Fluoride Varnish – What Is It?

Patient Presentation
A 3-year-old male came to clinic for his health supervision visit.
He had seen a dentist once in his life after a fall and had minor dental trauma. He and his parents brushed his teeth daily with toothpaste. There were no concerns about his oral health.
He lived in a community with a fluoridated water supply which the family used for cooking and drinking. Dietary history revealed that he drank water, milk, and 1-2 times per week some apple or orange juice. He ate a variety of foods but fewer vegetable choices than his parents wished.
The past medical history was non-contributory. His immunizations were current.
The pertinent physical exam showed a male preschooler with growth parameters in the 10-50% for age. His oral examination showed no obvious caries or soft tissue problems.
The rest of his examination was normal.
The diagnosis of healthy male was made. He received fluoride varnish on his teeth at the visit and a referral to the local agency which provides reduced-fee dental care was arranged to establish a dental home.

Discussion
Dental caries are the most common chronic disease world-wide. Caries are caused by Streptococcus mutans particularly serotypes cricetus, rattus, ferus, and sobrinus.
By themselves, dental caries cause pain, temperature sensitivity, and swelling. Extension can cause abscesses and deep infections with potentially life-threatening effects, especially if the airway is compromised.

Fortunately, dental hygiene and fluoride help to prevent caries.

Epidemiological data has shown that fluoridated water supplies reduce dental caries by 55-60% without significant dental fluorosis.
Oral health costs for children can be reduced by 50% with the use of fluoride.
The American Academy of Pediatric Dentistry recommends fluoridating community water supplies.
In areas where fluoridated water supplies are not available, daily oral fluoride supplements are recommended after carefully reviewing all potential sources of fluoride including toothpaste, fluoride containing dental gels and rinses, beverages (e.g. grape juice), prepared food, and all water supplies for drinking. This review is necessary to help prevent fluorosis especially in small children who may ingest larger amounts of toothpaste and/or other fluoride containing dental products.

The table below is the recommended oral fluoride supplementation. Dosages are in total milligrams of fluoride ion. Note: the dosage is NOT based upon body weight.

			Fluoride concentration in parts per million
Age			<0.3		0.3-0.6		>0.6
Birth-6 months		0		0		0
6 months-3 years	0.25 mg 	0		0
3-6 years		0.5 mg		0.25 mg		0
6-16 years		1 mg		0.5 mg		0

The first commercially available fluoride-containing toothpaste was Crest® in 1955.

Learning Point
Fluoride varnishes have an anticarious effect that has been confirmed in clinical trials with a decrease in caries from 18-70% depending on the study.
A meta-analysis of 9 studies found that there was a 46% reduction of caries for permanent teeth and a 3% reduction for primary teeth.
The varnish works to prevent or reverse demineralization of the enamel. There are two formulations available in the U.S.. Financial analysis has found that applications of dental varnish are cost effective in Medicaid-enrolled children.

To prevent caries, the recommendations currently are to apply fluoride varnish at 6-month intervals to permanent teeth of children who live in communities with all levels of fluoride in their water supplies.
Studies for primary dentitia are inconclusive,”???but there is no reason currently to assume that it would not provide a similar level of caries protection in younger children.”

The University of Iowa College of Dentistry gives the following indications for application:

  • Ages 0-36 months, well-child visit, and no application within the past 6 months
  • Cavities, previous cavities, plaque, stained grooves, Medicaid or no insurance, or new teeth erupting
  • Teeth present in the mouth
  • No contraindications to application of varnish

Application can be performed by a by a dentist or other trained healthcare provider including medical personnel by doing the following:

  • Place the child on the examination table
  • Gently use gloved fingers to open the child’s mouth
  • Remove excess saliva from teeth with gauze
  • Apply a thin layer of varnish to all surfaces of teeth

The patient should eat only soft foods for rest of day. The patient can brush and floss teeth the following morning (not that evening.
It is normal for the teeth to appear dull and yellow until they are brushed because of the varnish.

Questions for Further Discussion
1. What are the indications for subacute bacterial endocarditis prophylaxis for dental procedures?
2. What is the fluoride concentration of our local water supply?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for this topic: Tooth Disorders and Child Dental Health
and at Pediatric Common Questions, Quick Answers for this topic: Dental Care

To view current news articles on this topic check Google News.

Newbrun E. Topical fluorides in caries prevention and management: a North American perspective. J Dent Educ. 2001 Oct;65(10):1078-83.

Peng L, Kazzi AA. Dental Infections. eMedicine.
Available from the Internet at http://www.emedicine.com/emerg/topic128.htm (rev. 12/4/2004, cited 2/7/2007).

University of Iowa College of Dentistry. Fluoride Varnish Application. Provider handout (rev. 5/2006).

American Academy of Pediatric Dentistry. Oral Health Policies. Policy on Use of Fluoride. Available from the Internet at http://www.aapd.org/media/Policies_Guidelines/P_FluorideUse.pdf (rev. 2003, cited 2/7/2007).

Quinonez RB,
Stearns SC,
Talekar BS,
Rozier RG,
Downs SM. Simulating Cost-effectiveness of Fluoride Varnish During Well-Child Visits for Medicaid-Enrolled Children. Arch Pediatr Adolesc Med. 2006;160:164-170.

Adair SM.
Evidence-based use of fluoride in contemporary pediatric dental practice.
Pediatr Dent. 2006 Mar-Apr;28(2):133-42.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

    7. All medical and invasive procedures considered essential for the area of practice are competency performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    March 26, 2007

  • How Common is Syncope?

    Patient Presentation
    A 10-year-old female was referred to cardiology clinic after an episode of syncope 1 week previously. After she had been running sprints at the end of a sports practice, she went to the bathroom. After voiding, she stood up, felt lightheaded, warm, shaky, her heart was beating faster than it had been, she had blackness in her vision and then collapsed.
    She had no bladder or bowel incontinence. She does not know how long she was unconscious for, but a friend helped her get up.
    She reports dizziness at other times when she gets up quickly. One episode occurred about a month ago. She did not lose consciousness and says she continued her activities.
    She says she does drink water and sports drinks, and only urinates one time during the school day. She reports no caffeine or additional salt intake in her diet.
    She says she has no chest pain, palpitations, exercise intolerance or shortness of breath.
    The past medical history and review of systems are otherwise negative.
    The family history is negative for syncope, heart abnormalities, seizures and sudden death.
    The pertinent physical exam shows a healthy appearing school age female. Pulse is 72, respirations are 20, and blood pressure in the right arm is 102/61 with no significant differences in other extremities.
    Height and weight are in the 50-75% for age. Neck had no lymphadenopathy or thyromegaly. Lungs were clear. Heart showed a regular rate and rhythm without murmurs. Normal S1 without murmurs and normal splitting of S2.
    Pulses were equal in upper and lower extremities. Neurological examination was also normal.
    The work-up included an electrocardiogram which showed mild sinus bradycardia with a heart rate of 55 but was otherwise normal including a correct QT interval with no pre-excitation.
    The diagnosis of reflex syncope was made. She was advised to increase her fluid intake, add a moderate amount of salt to her food and to limit caffeine intake. If the symptoms return she will then call for followup.

    Discussion
    Transient loss of consciousness (TLOC) is a common presenting problem in children. Physical collapse may or may not be associated with TLOC as a presenting problem.
    The differential diagnosis of TLOC and collapse is often compounded by imprecise terminology use.

    The following algorithm can be considered when trying to differentiate between the multiple causes of collapse and TLOC.

    1. Did the patient collapse? (defined as abrupt loss of postural tone with or without TLOC)

    • No – consider other causes
    • Yes – ask question 2 below

    2. Did the patient have a spontaneous TLOC?

    • No – consider the causes below:
      • Falls
      • Hypoglycemia or other metabolic abnormalities
      • Medication side effects or drug abuse
      • Transient ischemic attack or cerebrovascular accident
    • Yes – consider the causes below:
      • Syncope (defined as TLOC caused by global impairment of cerebral perfusion which then causes the collapse. Onset is relatively rapid, recover is spontaneous, complete and usually prompt. )
      • Epilepsy (defined as spontaneous inappropriate discharge of cortical neurons leading to a clinical event)
      • Psychogenic seizure (defined as a transient neurological disturbance without organic cause)

    Epilepsy is also a common of TLOC. Unfortunately, there is a high rate of misdiagnosing epilepsy as the cause when other causes are the real culprits. In children, the misdiagnosis rate is as high as 40%.
    Epilepsy is a clinical diagnosis, but neurological consultation is necessary to confirm the diagnosis. Electroencephalogram also may be helpful in confirming the diagnosis.

    Psychogenic seizures are often seen in children and adults under age 50. The episodes are frequent, often occurring many times per day, but testing shows that the TLOC occurs without any change to blood pressure, heart rhythm or electroencephalic tracings.
    Tilt table testing may be help to make these determinations and reassuring the patient and family that there is no underlying cardiac or neurological events. Tilt table testing is being used less frequently though because of lack of sensitivity and specificity. Treatment with psychiatric help can then be offered.

    Learning Point

    Syncope is common with ~15% of children under the age of 18 having the problem. More females than males have syncope.

    Reflex syncope, also known by many other names including vasovagal syncope, neurocardiogenic syncope, pallid breath holding spells and others, is probably the most common cause of syncope.
    The initial event causing the reflex syncope is not known but higher cerebral centers appear to be involved. Some speculate that reflex syncope may be an evolutionary adaption, whereby in response to a predator, a person will abruptly collapse and become pallid. The person would appear to be dead to the predator and thereby escape being prey.
    Reflex syncope usually has a history of associated symptoms such as nausea, vomiting, feeling hot, sweating, lightheadedness, “closing in of vision” and palpitations. The patient also turns pale and consciousness quickly returns. There is often a precipitating event such as standing for a long period of time in a hot environment, a frightening episode such as the sight of blood, or intense pain or trauma.
    Recommended treatments include avoid caffeine (to avoid its diuretic effects), increasing fluid intake, and adding some salt (to increase fluid retention). Some cardiologists recommend sports drinks if patients are very active.
    Also having the patient be aware of common precipitating events so they can be avoided or modified, e.g. arising slowly after sitting for a long time. Patients often have resolution of the episodes within 6-9 months.

    Syncope after exercise is often caused by reflex syncope.
    Syncope during exercise may be caused by an underlying cardiomyopathy or arrhythmia and should be investigated. Any family history of underlying cardiac disease should also prompt investigation. Other indications for referral to a cardiologist include episodes that includes chest pain, palpitations, an abnormal electrocardiogram, syncope that causes injury or recurrent syncope.
    Some physicians recommend that any patient who has a syncopal episode have an electrocardiogram at least once. A search of clinical practice guidelines of the American Academy of Pediatrics, American Academy of Neurology and the American Heart Association did not find any specific recommendations for syncope and its evaluation.

    Questions for Further Discussion
    1. What are indications for an electroencephalogram?
    2. What are the indications for Holter monitoring?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Fainting, Arrhythmia and Epilepsy
    and at Pediatric Common Questions, Quick Answers for this topic: Fainting and Epileptic Seizures.

    To view current news articles on this topic check Google News.

    Fitzpatrick AP, Cooper P. Diagnosis and management of patients with blackouts.
    Heart. 2006 Apr;92(4):559-6.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1892-1894.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

    7. All medical and invasive procedures considered essential for the area of practice are competency performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Nicholas Von Bergan, M.D.
    Pediatric Cardiology Fellow, Children’s Hospital of Iowa

    Date
    March 5, 2007