When I was in hygiene school and we started clinic, my most dreaded moment was not when my instructor would check my work, it was when I had to place that big bulky tray full of fluoride gel or foam in my patients’ mouth. Then I had to make them keep it there for 4 minutes, if you think microwave minutes are long, they are no comparison to fluoride tray minutes. When I started working in private practice and could use fluoride varnish, it was life changing. I no longer dreaded that awful fluoride tray. You can imagine my shock when recently, a dear friend and fellow hygienist brought to my attention that fluoride foams and gels are still being used in many practices. The convenience factor alone was enough for me to move on to fluoride varnish and never look back. For those of you not easily convinced to change your fluoride protocol, here is a list of reasons you should consider making the change.
1. Convenience – As I’ve already mentioned the convenience of fluoride varnish compared to fluoride foam or gel is life changing. Fluoride varnish does not require isolation or drying of the teeth, it sets on contact with saliva. [2] It saves time, fluoride gels and foams require a 4-minute application. Some foams and gels state they only need to be applied for one minute, however the CDC states “The application time for fluoride gel and foam treatments is 4 minutes. In clinical practice, applying fluoride gel for 1 minute rather than 4 minutes is common, but the efficacy of this shorter application time has not been tested in human clinical trials” [4] Fluoride varnish can be applied with a simple brush in just 30 seconds. As a hygienist that has worked in some busy practices, those extra 3 minutes and 30 seconds add up. It can make a difference in whether you get a lunch break or not.
2. Age is not a factor – According to the ADA, fluoride foam and gels are not recommended for children under age 6, only 2.26% fluoride varnish is recommended for children under age 6. [3] A study was conducted that evaluated 2,424 children age 0-5, receiving on average 4 fluoride varnish treatments over a 3-year span, the researchers found zero fluoride varnish-related adverse events. [5] Fluoride varnish can be used for all age groups, which makes it a more universal product. There is no need to stock several different types of fluoride, if one type can be used on all patients. It will save storage space as well, no more big boxes or bags of foam trays.
3. Efficacy – Studies have shown that fluoride varnish is more effective at reducing dental caries than other topical fluoride treatments. Several studies show as much as a 75% reduction in dental carries with the use of fluoride varnish, as compared to a 26% reduction with fluoride gel and foam. [2,4] Fluoride foam seems to be less effective than gel, in one study they found “no preventative effect was displayed in fissures located on occlusal surfaces with the use of fluoride foam”. [1] I don’t know about you, but if I were presented with those statistics and the option to choose, I would certainly choose varnish every time.
4. Patient compliance – Patients seem to be more accepting of fluoride varnish treatments, when compared to other methods. [2] I believe there are several reasons for this, one being the taste. Fluoride varnish has a less offensive taste than foams and gels. Another reason is the time factor, patients always seem to be in a hurry, when I recommend a fluoride treatment, they always ask “How long will that take?” I like to be able to answer “About 30 seconds” versus having to tell them at least 4 minutes. Patients also prefer not to have to put that obnoxious tray in their mouth, it triggers their gag reflex at least 50% of the time. Let’s face it, no one likes to listen to someone retching for 4 solid minutes.
5. Less chance of ingestion – The CDC states “Proper application technique reduces the possibility that a patient will swallow varnish during its application and limits the total amount of fluoride swallowed as the varnish wears off the teeth over several hours.” [4] If you have ever had a patient vomit everywhere from ingesting too much fluoride foam or gel, you can appreciate the almost nonexistent risk of that happening with fluoride varnish. This is also one of the primary reasons fluoride gel and foams are contraindicated for children under age 6.
Though the pros outweigh the cons in my opinion, it would be irresponsible of me not to mention that varnish is not perfect. It is very sticky, if it gets on your clothes it is there to stay. Some patients do not like the way it makes their teeth feel. And most importantly, some varnishes contain ingredients derived from nut trees. This would be an issue for someone with a tree nut or peanut allergy. Not all varnishes have this ingredient, so be sure to check with the manufacturer on the safety of use for patients with tree nut and peanut allergies. It is worth mentioning that some fluoride gels are manufactured in warehouses that also manufacture tree nut products, therefore cross contamination is possible with gel as well. For the safety of your patients, please always check with the manufacturer when your patient is allergic to peanuts or tree nuts. If you are still using fluoride foam or gel, I challenge you to give fluoride varnish a try. I believe you and your patients will prefer it over the gag fest that ensues when using fluoride foam and gel trays.
Resources
1. Twetman S., Keller M.K. Fluoride Rinses, Gels and Foams: An Update of Controlled Clinical Trials. Caries Res 2016;50(suppl 1):38-44. Retrieved from https://www.karger.com/Article/FullText/439180
2. Tayebeh Malek Mohammadi, Abolghasem Hajizamani, Hamid Reza Hajizamani, and Batol Abolghasemi. Fluoride Varnish Effect on Preventing Dental Caries in a Sample of 3-6 Years Old Children. J Int Oral Health. 2015 Jan; 7(1): 30-35. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4336657/#ref15
3. ADA. Fluoride: Topical and Systemic Supplements. Retrieved from http://www.ada.org/en/member-center/oral-health-topics/fluoride-topical-and-systemic-supplements
4. CDC. Recommendatioms for Using Fluoride to Prevent and Control Dental Caries in the United States. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm
5. Garcia RI, Gregorich SE, Ramos-Gomez F, Braun PA, Wilson A, Albino J, Tiwari T, Harper, M, Batliner TS, Rasmussen M, Cheng NF, Santo W, Geltman PL, Henshaw M, Gansky SA. Absence of Fluoride Varnish Related Adverse Events in Caries Prevention Trials in Young Children, United States. Prev Chronic Dis. 2017 Feb 16;14:E17. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28207379
Comments