FLUORIDATED DENTIFRICES

Irrespective of caries risk, all age groups should use commercially available fluoridated toothpaste at least twice per day. Children younger than 2 should limit the amount of paste to a pea-size amount, applied on a soft toothbrush by the caregiver, to minimize the risk of fluorosis. Studies on the efficacy of fluoridated dentifrices in children of two to three years’ duration have reported reductions in caries experience of 15 percent to 50 percent. In the United States, the concentration of fluoride in fluoride toothpastes is usually 1,000 to 1,100 ppm F. In recent years, 1.1 percent NaF toothpaste and gel (5,000 ppm F) (Prevident 5000, Control RX, Fluoridex Daily Defense) have become available for treating root sensitivity and have been approved for safety and efficacy by the Food and Drug Administration. Its use as an “off -label” anticaries agent is based on the likelihood of it being more beneficial in treating rampant caries, root caries and patients with decreased salivation or decreased cooperation in applying other forms of fluoride. In a clinical study that followed root caries progression, the use of a 5,000 ppm F toothpaste produced statistically significantly less caries than the control 5,000 ppm F product.
Conclusion
It is reasonable to assume that the anticaries effect of high fluoride concentration toothpastes is an extension of the evidence base for the routinely used toothpastes with lower amounts of fluoride and may prove helpful with patients who will not cooperate with other recommended sources of topical fluoride such as OTC fluoride rinses. These high fluoride toothpastes require a prescription.
Application
In the extreme-risk and high caries risk adult (i.e., rampant caries, root caries, or excessive gingival recession, or decreased salivation) it is reasonable to recommend the use of 1.1 percent NaF toothpaste twice per day (refer to Jenson et al., this issue, for recommended treatment protocols for the various risk levels and to Featherstone et al., this issue, for caries risk determination procedures). It can be used after breakfast, lunch, dinner, or at bedtime, as long as it does not interfere with any other fluoride modality that is recommended. If it is used only once per day, it is preferable to use at bedtime. Ideally, patients should be instructed to expectorate, but not rinse with water following brushing. When the tongue and lips are cleared of foam, the mild flavor of the paste is pleasantly tolerable. If patients prefer to rinse with water to eliminate food or other debris, they should try to rinse with just one mouthful of water holding it in the mouth for at least one minute, or alternatively reapplying a small amount of the toothpaste after rinsing.
The utility of 1.1 percent NaF toothpaste is that it is a single product. It does not require brushing first and then applying a high concentration fluoride gel, which may discourage some patients. One optional procedure in the extreme-risk patient with low salivary flow is the construction of custom trays and the use
of the 1.1 percent NaF gel (10 minutes per night). This is justifiable even though it is more costly. Use of the high concentration fluoride toothpastes should be continued until the caries status of the patient has changed and remains controlled. One cautionary note: Avoid using the 5,000 ppm fluoride toothpaste or gel directly after the use of chlorhexidine. Separating their use by an hour or more will help prevent the cationic charge of CHX from binding with the anionic charge of the fluoride, and allow either product to interact independently with the bacteria on the plaque and with the tooth.