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reports
Summary of guidance for the use of fluorides
C COOP, AC FITZGERALD, RA WHYMAN, A LETHABY, E BEATSON, C
CADDIE, BK DRUMMOND, B HEGAN, D JENNINGS, PIKOOPU, JM LEEANDWM
THOMSON
New Zealand Dental Journal 105, No. 4: 135-137; December
2009
BACKGROUNDThe overall standard of oral health in New Zealand
has
improved in the last 30 years. However, early childhood
oralhealth trends show signs of worsening caries experience,and
high levels of dental caries remain in vulnerable groupsin the
population (Ministry of Health, 2006). The purposeof this guideline
is to provide an evidence-based summaryof current New Zealand and
international evidence in order
to inform best practice in the use of uoride treatments.This
guideline specically addresses the use of topicaluoride
treatmentsincluding uoride toothpastes, uoridevarnishes, uoride
mouthrinse, uoride gels and foams, anduoride tabletsand is intended
primarily for the providersof oral health care to New Zealanders
(including primaryhealth care services where applicable). It is
also expectedthat the guideline will have implications for health
service
provider organisations and funders.The Ministry of Health
recommends the adjustment of
uoride to between 0.7 ppm and 1.0 ppm in drinking wateras the
most effective and efcient way of preventing dentalcaries in
communities receiving a reticulated water supply,and strongly
recommends the continuation and extension ofwater uoridation
programmes where technically feasible.This guideline has not
undertaken a further analysis andreview of the policy and situation
with water uoridation.
METHODSThe New Zealand Guidelines Group (NZGG) convened
an Expert Advisory Group (EAG), nominated for theirknowledge of
uorides and uoride use by a range ofstakeholder groups, including
the Royal New Zealand PlunketSociety, Te Ao Marama (the New Zealand
Mori DentalAssociation), academic institutions, and District
HealthBoards. The EAG considered the evidence for a number ofuoride
interventions and formed recommendations, at the
same time ensuring that these were in a safe range for
dietaryuoride intake.
Recommendations are based on existing guidelines andsystematic
reviews, with an updated search of the literaturefrom 2006 onwards.
Australian consensus guidelines(Australian Research Centre for
Population Oral Health,2006) were used as a base to develop the
NZ-specicrecommendations. Full methodological details can
beaccessed on the NZGG website (www.nzgg.org.nz).
Risk categoriesIn their uoride recommendations, the American
Dental
Association listed factors that increase the risk of
developing
dental caries (American Dental Association, 2006). Thesefactors
were considered, and the EAG amended the ADAlist to reect risks
pertinent to the New Zealand population.The following risk factors
were agreed upon by the EAG:socio-economic deprivation, sub-optimal
uoride exposure,
ethnicity, poor oral hygiene, prolonged bottle feeding,
poorfamily dental health, enamel defects, eating disorders,
irregulardental care, a high-sugar diet, a high-carbohydrate diet
(in
people with complex medical conditions), active
orthodontictreatment, or low salivary ow. The following risk
categorieswere then determined, and include both an assessment of
thecurrent prevalence of dental caries and assessment of
riskfactors for dental caries in the individual being
evaluated.
High Risk of Dental CariesExperience of dental caries (including
pre-cavitated lesions)
in the past three years and health professional assessment
ofindividual and/or family risk of dental caries.
Low Risk of Dental CariesNo evidence of active dental caries in
the past three years
and no other signicant factors which contribute to dentalcaries
risk.
The EAG also discussed the fact that oral healthprofessionals
need to consider the collective risk of thesefactors; there is not
enough evidence to individually weighteach risk factor, but their
cumulative effect is important.
RecommendationsThe recommendations which follow are summarised
in
Figure 1, which is intended to assist practitioners in
applyingthe guidelines.
Fluoride toothpasteToothpaste should be labelled in parts per
million (ppm)
uoride.Toothpaste of at least 1000ppm is recommended for all
ages and should be used twice daily.Parents and caregivers
should be advised that a smear of
uoride toothpaste is recommended until ve years of age.From age
six years, a pea-sized amount should be used.
For children aged under six years in uoridated areas whoare at
low risk of dental caries, toothpaste with less than1000ppm uoride
may be considered in order to reduce totaluoride intake.
In deciding whether to provide low-uoride toothpaste,parents and
caregivers should be advised of the issuesassociated with reduced
uoride exposure (less protectionagainst dental caries) versus the
risk of uorosis.
Children should be supervised when using toothpaste.Toothpaste
should not be eaten.
Fluoride varnishesProfessionallyapplied, high-concentration
uoridevarnishes are not recommended in people with a low risk
ofdental caries.
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DECEMBER2009 NEWZEALANDDENTALJOURNAL 137
Professionallyapplied, high-concentration uoridevarnishes may be
used for people aged over 12 months whoare at high risk of dental
caries:
Fluoride varnish applications should be applied atsix-monthly
intervals as part of a preventive oralhealth plan
Fluoride varnish should be applied to all eruptedteeth
Health practitioners applying uoride varnish shouldhave
appropriate training
Fluoride mouthrinseFluoride mouthrinses are not recommended for
children
under six years or people aged 6+ who are at low risk ofdental
caries.
Fluoride mouthrinse may be used by people aged 6+ whoare at high
risk of developing dental caries:
After rinsing, mouthrinse should be spat out, notswallowed
Fluoride mouthrinse should be used as part of apreventive oral
health plan
Topical fluoride gels and foamsProfessionallyapplied,
high-concentration uoride gels
and foams are not recommended for children under six yearsor
people aged 6+ who are at low risk of dental caries.
Professionallyapplied, high-concentration uoride gelsand foams
may be used for people aged 6+ who are at highrisk of dental
caries:
Fluoride gel applications should be applied at three-to
six-monthly intervals as part of a preventive oralhealth plan
Neutral gels are preferable to acidulated gels in
patients with porcelain and composite restorations
Fluoride tabletsFluoride tablets are not recommended as a
population
health measure in NZ.Fluoride tablets may be recommended for
those aged 3
years and over at high risk of dental caries.Tablets should be
chewed or sucked, or dissolved in
drinking liquid.
REFERENCESMinistry of Health (2006). Good oral health for all,
for life: thestrategic vision for oral health in New
Zealand.Wellington, Ministry
of Health.Australian Research Centre for Population Oral Health
(2006). Theuse of uorides in Australia: guidelines.Australian
Dental Journal51: 195-199.
American Dental Association Council on Scientic Affairs
(2006).Professionally applied topical uoride: evidence-based
clinicalrecommendations. Journal of the American Dental
Association137: 1151-1159.
Members of the Expert Advisory groupDRROBINWHYMAN(CHAIR)Chief
Dental Ofcer, Ministry of Health, WellingtonERINBEATSON
Clinical Advisor, Royal New Zealand Plunket
Society,WellingtonCLAIRECADDIEService Manager, Audiology, Oral and
PreventativeProgrammes, Maternal, Child and Youth Continuum,Hawkes
Bay DHB
DRBERNADETTEK DRUMMONDAssociate Professor, Paediatric Dentistry,
Department ofOral Sciences, Sir John Walsh Research Institute,
Faculty ofDentistry, University of Otago,
DunedinBARBARAHEGANAnalyst, Nutrition and Physical Activity Policy,
Health
and Disability Services Policy Group, Population
HealthDirectorate, Ministry of Health,
WellingtonDEBBIEJENNINGSClinical Team Leader, School Dental
Service, Hutt ValleyDHBDRPAULINEKOOPUPublic Health Dentist,
Tumuaki, Te Ao Marama (The NewZealand Mori Dental Association),
RotoruaDRMARTINLEEPublic Health Dentist, Clinical Director,
Community DentalService, Canterbury District Health Board,
ChristchurchDRW. MURRAYTHOMSONProfessor, Dental Epidemiology and
Public Health,
Department of Oral Sciences, Sir John Walsh ResearchInstitute,
Faculty of Dentistry, The University of Otago,Dunedin
New Zealand Guidelines Group TeamJessica Berentson-Shaw,
Research Manager (until July2009)Anne Lethaby, Interim Research
Manager (from July 2009)Catherine Coop, ResearcherAnita Fitzgerald,
Senior ResearcherMeagan Stephenson, ResearcherMargaret Paterson,
Information SpecialistLeonie Brunt, Publications Manager
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