Preventative Treatment in the Modern World

There has always been an ongoing debate about whether or not Fluoride supplementation is necessary in our modern society.  We have fluoridated water in Sydney and in most capital cities.  I regularly ask patients what sort of water they are drinking, whether it is bottled water, town supplied water, or filtered water, and there are an ever increasing number of patients who only drink bottled or filtered water.  This, of course, is a personal choice but it does create a necessity for patients to be aware of added preventative measures that may be necessary for them.  An added complication to this is the ever increasing intake of sugars, simple carbohydrates or low GI foods and also acidic drinks and foods.

When buying bottled water make sure it contains no fluoride or less than .5mg/L because, unfortunately, some bottled water contains excessive fluoride, especially those of the carbonated, mineralised varieties.  This is important for parents, so they then know how much fluoride is being consumed by their children.

During this article I wish to draw some attention to some basic guidelines for the use of fluoride products by adults and children, and also some other preventative methods available to dental patients of all ages.

Fluoride use in the community has always been a debated subject.  Over 100 studies, in more than 20 countries, over the last 50 years have shown that the use of fluoride reduces dental caries (holes in the teeth).  The general public has long thought that fluoride is only beneficial to the teeth of developing children.  It is true that there is a benefit to children whilst their teeth are developing but it has also been shown that the daily washing of fluoride products across the teeth, at any age, reduces the risk of caries (cavities).  Appropriate fluoride intake has been shown to reduce caries by as much as 50-60% in children and also acts as a preventative measure in adults.

Now that we realise that fluoride use is beneficial, it is also important to note that when children and their teeth are developing, you can have too much fluoride, which can lead to Dental Fluorosis.

Dental Fluorosis is a developmental defect of the enamel (hard outer shell of the teeth) that occurs when an excessive amount of fluoride is ingested, during the period of enamel formation (between birth and the age of six years of age on average).  The severity of dental fluorosis depends on the amount of fluoride ingested, the duration of exposure, and age(s) when exposure occurs.

Clinically, the appearance of dental fluorosis ranges from barely discernable, opaque white flecks in its mildest form, through to total loss of enamel in the most severe form.  There are other factors that contribute to dental fluorosis besides fluoride intake.  However, the underlying message is that careful use of fluoride is very beneficial, without undue risk of increased prevalence of dental fluorosis.


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Another very good preventive measure for adults and children is the use of fissure sealants.  Fissure sealants are basically a liquid filling material that is run into the grooves of the biting surfaces of the teeth.  They have been proven to reduce the risk and likelihood of dental caries.  It has long been thought that fissure seals should only be placed in children, as the adult teeth erupt.  This is correct, but my opinion is changing, according to the changing dietary intakes and types of water consumed by teenagers and adults.

My current opinion is that fissure seals are recommended for anybody who has deep grooves or fissures in their teeth, and/or where the grooves and the fissures seem to be catching material, therefore becoming stained.  If there has been some breakdown of the enamel surface, very early dental decay is present.  In the case of very early dental decay, the fissures are usually opened with a fine bur and checked.  If the dental caries (decay) seem to have penetrated the enamel, then a Preventative Resin Restoration (PRR) is placed.  This is basically a very small filling that stops the progression of the decay at an early stage, attempting to reduce necessary treatment later on that may require a larger filling and the destruction of a greater amount of tooth structure.

Unfortunately, one of the implications of having stronger teeth from fluoride exposure is that once the decay has broken through the hard outer shell of enamel, even just a hole the size of a pin prick, the decay then spreads quickly through the softer dentine and can be missed because there is no visible break in the enamel surface.

The message here is that prevention is always better than a cure.  The earlier these grooves are checked and sealed, the better.  This doesn’t mean everybody from every age group should rush in and have their teeth sealed, it is just to make you aware of the intentions of your dentist if these issues are raised.

Basic Guidelines For The Use Of Fluoride For Children 0-8 Years Of Age

These guidelines are for the use of all children and do not depend on the type of water being consumed.  If your child is mainly drinking bottled water or you have a filter that removes fluoride from the water, then it is particularly important.

  • Always remember that more is not better.
  • The age of initiation of toothpaste should be delayed to approximately two years of age.  The use of a plain toothbrush without toothpaste is recommended prior to this age.
  • Parents should supervise the use of toothpaste and tooth brushing by their children (twice a day for two minutes) until six to eight years of age.  Parents should encourage spitting the excess toothpaste out but not rinsing afterwards for half an hour.
  • Toothbrushes with small heads should be used by children, with only a pea size amount of toothpaste used.
  • The toothpaste should be of a low fluoride type.  Parents should be aware that some toothpaste, advertised for children, is actually adult strength toothpaste and is not appropriate for children.
  • After the age of six, parents can start implementing the use of a low strength, fluoridated mouthwash, three to four times a week, at night before bed.  However, always encourage spitting the mouthwash out, and avoid eating, drinking or rinsing for half an hour.  Preferably, just send the child to bed.
  • Toothpaste tubes should be kept out of the reach of children.
  • Parents who are using baby formula need to be aware that the formulas made using demineralised water are preferable.  Some baby formulas’ use dehydrated town water that causes the fluoride to concentrate in the formula, increasing the risk or Dental Fluorosis greatly.  Most companies now use demineralised water because of this fact, but it is wise to double-check.  Deviating slightly, NEVER PUT YOUR CHILD TO BED WITH A BOTTLE OF ANYTHING BUT PLAIN WATER.

Fluoride supplementation and preventative restorative treatment, as part of a good oral hygiene regime, including regular visits to your dentist and dental hygienist, can benefit all age groups.  A table on the next page has been generated, with general guidelines for different age groups.  A table on the next page has been generated with guidelines for different age groups and medical status etc.  Please go through with your dentist in case slight changes need to be made.

General Population Groups

1. Child 0-2 years of age
2. Child 2-6 years of age
3. Child 6-8 years of age
4. Child >8 years of age
5. Teenager in orthodontic treatment
6. Adult <50 years of age with little dental restorations < 6 fillings
7. Adult <50 years of age with moderate dental restorations >6 fillings with few crowns
8. Adults >50 years of age with root exposure
9. Adults >50 years of age on medication that decreases saliva output
10. Adult with conditions that decrease saliva output, e.g. Sjrogens Syndrome, Sicca Syndrome, undergoing or have had radiation treatment to the head and neck region, or any salivary gland problems in the head and neck region
11. Adult > 70 years of age
12. Elderly in care

Group

Type of Water Recommended

Toothpaste

Mouthwash

Hygienist

1. Town water and/or bottled water ≤ .5mg/l of Fluoride and/or filtered water Children’s toothpaste ≤500 ppm Not advisable Not advisable
2. Town water and/or bottled water ≤ .5mg/l  of Fluoride and/or filtered water Children’s toothpaste ≤500 ppm Not advisable From 4, occasional for instruction
3. Town water and/or bottled water ≤ .5mg/l of Fluoride and/or filtered water Children’s toothpaste ≤500 ppm Normal strength 3-4× weekly  ≈ 200ppm 1-2 × annually, for clean and instruction
4. Town water and/or bottled water ≤ .5mg/l of Fluoride and/or filtered water Normal toothpaste ≈ 1000ppm Normal strength 1× daily at night ≈ 200ppm 3-4 × annually
5. Town water and/or bottled water ≤ .5mg/l of Fluoride and/or filtered water Normal toothpaste ≈ 1000ppm High Strength mouthwash 1× daily at night  ≈ 900ppm 3-4 × annually
6. Town water and/or bottled water ≤ .5mg/l of Fluoride and/or filtered water Normal toothpaste ≈ 1000ppm Normal strength 1× daily at night  ≈ 200ppm 3-4 × annually
7. Town water and/or bottled water any concentration and/or filtered water Normal toothpaste ≈ 1000ppm Normal strength 1× daily at night  ≈ 200ppm 3-4 × annually
8. Town water and/or bottled water any concentration and/or filtered water Normal toothpaste ≈ 1000ppm Normal strength 1× daily at night  ≈ 200ppm 3-4 × annually
9. Town water and/or bottled water any concentration and/or filtered water Normal toothpaste ≈ 1000ppm Normal strength 1× daily at night  ≈ 200ppm 3-4 × annually
10. Town water and/or bottled water any concentration and/or filtered water Normal or high strength toothpaste High Strength mouthwash 1× daily at night  ≈ 900ppm 3-4 × annually
11. Town water and/or bottled water any concentration and/or filtered water Normal or high strength toothpaste High Strength mouthwash 1× daily at night  ≈ 900ppm 3-4 × annually
12. Town water and/or bottled water any concentration and/or filtered water High strength toothpaste High Strength mouthwash 1-2 × daily  ≈ 900ppm

3-4 × annually or as much as able

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