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The Adolescent Years

A Prime Time for Caries Prevention Interventions

Abstract

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.

Key points

  • 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.

Introduction

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.

Epidemiology

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

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.

Risks

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 products.

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 fluoride treatment.

Current recommendations

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 long-lasting varnishes.

Summary

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.


References

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 2013;73(4):304-310.

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 1999;57(6):325-329.

8.            Pizzo G, Piscopo MR, Pizzo I, Giuliana G. Community water fluoridation and caries prevention: a critical review. Clin Oral Investig. Sep 2007;11(3):189-193.

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.

10.         Wright 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 2014;145(2):182-189.

11.         Hooper 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.

12.         Marinho 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.

13.         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.

Tables

Table 1: Priority ranking of different recommendations for preventive dental care in patients at increased risk for caries

Preventive measure

Increased risk-root caries

Rankinga

HEAb

Fluoride-toothpaste (5,000 ppm fluoride) twice a day

3

+

Fluoride rinsing/daily (0.2 % sodium fluoride)

3

+

Fluoride rinsing/daily (0.05 % sodium fluoride)

4

+

Fluoride gel (in tray)/daily

3

+

Fluoride varnish/2–4 times a year

3

+

Fluoride tablets/daily

7

-

Fluoride chewing gum/daily

7

-

Professional tooth-cleaning with fluoride paste/every 2nd month

6

(+)

Stannous fluoride gel/4× year

6

(+)

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

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