The Adolescent Years
A Prime Time for Caries Prevention Interventions
Adolescents represent a particular challenge to dentists as
they often consume larger amounts of sweetened carbonated beverages, sweetened fruit juices, sweetened coffee, and sport or
energy drinks. They tend to be
less compliant with tooth-brushing. Intervention to prevent caries at this age
can provide powerful improvements in adult dental-related quality of life. Fluoride
treatment has been proven to provide this protection. Fluoride works at the
tooth/plaque interface by forming a hard crystalline layer on the tooth,
protecting the tooth from the effects of acid. The most common method of
delivering fluoride is through the fluoridation of the city water supplies and the
use of toothpastes. Fluoride varnishes can provide additional protection.
- Fluoride is an effective preventive and
therapeutic agent in dental caries.
- The use of fluoride in water and in toothpastes
has dramatically reduced the incidence of dental caries.
- Fluoride works at the interface between the
surface of the tooth and plaque, and strengthens the protective enamel surface
of the tooth.
- The adolescent age group represents a particular
challenge as they tend to adopt less healthy lifestyles and develop poorer
compliance with recommended treatments.
Dental professionals have advocated the use of fluoride for
the treatment and prevention of tooth decay for over 5 decades. Odorless and
tasteless, fluoride was first introduced in public water 60 years ago,1 resulting in dramatic
reductions in the incidence of caries. While there are many methods of
application, fluoride-containing toothpastes have revolutionized treatment
worldwide. Preventive efforts are more important in children and adolescents in
whom remineralization can occur. Adolescents represent a particular challenge
given their poorer compliance with brushing and selection of high-sugar foods
and beverages.2 Several methods of fluoride application
are available to optimize care.
Caries disease can be considered a worldwide epidemic with
as many as 90% of adults showing evidence of tooth decay. Caries are more
commonly in lower socioeconomic status patients possibly due to less access to
care or less knowledge3. (Figure 1a and Figure 1b)
The adolescent population represents a particularly powerful
point of intervention for dentists. Many young teens have no evidence of caries
when they enter a dental practice for evaluation4, yet are at an age where they
tend to consume sugary sports drinks5
and may exhibit poorer compliance with recommendations on oral health.
Reinforcement of healthy habits and diets can make a significant difference in their
eventual dental quality of life.
Mechanism of action of
Fluoride is thought to exert its action locally at
tooth/plaque interface6. Fluoride promotes
remineralization and reduces enamel solubility in the presence of acid. At
higher oral pH fluoride combines with calcium and phosphate to form a crystalline
material within and on the tooth.7 In addition, at higher
concentration calcium ﬂuoride is precipitated on the enamel surface and in the
plaque acting as a ﬂuoride reservoir which is released when the oral pH falls.6
Methods of application
Fluoride was first added to a city water supply in Grand
Rapids, MI in 1945 and the results were reported in 19501 demonstrating a dramatic
decrease in caries rate. Internationally, fluoridated toothpastes and
mouthwashes are a more common method of fluoride supplementation. In fact, fluoride
toothpastes are probably responsible for worldwide reductions in dental caries
with or without fluoride supplementation in water8.
Fluoride dentifrices are available in a variety of strengths, with higher
strengths providing more effective caries prevention.9 Fluoride gels used daily
(Figure 2) and fluoride varnishes applied by the dentist (Figure 3) are highly
effective interventions6, especially in adolescents in
whom compliance with brushing practices may be poorer.
Flavorless and odorless, fluoride supplements are considered
safe and acceptable. Excessive intake of fluoride can result in dental
fluorosis, a mild whitish discoloration of the teeth. Fluorosis is a benign
process that is mostly cosmetic and doesn’t impact hardness of teeth. Fluoride
toxicity is rare, occurring more often from industrial exposures than from
Dental care in teens
Care-givers of adolescents all face the unique challenges
that this age group presents. Teenagers are more independent thinkers, seeking
greater autonomy while still needing the protection of a parent or guardian.
This transfer or power starts at different ages for different kids, based
largely on their parenting experiences and their socioeconomic status.
Risk-taking behavior increases in adolescents as well, including risks of
omission of self-care and risks of commission by using drugs, tobacco, and poor
dietary choices. The dentist must understand the mental state of their
adolescent patient when trying to teach about the importance of compliance with
The American Dental Association recommends brushing twice
per day using a fluoride-containing toothpaste, even in young children less
than 2 years of age10. For patients with known
caries the addition of a fluoride mouthwash may be helpful. Stannous-containing
sodium fluoride dentifrices may show greater promise in remineralization.11 Fluoride varnishes applied 3
to 4 times per year are highly effective, providing higher local
concentrations of fluoride with less concerns of toxicity.6 (See Table 1) In a systematic
Cochrane review by Marinho in 2004, studies failed to show a significant
benefit of high-frequency/low concentration, high concentration/low-frequency,
or daily fluoride toothpaste fluoride application in the prevention of caries.12 Selection of a
specific approach should be based on the likelihood of compliance with
treatment regimens. Patients deemed unlikely to comply with daily tooth-brushing
and fluoride mouthwashes may be better candidates for application of
Caries formation is a significant problem for adolescents. Fluoride
is highly effective at strengthening tooth resistance to development of caries.
Worldwide the use of fluoride dentifrices has been associated with a large
decrease in the incidence of caries. The adolescent years are pivotal for
teaching effective prevention of caries. Professionally-applied varnishes
provide additional protection in adolescents in whom tooth-brushing compliance
and technique may be less than optimal.
1. Dean H, Arnold F, Jay P, Knutson J.
Studies on mass control of dental caries through fluoridation of the public
water supply. Public Health Rep. 1950;65(43):1403-1408.
2. Broffitt B, Levy
SM, Warren J, Cavanaugh JE. Factors associated with surface-level caries
incidence in children aged 9 to 13: the Iowa Fluoride Study. J Public Health Dent. Fall
3. Burt B, Tomar S.
Changing the face of America: water fluoridation and oral health. In: Ward J,
Warren C, eds. Silent Victories: The
History and Practice of Public Health in Twentieth-century America: Oxford
University Press; 2007:307-322.
4. Nordstrom A,
Birkhed D. Preventive effect of high-fluoride dentifrice (5,000 ppm) in
caries-active adolescents: a 2-year clinical trial. Caries Res. 2010;44(3):323-331.
5. Armfield JM,
Spencer AJ, Roberts-Thomson KF, Plastow K. Water fluoridation and the
association of sugar-sweetened beverage consumption and dental caries in
Australian children. American journal of
public health. Mar 2013;103(3):494-500.
6. Marinho VC,
Worthington HV, Walsh T, Clarkson JE. Fluoride varnishes for preventing dental
caries in children and adolescents. Cochrane
Database Syst Rev. 2013;7(7):CD002279.
7. ten Cate JM.
Current concepts on the theories of the mechanism of action of fluoride. Acta Odontol Scand. Dec
8. Pizzo G, Piscopo
MR, Pizzo I, Giuliana G. Community water fluoridation and caries prevention: a
critical review. Clin Oral Investig. Sep
9. Walsh T,
Worthington HV, Glenny AM, Appelbe P, Marinho VC, Shi X. Fluoride toothpastes
of different concentrations for preventing dental caries in children and
adolescents. Cochrane Database Syst Rev. 2010;1(1):CD007868.
JT, Hanson N, Ristic H, Whall CW, Estrich CG, Zentz RR. Fluoride toothpaste
efficacy and safety in children younger than 6 years: a systematic review. Journal of the American Dental Association. Feb
S, Seong J, Macdonald E, et al. A randomised in situ trial, measuring the
anti-erosive properties of a stannous-containing sodium fluoride dentifrice
compared with a sodium fluoride/potassium nitrate dentifrice. Int Dent J. Mar 2014;64 Suppl 1:35-42.
VC, Higgins JP, Sheiham A, Logan S. One topical fluoride (toothpastes, or
mouthrinses, or gels, or varnishes) versus another for preventing dental caries
in children and adolescents. Cochrane
Database Syst Rev. 2004(1):CD002780.
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.
Table 1: Priority ranking of different recommendations for preventive dental care in patients at increased risk for caries
Fluoride-toothpaste (5,000 ppm fluoride) twice a day
Fluoride rinsing/daily (0.2 % sodium fluoride)
Fluoride rinsing/daily (0.05 % sodium fluoride)
Fluoride gel (in tray)/daily
Fluoride varnish/2–4 times a year
Fluoride chewing gum/daily
Professional tooth-cleaning with fluoride paste/every 2nd
Stannous fluoride gel/4× year
aRanking 1–3 high priority; ranking 4–6 moderate
priority; ranking 7–10 low priority
bHEA – Health economic assessment; + = positive
cost-benefit analysis, - = negative cost-benefit analysis, (+) = probably
positive cost-benefit analysis