fluoride is precipitated on the enamel surface
and in the plaque. This calcium fluoride acts as a
fluoride reservoir which is released when the oral pH
falls.[15,16]
The objective of this report is to update the evidence
at the 5-year interval according to ADA policy, to
have an updated knowledge, and address additional
questions related to the use of prescription-strength,
home-use topical fluorides. In this review, the
authors evaluated sodium, stannous, and acidulated
phosphate fluoride for professional and prescription
home use, including varnishes, gels, foams, rinses,
and prophylaxis pastes.
MATERIALS AND METHODS
A systematic search was conducted in databases
such as PubMed, Cochrane, and Google Scholar
using the terms fluoride, prevention, dental caries,
and demineralization. Furthermore, on-going trials
were searched in the US National Institutes of
Health Trials Register (http://clinicaltrials.gov), the
WHO Clinical Trials Registry Platform (http://apps.
who.int/trialsearch/default.aspx), and Clinical Trial
Registry of India (http://ctri.nic.in/Clinicaltrials/
advsearch.php). All systematic reviews, in vitro
studies, randomized controlled and clinical trials and
literature in other languages which can be translated
by the reviewer were included in the study. Animal
studies, reviews, and literatures in other languages
which cannot be translated by the reviewer were
excluded from the study. Only articles in English and
human species were applied during the electronic
search to include all the possible clinical trials that
are relevant for the search phase of the systematic
review. Reference list of the identified randomized
trials was also checked for possible additional
studies.
A group of six examiners was involved in the process
identifying the clinical problems. Around seven
clinical problems were identified and discussed
which were then converted to research questions for
which the committee aimed at providing evidence-
based recommendations. The research questions
were (1) Does application of topical fluoride bring
452
about reduction in incidence of new caries lesion?
(2) Which kind of topical fluoride is more effective
in treating enamel and dentinal lesions? (3) Does
fluoride therapy bring any change in incidence of
dental caries among Xerostomia patients? (4) Is
fluoride application effective in remineralizing
white spot lesions among patients undergoing fixed
orthodontic therapy? (5) Is there an alternative with
same effectiveness to fluoride dentifrices in endemic
fluorosis areas? (6) Does addition of silver diamine
to fluoride bring about any change in its action?
(7) Does addition of milk proteins to fluoride increase
its effectiveness? The same set of examiners was
involved in selection of articles and all the examiners
graded each article based the evidence. Any dispute
during grading was discussed by the panel and final
decision was arrived.
System used for grading evidence
Grade Category of evidence
Ia Evidence from systematic reviews of
randomized controlled trials
Ib Evidence from at least one randomized
controlled trial
IIa Evidence from at least one controlled study
without randomization
IIb Evidence from at least one other type of quasi-
experimental study
III Evidence from non-experimental descriptive
studies, such as comparative studies, correlation
studies, cohort studies, and case–control studies
IV Evidence from expert committee reports or
opinions or clinical experience of respected
authorities
System used for classifying the strength of
recommendations
Classification Strength of recommendations
A Directly based on category I evidence
B Directly based on category II evidence
or extrapolated recommendation from
category I evidence
C Directly based on category III evidence
or extrapolated recommendation from
category I or II evidence
D Directly based on category IV evidence
or extrapolated recommendation from
category I, II or III evidence
RESULTS
Recommendations for Dentifrices
• Herbal dentifrices can be advised for people living
in endemic fluorosis areas[17]
• Dentifrices with triclosan should be used with
caution. Dentifrices without triclosan is preferred
than dentifrices with triclosan[18] (IV)
Drug Invention Today | Vol 14 • Issue 3 • 2020
 Shivashankar Kengadaran, et al.

• Anticaries potential of fluoridated dentifrices
decreased with storage time[19] (IIb)
• The application of a high-fluoride containing
dentifrice (5000 ppm F) in adults, twice daily,
significantly improves the surface hardness of
otherwise untreated root caries lesions when
compared with the use of regular fluoride-containing
(1350 ppm F) toothpaste.[20] (Ib)
Recommendations for Fluoride Gel Application
• Application of fluoride gel in children using a
toothbrush can be utilized as an option rather than
traditional trays. There is no difference in fluoride
retention after application of small amounts of
acidulated phosphate fluoride (APF) with a toothbrush
compared to traditional gel application[21] (Ib)
• Combination of APF and 0.05% NaF is not
clinically relevant either for caries or dental
hypersensitivity.[22] (IIb)
Recommendations for Fluoride Varnish
• Substantial caries inhibiting effect was found using
fluoride varnish in both permanent and primary
teeth[23] (Ia)
• Professionally applied 5% sodium fluoride varnish,
biannually can remineralize early enamel caries and
38% silver diamine fluoride (SDF) biannually is
effective in arresting dentine caries[24] (Ia)
• AgNO3/NaF could be widely recommended
and promoted as an alternative treatment to
conventional invasive management of early
childhood caries[25] (IV)
• SDF applications or daily tooth brushing with
fluoride toothpaste is not effective in arresting or
slowing down the progression of active dentin
caries in primary teeth in children.[26] (Ia) Atraumatic
restorative treatment must be considered for active
lesions.[27] (IIb)
Recommendations for High Caries Risk Population
• There is no clear evidence to support or refute
that quarterly applications of fluoride varnish can
prevent the development of dental caries in people
with Sjogren’s syndrome[28] (Ib)
• Applications of 5% NaF varnish biannually for
2 years can be recommended as a public health
measure for reducing caries incidence in this high
caries risk population[29] (Ib)
• Fluoride induced faster remineralization than
chlorhexidine. Two applications of fluoride varnish
or 2% chlorhexidine gel at 1-week intervals were
effective in controlling white spot lesions around
orthodontic brackets.[30] (IIb)
Recommendations for Using Fluoride Varnish with
Additional Materials
• MI paste plus does not appear to be more effective
than PreviDent fluoride varnish for improving the
appearance of white spot lesions over an 8-week
period[31] (Ib)
• Fluoride varnish with calcium glycerophosphate did
not increase in the preventive effect against enamel
demineralization[32] (IIb)

Summary

Recommendations for prescribing dentifrices

Category of Recommendations Strength of
evidence recommendation
IV Herbal dentifrices can be advised for people living in endemic fluorosis areas[17] D
IIb Anticaries potential of fluoridated dentifrices decreased with storage time[19] D
Ib The application of a high-fluoride containing dentifrice (5000 ppm F) in adults, twice A
daily, significantly improves the surface hardness of otherwise untreated root caries
lesions when compared with the use of regular fluoride-containing (1350 ppm F)
toothpaste[20]
IV Dentifrices with triclosan should be used with caution. Dentifrices without triclosan D
are preferred than dentifrices with triclosan[18]

Recommendations for the application of acidulated phosphate fluoride gel

Category of evidence Recommendations Strength of recommendation
Ib Application of fluoride gel in children using a toothbrush can A
be utilized as an option rather than traditional trays. There is
no difference in fluoride retention after application of small
amounts of APF with a toothbrush compared to traditional gel
application[21]
IIb Combination of APF and 0.05% NaF is not clinically relevant B
either for caries or dental hypersensitivity[22]

Drug Invention Today | Vol 14 • Issue 3 • 2020 453

 Shivashankar Kengadaran, et al.

Recommendations for application of fluoride varnish

Category of evidence Recommendations Strength of recommendation
Ia Substantial caries inhibiting effect was found using fluoride A
varnish in both permanent and primary teeth[23]
Ia Professionally applied 5% sodium fluoride varnish, biannually A
can remineralize early enamel caries and 38% SDF biannually
is effective in arresting dentine caries[24]
IV AgNO3/NaF could be widely recommended and promoted as an D
alternative treatment to conventional invasive management of
early childhood caries[25]
Ia SDF applications or daily tooth brushing with fluoride A
toothpaste is not effective in arresting or slowing down the
progression of active dentin caries in primary teeth in children[26]
IIb Atraumatic restorative treatment must be considered for active C
lesions[27]
SDF: Silver diamine fluoride

Recommendations for application of topical fluoride varnish to high-risk population

Category of evidence Recommendations Strength of recommendation
Ib There is no clear evidence to support or refute that quarterly A
applications of fluoride varnish can prevent the development of
dental caries in people with Sjogren’s syndrome[28]
Ib Applications of 5% NaF varnish biannually for 2 years can be A
recommended as a public health measure for reducing caries
incidence in this high caries risk population[29]
Ib Fluoride induced faster remineralization than chlorhexidine. C
Two applications of fluoride varnish or 2% chlorhexidine gel at
1-week intervals were effective in controlling White spot lesions
around orthodontic brackets[30]

Recommendations for addition of products to fluoride varnish

Category of evidence Recommendations Strength of recommendation
Ib MI paste plus does not appear to be more effective than A
PreviDent fluoride varnish for improving the appearance of white
spot lesions over an 8-week period[31]
IIb Fluoride varnish with calcium glycerophosphate did not increase D
in the preventive effect against enamel demineralization[32]

CONCLUSION
The dentist, knowing the patient’s health history and
vulnerability to oral disease, is in the best position to
make treatment decisions in the interest of each patient.
These clinical recommendations must be balanced
with the practitioner’s professional expertise and the
individual patient’s preferences. It is recommended
that all age and risk groups use an appropriate
amount of fluoride toothpaste when brushing twice a
day. Fluorides irrespective of forms and methods of
application are effective in preventing dental caries.
REFERENCES
1. Baelum V, van Palenstein Helderman W, Hugoson A, Yee R,
Fejerskov O. A global perspective on changes in the burden
of caries and periodontitis: Implications for dentistry. J Oral
Rehabil 2007;34:872-906.
2. Shourie KL. Dental caries in Indian children. Indian J Med Res
3.
1941;29:709-21.
Damle SC, Patel AR. Caries prevalence and treatment need
amongst children of Dharavi, Bombay, India. Community Dent
Oral Epidemiol 1994;22:62-3.
4. Antia FE. The dental caries experience of school going children
in the city of Bombay. JIDA 1962;39:325.
5. Tewari A, Chawla HS. Study of prevalence of dental caries
in an urban area of India (Chandigarh). J Indian Dent Assoc
1977;49:231-9.
6. Dash JK, Sahoo PK, Bhuyan SK, Sahoo SK. Prevalence of
dental caries and treatment needs among children of Cuttack
(Orissa). J Indian Soc Pedod Prev Dent 2002;20:139-43.
7. Dhar V, Jain A, Van Dyke TE, Kohli A. Prevalence of dental
caries and treatment needs in the school-going children of
rural areas in Udaipur district. J Indian Soc Pedod Prev Dent
2007;25:119-21.
8. Saravanan S, Kalyani V, Vijayarani MP, Jayakodi P, Felix J,
Arunmozhi P. Caries prevalence and treatment needs of rural
school children in Chidambaram Taluk, Tamil Nadu, South
India. Indian J Dent Res 2008;19:186-90.
9. Harris R, Nicoll AD, Adair PM, Pine CM. Risk factors for
dental caries in young children: A systematic review of the
literature. Community Dent Health 2004;21 Suppl 1:71-85.

454 Drug Invention Today | Vol 14 • Issue 3 • 2020

 Shivashankar Kengadaran, et al.
10. Burt BA. Prevention policies in the light of the changed
distribution of dental caries. Acta Odontol Scand 1998;56:179-86.
11. Marinho VC, Worthington HV, Walsh T, Clarkson JE.
Fluoride varnishes for preventing dental caries in children and
adolescents. Cochrane Database Syst Rev 2013;7:CD002279.
12. Featherstone JD, Cate JM. Physicochemical aspects of
fluoride-enamel interactions. In: Ekstrand J, Fejerskov O,
Silverstone LM, editors. Fluoride in Dentistry. Copenhagen:
Munksgaard; 1988. p. 125-49.
13. Cate JM. Current concepts on the theories of the mechanism of
action of fluoride. Acta Odontol Scand 1999;57:325-9.
14. Featherstone JD. The science and practice of caries prevention.
JADA 2000;131:887-99.
15. Horowitz HS, Ismail AI. Topical fluorides in caries prevention.
In: Fejerskov O, Ekstrand J, Burt BA, editors. Fluoride in
Dentistry. Copenhagen: Munksgaard; 1996. p. 311-27.
16. Ogaard B, Seppa L, Rolla G. Professional topical fluoride
applications-clinical efficacy and mechanism of action. Adv
Dent Res 1994;8:190-201.
17. Tatikonda A, Debnath S, Chauhan VS, Chaurasia VR,
Taranath M, Sharma AM. Effects of herbal and non-herbal
toothpastes on plaque and gingivitis: A clinical comparative
study. J Int Soc Prev Community Dent 2014;4:126-9.
18. Riley P, Lamont T. Triclosan/copolymer containing
toothpastes for oral health. Cochrane Database Syst Rev
2013;12:CD010514.
19. Matias JB, Azevedo CS, Do Vale HF, Rebelo MA, Cohen-
Carneiro F. Fluoride stability in dentifrices stored in schools in
a town of Northern Brazil. Braz Oral Res 2015;29:1-5.
20. Srinivasan M, Schimmel M, Riesen M, Ilgner A, Wicht MJ,
Warncke M, et al. High-fluoride toothpaste: A multicenter
randomized controlled trial in adults. Community Dent Oral
Epidemiol 2014;42:333-40.
21. Ribeiro CC, Lula EC, Azevedo IM, de Maia MF, Lopes FF.
Salivary retention after application of fluoride gel using
toothbrush or tray: A crossover trial. Braz Oral Res
2012;26:493-7.
22. Falcão A, Masson N, Leitão TJ, Botelho JN, Ferreira-
Nóbilo ND, Tabchoury CP, et al. Fluoride rinse effect on
retention of CaF2 formed on enamel/dentine by fluoride
application. Braz Oral Res 2016;30:S1806.
23. Marinho VC, Higgins J, Logan S, Sheiham A. Fluoride
Varnishes for Preventing Dental Caries in Children and
Drug Invention Today | Vol 14 • Issue 3 • 2020
View publication stats
Adolescents. London, United Kingdom: The Cochrane Library;
2002.
24. Gao SS, Zhang S, Mei ML, Lo EC, Chu CH. Caries
remineralisation and arresting effect in children by
professionally applied fluoride treatment-a systematic review.
BMC Oral Health 2016;16:1.
25. Duangthip D, Jiang M, Chu CH, Lo EC. Non-surgical treatment
of dentin caries in preschool children-systematic review. BMC
Oral Health 2015;15:1.
26. Chu CH, Gao SS, Li SK, Wong MC, Lo EC. The effectiveness
of the biannual application of silver nitrate solution followed by
sodium fluoride varnish in arresting early childhood caries in
preschool children: Study protocol for a randomised controlled
trial. Trials 2015;16:1.
27. Monse B, Heinrich-Weltzien R, Mulder J, Holmgren C, van
Palenstein Helderman WH. Caries preventive efficacy of silver
diammine fluoride (SDF) and ART sealants in a school-based
daily fluoride toothbrushing program in the Philippines. BMC
Oral Health 2012;12:52.
28. Xin W, Leung KC, Lo EC, Mok MY, Leung MH. A randomized,
double-blind, placebo-controlled clinical trial of fluoride
varnish in preventing dental caries of Sjögren’s syndrome
patients. BMC Oral Health 2016;16:102.
29. Arruda AO, Kannan RS, Inglehart MR, Rezende CT, Sohn W.
Effect of 5% fluoride varnish application on caries among
school children in rural Brazil: A randomized controlled trial.
Community Dent Oral Epidemiol 2012;40:267-76.
30. Restrepo M, Bussaneli DG, Jeremias F, Cordeiro RC,
Magalhães AC, Spolidorio DM, et al. Control of white spot
lesion adjacent to orthodontic bracket with use of fluoride
varnish or chlorhexidine gel. ScientificWorldJournal
2015;2015:218452.
31. Huang GJ, Roloff-Chiang B, Mills BE, Shalchi S,
Spiekerman C, Korpak AM, et al. Effectiveness of MI Paste
Plus and PreviDent fluoride varnish for treatment of white spot
lesions: A randomized controlled trial. Am J Orthod Dentofacial
Orthop 2013;143:31-41.
32. Carvalho TS, Peters BG, Rios D, Magalhães AC, Sampaio FC,
Buzalaf MA, et al. Fluoride varnishes with calcium
glycerophosphate: Fluoride release and effect on in vitro
enamel demineralization. Braz Oral Res 2015;29:1-6.
Source of support: Nil; Conflicts of interest: None Declared
455