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.
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.
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?
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).
Downs SM. Simulating Cost-effectiveness of Fluoride Varnish During Well-Child Visits for Medicaid-Enrolled Children. Arch Pediatr Adolesc Med. 2006;160:164-170.
Evidence-based use of fluoride in contemporary pediatric dental practice.
Pediatr Dent. 2006 Mar-Apr;28(2):133-42.
ACGME Competencies Highlighted by Case
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.
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.
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.
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.
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
March 26, 2007