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Fluoride Therapy for Adult Patients

Introduction

In the general population adult dental patients are more likely to have established disease upon presentation to the office. Dental caries creates an enormous economic burden and negatively impacts dental-related quality of life. The challenge facing dentists is preventing complications from developing rather than preventing primary disease.1 While adult teeth may already have decay, fluoride in combination with other modalities can still contribute to prevention and improved oral health.2

Caries disease in adults  

Up to 90% of adults have caries and gingivitis3, known risk factors for infection, pain, and chronic systemic inflammation. Gingival recession, poor oral hygiene, bad habits such as smoking and high-sugar candies and drinks, comorbid conditions, and certain medications contribute to this pathological process.4 The treatment goals in adults are significantly different relative to those in children and adolescents given their differences in physiology and stage of oral disease.

Primary vs. secondary prevention 

Primary prevention is aimed at preventing development of disease, in this case caries in permanent teeth. Toothbrushing, interdental cleaning5, professional examinations and cleanings, radiographs6, and patient education are tools commonly used in primary prevention. Interventions are based on risk assessments and surveillance in an effort to avoid subtractive methods of rehabilitation. In contrast, secondary prevention is practiced in the presence of known disease to prevent complications including decayed, missing, or filled teeth (DMFT). Techniques include restorations, fillings, and extractions along with ongoing surveillance and patient education. Sometimes secondary prevention may require coordination of care with the patient’s primary care physician.

Barriers to care

In the US, children receive more consistent dental care than do adults.7 Many Americans do not have dental insurance and cannot afford the expense of even basic care.8 The lowest socioeconomic groups typically have Medicaid which does include dental insurance,3 whereas people in the poor to middle class often do not have dental insurance and might not present to the dentist for preventive care. In addition, there is significant racial and ethnic group variability with minorities typically having poorer access to care.9 Other burden of illness in an adult such as cancer or dementia may make obtaining dental care an even lower priority.10 As a result of these socioeconomic factors, dentists are more likely to see adult patients with more advanced disease and less adherence to care guidelines.

Role of fluoride 

Fluoride therapy has a significant role in the treatment of common dental conditions in adults.

Caries

Even though adults have a limited capacity for remineralization of thinned enamel, fluoride has a role in regulating oral bacteria and reducing a pathogenic biofilm, diminishing the progression of caries.11-13 (See Figure 1)

Periodontal disease

Again through its role in regulating the biofilm, fluoride reduces progression of periodontal disease including periodontitis and gingivitis11. Fermenting bacteria are reduced and higher pH is restored.

Dentin hypersensitivity

When dentinal tubules become exposed through enamel erosion and gingival recession the tooth becomes more sensitive to pain. (See Figure 2) Various treatment modalities have been used including laser treatments, tubule-sealing toothpastes, and enamels. Fluoride has been shown to provide rapid and long-lasting relief of dentin hypersensitivity through the sealing of dentinal tubules. Fluoride toothpastes, mouthwashes, and dental varnishes are highly effective.14

The Dentist’s role 

In adults the dentist’s role involves appropriate risk assessment and minimal intervention.7 Patients should be educated about the benefits of fluoride treatment and surveillance with early intervention continue to be important. Dentists may also screen for comorbid disease such as HIV and cancer and may in fact see the earliest signs of these diseases, and appropriate referrals to medical colleagues may be indicated. Restorative treatments and fluoride varnishes can provide significant improvements in the quality of life for adult patients.

Conclusions 

Fluoride therapy continues to be beneficial for adult patients even though adults are more likely to present with established disease. The tenets of secondary prevention focus on avoiding complications of disease, and the dentist has a powerful role in improving the quality of life for adult patients even with known dental and periodontal disease. Screening, surveillance, education, and early intervention will help to improve oral health and reduce health care costs.

References

  1. Baelum V. Dentistry and population approaches for preventing dental diseases. J Dent. Dec 2011;39 Suppl 2:S9-19.
  2. Huang DL, Chan KC, Young BA. Poor oral health and quality of life in older U.S. adults with diabetes mellitus. J Am Geriatr Soc. Oct 2013;61(10):1782-1788.
  3. Kim JK, Baker LA, Seirawan H, Crimmins EM. Prevalence of oral health problems in US adults, NHANES 1999–2004: exploring differences by age, education, and race/ethnicity. Special Care in Dentistry. 2012;32(6):234-241.
  4. Lu HX, Wong MC, Lo EC, McGrath C. Trends in oral health from childhood to early adulthood: a life course approach. Community Dent Oral Epidemiol. Aug 2011;39(4):352-360.
  5. Sambunjak D, Nickerson JW, Poklepovic T, et al. Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database Syst Rev. 2011;12(12):CD008829.
  6. Azarpazhooh A. Radiographic Analysis of Acquired Pathological Dental Conditions. In: Basrani B, ed. Endodontic Radiology. 2nd ed: Wiley; 2012:153-165.
  7. Ramos-Gomez F, Ng M-W. Into the future: keeping healthy teeth caries free: pediatric CAMBRA protocols. Journal of the California Dental Association. 2011;39(10):723.
  8. Bayaz Ozturk G, Gallo W, Fahs M. Use of Preventive Care by Older Adults in New York City: Income Related Disparities in Dental and Vision Care. Journal of Health Behavior and Public Health. 2012;1(2):17-23.
  9. Shelley D, Russell S, Parikh NS, Fahs M. Ethnic disparities in self-reported oral health status and access to care among older adults in NYC. J Urban Health. Aug 2011;88(4):651-662.
  10. McNeely J, Wright S, Matthews AG, et al. Substance-use screening and interventions in dental practices Survey of practice-based research network dentists regarding current practices, policies and barriers. The Journal of the American Dental Association. 2013;144(6):627-638.
  11. Agarwal R, Singh C, Yeluri R, Chaudhry K. Prevention of Dental Caries-Measures beyond Fluoride. Oral Hyg Health. 2014;2(122):2332-0702.1000122.
  12. ten Cate JM. Current concepts on the theories of the mechanism of action of fluoride. Acta Odontol Scand. Dec 1999;57(6):325-329.
  13. Weyant RJ, Tracy SL, Anselmo TT, et al. Topical fluoride for caries prevention: executive summary of the updated clinical recommendations and supporting systematic review. Journal of the American Dental Association. Nov 2013;144(11):1279-1291.
  14. Petersson LG. The role of fluoride in the preventive management of dentin hypersensitivity and root caries. Clin Oral Investig. Mar 2013;17 Suppl 1(1):S63-71.
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