People at high risk for caries can safely protect their teeth by applying their own gels, pastes, and rinses with prescription-level concentrations of fluoride, the American Dental Association (ADA) said today in its first-ever guidelines on these products.

The recommendation was included in guidelines on prescription topical fluoride products that the ADA updated for the first time since 2006. The previous version of the guidelines made no recommendation on prescription fluoride products used at home.

“What’s really changed is that the panel decided to look at prescription-strength, home-use topical fluorides as well as professionally applied topical fluorides,” Julie Frantsve-Hawley, RDH, PhD, senior director of the ADA’s Center for Evidence-Based Dentistry, told Medscape Medical News.

The guidelines were published in the November issue of the Journal of the American Dental Association.

In another departure from the 2006 version, the new guidelines recommend that professionally applied gel should contain only acidulated phosphate fluoride, not sodium fluoride.

Acidulated phosphate fluoride “is more effective than sodium fluoride gel,” said Dr. Frantsve-Hawley, a member of the guidelines committee. For the previous version of the guidelines, the expert panel did not stratify the research to see whether there was a difference between the 2 types of fluoride.

The other key points from the guidelines:

• For use at home, clinicians should prescribe gels or pastes with fluoride concentrations of 0.5% twice daily or mouth rinses with concentrations of 0.09% fluoride at least weekly for patients at high risk for caries.
• In the office, clinicians should apply fluoride varnish with concentrations of 2.26% at least every 3 to 6 months.
• In patients aged 6 years and older, clinicians should apply the same varnish or 1.23% fluoride gel for 4 minutes. They should apply these treatments at least every 3 to 6 months.
• Prophylaxis such as cleaning, polishing, and scaling is not necessary before applying the gel.
• The ADA does not recommend foam and prophylaxis pastes with 1.23% fluoride and varnish with 0.1% fluoride for preventing coronal caries.

The prescription products for home use are more effective than over-the-counter gels, pastes, and rinses because they contain much higher concentrations of fluoride, said Dr. Frantsve-Hawley. Typically, over-the-counter toothpastes have concentrations of about 0.12% fluoride, and over-the-counter rinses have concentrations of about 0.02% fluoride, she said. However, that does not mean over-the-counter products are not effective, she noted. The ADA has a separate seal-of-approval process for evaluating products sold over the counter.

The ADA only recommends the high-concentration products for people at “elevated” risk for caries.

To identify these patients, Dr. Frantsve-Hawley said, dentists can use the ADA’s caries risk assessment forms, which come in different versions for patients older than 6 years and those aged 6 years or younger.

Categorizing patients according to their risk for caries has been somewhat controversial, with few dental plans willing to reimburse providers for more than 2 routine cleaning and examination appointments per year.

Dr. Frantsve-Hawley said clinicians and patients should work together to determine the best interval for visits to get fluoride professionally applied. The decision should depend partly on whether patients are applying fluoride at home, she said.

“We definitely know that people who are at high risk would benefit from more frequent fluoride applications,” said Dr. Frantsve-Hawley.

The new guidelines rest on a more solid foundation than the previous version because the committee that created them used a more rigorous method of weighing evidence based on the Preventive Services Task Force, she concluded.

JADA. 2013;144:1279-1291. Abstract

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