Fluoride
Guide
Earn
4 CE credits
This course was
written for dentists,
dental hygienists,
and assistants.
Written by Fiona M. Collins, BDS, MBA, MA
and Michael Florman, DDS
$59.00
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Foreword
Optimizing a fluoride protocol for individuals at dental caries risk is the most important
measure that can be done to prevent future and arrest current disease. However, fluoride
therapy remains complex and controversial. Since the introduction of water fluoridation,
fluoride supplements, and topical fluoride therapies in the late 1940s, the mechanisms of
action, dosages and delivery systems have been debated and have evolved.
Originally, the mechanisms of fluoride action were ascribed solely to reducing enamel
solubility. Now, other mechanisms such as fluoride’s effect on remineralization and
its effect on bacterial metabolism also are recognized. Similarly, the initial dosage of
fluoride supplements was empirical, based on simulating fluoride exposure from optimally
fluoridated water. As a result of epidemiologic studies showing mild fluorosis in some
children with the original dosage and the fact that fluoride is now a ubiquitous part of
a child’s diet, the fluoride supplement dosage has been altered several times over the
past 30 years. These issues of dosage are further compounded by epidemiologic studies
showing changing prevalence of caries and fluorosis.
Topical fluoride use in preschool children, as well, has evolved. New modalities, such as
fluoride varnishes, have become more prevalent for office treatment for children because of
the safety of premeasured doses, ease of application and better patient acceptance.
Overlaying both the issues of topical fluoride therapy and fluoride supplement use is the
current focus on individualized therapy for patients based on caries risk. One should no
longer prescribe fluoride supplements or perform a professionally applied topical fluoride
treatment without considering an individual’s caries risk. Recent recommendations suggest
limited use of fluoride for those at low caries risk, but significantly more frequency and
intensity for those at high risk.
This Fluoride Guide addresses the current concepts of fluoride mechanism, systemic and
topical therapy based on the best evidence in the literature. Not only does the Guide
provide scientific rationale, it also offers the dental provider options, based on efficacy
for systemic fluoride, office treatments and home-use fluoride products.
Dr. Norman Tinanoff
Chairman of the Department of Health Promotion and Policy,
University of Maryland
Educational Objectives
The overall goal of this article is to provide the reader with information on the use of
systemic and topical fluorides for caries prevention.
Upon completion of this course, the dental professional will be able to do the following:
1. List intentional and unintentional sources of systemic fluoride.
2. List and describe caries risk factors and the ADA recommendations for in-office topical
fluorides corresponding to different risk levels.
3. List and describe the considerations involved in selecting in-office and home-use topical fluorides.
4. List and describe the various home-use topical fluorides available and the clinical
efficacy of each.
Abstract
Water fluoridation heralded the use of fluoride as an anti-caries agent. Since that time,
both systemic and topical fluorides have become available and the use of fluorides
has contributed greatly to reducing the level of caries seen in the population. Systemic
fluoride supplements are available as tablets and drops, for use in accordance with the
recommendations on fluoride supplement dosing. Vehicles for topical fluorides include
in-office fluoride varnishes, gels, and foams, and home-use fluoride dentifrices, rinses and
prescription products. The primary mechanisms of action involved with the use of topical
fluorides are the prevention of demineralization and promotion of remineralization, by
ensuring the ready availability of intra-oral fluoride.
Considerations in selecting an appropriate in-office and home-use topical fluoride protocol for individual patients include the patient’s age, caries risk level, exposure to fluoride
from all sources, and the current recommendations on professionally-applied topical
fluorides. Other important considerations include product efficacy and safety, the patient’s
dental status as well as compliance with brushing and age-appropriate use of fluoride
toothpaste, and clinician and patient preferences.
Introduction
Fluoride has been used in the United States as an anti-caries agent since the 1940s,
when water fluoridation was first introduced. Since then, numerous agents have become
available for both the systemic and topical applications of fluoride.
Currently available fluorides include sodium fluoride, sodium monofluorophosphate,
acidulated phosphate fluoride and stannous fluoride. In addition to its use as a caries
preventive to help prevent demineralization and aid remineralization, fluoride is used for
the treatment of dentinal hypersensitivity.
The focus of this guide is on the anti-caries benefits of fluoride. Systemic and topical
fluorides will be addressed, including the mechanisms of action, categories of fluoride
products and evidence for their use, as well as current recommendations on systemic and
topical fluorides.
Systemic fluoride
Intentional sources of systemic fluoride for the prevention of caries include fluoridated
water and fluoride supplements. Inadvertent (unintentional) sources include naturally occurring fluoride in well water, fluoride toothpaste, brewed tea, bottled water, drinks and
goods processed using fluoridated water, and foods such as fish. In addition, certain
medications contain fluoride. (Table 1)
Table 1. Sources of systemic fluoride
Intentional
Fluoridated water
Fluoride supplements
Fluoridated salt
Fluoridated milk
Fluoridated foods
Unintentional
High fluoride level well water
Foods containing fluoride
Home-use topical fluoride products,
including fluoride toothpaste
Medications containing fluoride
High fluoride level bottled water
Water fluoridation
Water fluoridation was first introduced in the 1940s,1 and its use has resulted in substantial declines in caries rates. Water fluoridation, as a public health measure, is achieved
through the addition of fluoride at water plants, typically to obtain a level of 1 ppm
fluoride in drinking water. In other areas where the level of fluoride is substantially higher
than the recommended level, excess fluoride can be removed during processing.
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Fluoride-enriched salt
Fluoridated salt has been used in several areas of the world, including parts of Europe
and Latin America. A recent review of the literature led to the determination that there are
no randomized, controlled clinical trials on the use of fluoridated salt to enable conclusions to be drawn as to its efficacy. The same reviewer located two studies on fluoridated milk, one of which showed, at the conclusion of the study, a significant reduction
in caries in children age 8 after three years of use.2
Fluoride supplements
Fluoride supplements can be given to at-risk children as drops, lozenges or tablets, with
the dose varying with the level of fluoride contained in the domestic water supply and
age of the child. The use of fluoride supplements by pregnant women does not result in
any benefit for the baby.
• Current recommendations from the American Academy of Pediatric Dentistry, American Dental Association and American Academy of Pediatrics are to start fluoride
supplements, if required, at 6 months3,4 (Table 2)
• The Centers for Disease Control and Prevention (CDC) suggests that fluoride supplements be given to children living in areas with suboptimal water fluoridation who are at high risk of caries5
• Chewing or sucking fluoride tablets and lozenges prior to swallowing will maximize
the effect of these supplements by providing an additional topical effect.
Table 2. Recommended fluoride supplement dosing (mg/day)
Fluoride in domestic water supply
Age of Child
< 0.3 ppm
0.3-0.6 ppm
> 0.6 ppm
Up to 6 months
None
None
None
6 months to 3 years
0.25 mg/day
None
None
3-6 years
0.5 mg/day
0.25 mg/day
None
6-16 years
1.0 mg/day
0.5 mg/day
None
Systemic fluoride and mechanisms of action
During tooth development, the cumulative ingestion of fluoride prior to pre-eruptive
enamel maturation results in fluoride ions replacing hydroxyl ions and the formation of
fluorapatite crystals instead of hydroxyapatite crystals.6 (Figure 1) The fluorapatite crystals
are smaller and stronger than hydroxyapatite crystals and are more resistant to demineralization associated with the dental caries process. Recent reviews have suggested that the
effect of fluoride, including that contained in supplements, foods and drinks, is mainly the
result of its topical effect.7,8,9
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Figure 1. Crystal formation and fluoride substitution
Hydroxyapatite
O
Ca++
–
O P O–
OHCa++O
–
Fluorapatite
Substitution
of fluoride
O–
Ca++
O P O–
FCa++O
–
Ingested fluoride works through a number of mechanisms:
• Systemic fluoride use results in a concentration of fluoride of 1,000 – 2,000 ppm in
the outer layer of the enamel
• The remainder of the enamel contains about 20 –100 ppm
• Pre-eruptively, formed enamel is bathed in plasma that contains fluoride and contributes to the outer fluoride-rich layer
• Post-eruptively, the enamel is bathed in fluoride contained in saliva and crevicular
fluid, that was derived from systemically absorbed (ingested) fluoride
• Both the fluoride-rich layer and the inner layers of the enamel containing 20 – 100
ppm fluoride are still susceptible to acid attacks10
• Ongoing caries prevention from fluoridated water and other fluoride-containing drinks
and/or foods also occurs as a result of their direct topical effect with some retention
of fluoride intra-orally on the teeth and in dental biofilm (plaque).
Inadvertent ingestion of excessive amounts of fluoride during enamel development,
from all sources combined, can result in fluorosis and is dependent on the dose, age of
the child and duration of excessive fluoride ingestion. A risk of fluorosis with regular use of
fluoride supplements and toothpaste has been found, underscoring the importance of total
fluoride ingestion when prescribing supplements.11
Fluorosis
Fluoride sources that may contribute to a high total level of fluoride ingested, and therefore
fluorosis, include high-fluoride-level well water, foods and drinks containing high levels
of fluoride, the repeated ingestion of fluoride intended for topical use only and certain
medications.
• Mild fluorosis results in white mottled areas of enamel as a result of hypomineralization, which can be a cosmetic concern in the anterior dentition
Severe fluorosis can
result in pitted and malformed areas of enamel, brittle enamel, breakdown of areas of
enamel and teeth with abnormal morphology
• Fluorosis seen in the United States is generally very mild or mild12
• Severe fluorosis is more common in areas with high-fluoride-level well water
• For fluorosis to occur, excess fluoride must be ingested prior to pre-eruptive enamel
maturation; ingestion after this developmental phase cannot result in fluorosis
• Fluorosis as a result of excess ingestion of fluoride from age 6 onward is not a concern as pre-eruptive enamel maturation of the anterior (and majority) of the dentition
has been completed by then and for all of the dentition by age 8
• Topical fluorides are relevant for fluorosis only if inadvertently swallowed.
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Topical fluorides
Topical fluorides are available as in-office fluorides and home-use fluorides. Topical
fluorides act intra-orally by:
• Providing periodic high doses of fluoride (in-office)
• Providing low regular doses of fluoride (home-use).
Topical fluorides available in the United States include:
• Sodium fluoride
• Sodium monofluorophosphate
• Acidulated phosphate fluoride (or acidulated sodium fluoride)
• Stannous fluoride
• Fluoride from glass ionomer cements
• Other fluoride-releasing dental materials.
Acidulated formulations were first investigated with the goal of increasing fluoride
uptake and ion exchange through the use of a low pH. These included phosphate to
prevent dissolution of dental hard tissues.13,14 Other investigators focused on formulations that had the potential to bind the fluoride to the tooth surface or to prolong the
application for greater fluoride release and availability.
Caries and the mechanism of action of topical fluoride
Dental caries is a multifactorial infectious disease that always requires the presence
of cariogenic bacteria – primarily mutans streptococci (Streptococcus mutans and S.
sobrinus) as well as lactobacilli. These bacteria metabolize fermentable carbohydrates,
producing acid that is capable of demineralizing dental hard tissues at below pH 5.5,
under conditions favoring this. During acid attacks, subsurface dissolution occurs at pH
3.8 – 4.8, with the loss of calcium and phosphate ions from the crystals. The intra-oral
pH rebounds approximately 30 minutes after an acid attack, during which time remineralization with calcium phosphate and fluoride ions occurs at the site of demineralization.
During acid attacks, subsurface dissolution occurs at pH 3.8 – 4.8,
with demineralization and the loss of calcium and phosphate ions
from the crystals. In dentin, unhindered disease progression is
more rapid due to collagen fibril degradation.
As a result of repeated episodes of demineralization (and in the absence of remineralization), white spots may appear due to subsurface demineralization. In orthodontic patients, these white spots can be found adjacent to brackets in particular and are referred
to as orthodontic decalcifications.15 Unhindered, once sufficient subsurface structure has
been lost, the surface collapses and cavitation occurs. Disease progression is more rapid
in dentin as demineralization of the dentin is followed by enzymatic degradation of the
exposed collagen fibrils.16,17 (Figure 2, 3)
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Figure 2. Caries process: demineralization and remineralization
pH
Demineralization
pH
Remineralization
Ca++
Ca++
PO4
PO4
Acid Attack
Ca++
Ca++
PO4
PO4
Drop in pH as a result of an acid attack results in loss of ions and demineralization of the
tooth structure; under favorable conditions, this is followed by the migration of ions to the site of the
lesion and remineralization.
Figure 3. Destructive phase of the caries process in dentin
Demineralization
Degradation of
collagen fibrils
Ca++
PO4
Ca++
+
PO4
Drop in pH as a result of an acid attack results in loss of ions and demineralization of the tooth
structure; if the lesion is not remineralized, this is followed by degradation of the exposed collagen
fibrils resulting in more rapid progression of caries in dentin than in enamel.
Anti-caries benefit of fluoride
The anti-caries benefit derived from topical fluorides can be attributed primarily to the
prevention of demineralization and the promotion of remineralization. Ensuring the
ready availability of intra-oral fluoride helps prevent demineralization from occurring
and, should it occur, aids remineralization. The application of high concentrations of
topical fluoride results in the formation of alkali-soluble calcium fluoride-like globules at
the tooth surface, the amount being influenced by the length of application and the concentration of fluoride used. These globules act as a fluoride reservoir and have been
observed with scanning electron microscopy.18,19,20 It is believed that the phosphate
associated with these globules is responsible for their stability at a normal pH. When
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acid attacks occur, the globules start to break down and release calcium, phosphate
and fluoride, resulting in a higher concentration of these ions at the tooth surface than
internally. These then migrate to demineralized sites and remineralize these defects,
also forming fluoridated hydroxyapatite. (Figure 4)
At lower concentrations of topical fluoride (as used in dentifrices and rinses), fluoride is retained in solution in saliva as well as being retained as alkali-soluble calcium
fluoride. Thus, topical fluorides result in the retention of fluoride on the tooth surface; in
saliva and dental plaque; and on intra-oral soft tissues, especially the tongue and lower
posterior vestibule of the mouth.18,19,21
Figure 4. Fluoride adsorption and caries control
Ca++
F-
Acid Attack
F-
F-
PO4
Ca++
F-
F-
Acid Attack
PO4
F-
F-
High concentrations of topical fluorides result in the formation of calcium fluoride-like globules. These are
stable until exposed to acid, when they release calcium, phosphate and fluoride. Low concentrations
of topical fluorides also result in the presence of bioavailable fluoride in plaque, saliva and oral mucosa.
Together, these mechanisms provide for reservoirs of fluoride available during acid attacks.
Topical fluoride is also believed to inhibit caries activity through bacterial inhibition.16 (Figure 5)
Figure 5. Bacterial inhibition
Fluoride-induced
inhibition
of enzymes
responsible for
carbohydrate
metabolism
Hydrogen fluoride
molecules enter
the bacterial cell
Fluoride and hydrogen
dissociate, enabling fluoride
activity inside the cell
Fluoride combines with hydrogen and then enters the bacterial cell. Following entry into the cell, the fluoride and
hydrogen dissociate and the fluoride inhibits enyzmes involved in bacterial metabolic processes; this includes inhibition of
enolase that metabolizes fermentable carbohydrates, thereby reducing the production of acid involved in the caries process.
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Most of the topical effect of fluoride is due to the presence of available fluoride rather than the influence of fluoride uptake during fluoride therapy (in-office or home-use). As
previously mentioned, ingested fluoride also contributes to the topical effect of fluorides.
Omitting plaque removal with a professional prophylaxis prior to the use of in-office topical fluorides has been found to still result in the formation of calcium fluoride-like globules
at the tooth surface and, in fact, to increase fluoride retention and the efficacy of fluoride
therapy. Regular rinsing with fluoride in the presence of plaque has been shown to result
in the deposition of alkali-soluble (available) fluoride.22,23,24
Most of the topical effect of fluoride is due to the presence
of available fluoride.
In-office fluorides
In-office fluorides are available as varnishes, gels, foams and rinses. These differ by type
of fluoride, concentration, and method and length of application. (Table 3)
Table 3. Fluoride concentration in ppm fluoride
5% sodium fluoride varnish
APF gels and foams
Sodium fluoride gels and foams
Dual rinses
22,600 ppm
12,300 ppm
9,050 ppm
3,300 ppm
The selection, use and frequency of use of in-office fluorides for an individual patient
should be based on his or her risk level, and should consider ADA recommendations;25 patient age; product efficacy, clinical support and safety; ease of use and patient preference.
Varnishes
In the United States, fluoride varnish is available as 5% sodium fluoride, equivalent to
22,600 ppm fluoride. While the FDA has cleared varnish as a device for the relief of
hypersensitivity and as a cavity liner, the vast majority of clinical trials, evidence-based
studies and the major use worldwide is as an in-office topical fluoride for the prevention of dental caries. In addition, the American Dental Association recommends the use
of 5% sodium fluoride varnish for caries prevention for children of all ages (including
children under 6 years of age) and for adults. Both tinted and white/clear versions are
available in tubes and/or unit doses. Studies have demonstrated patient preference for
white/clear varnish due to the improved esthetics while the varnish remains on the teeth,
while clinicians have found the use of unit doses simplifies application, results in the use
of a defined amount of varnish and reduces any risk of cross-contamination. Application frequencies of twice or four times per year have been advocated, as well as more
frequently than four times per year in some cases of early childhood caries.26,27
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The American Dental Association recommends the use of 5% sodium fluoride
varnish for caries prevention for children of all ages and for adults.
Clinical effectiveness
Five percent sodium fluoride varnish has been found to be effective in reducing caries in the
primary dentition – including early childhood caries – and the permanent dentition.28,29,30,31
Trials and studies have demonstrated reductions in coronal and root caries as well as
recurrent caries. One meta-analysis by Marinho et al. pooled data from clinical studies of
at least one year’s duration in patients under age 17 who were blinded or double-blinded
and met all criteria. They found an overall caries reduction in the primary dentition (dmfs)
of 33%, with a range of 19 – 48%, and in the permanent dentition (DMFS) of 46%, with
a range of 30 – 63%.32 An earlier, smaller meta-analysis with fewer studies had yielded a
caries reduction of 38% in children (Helfenstein and Steiner).33 In an open study, Weinstein
et al. found a significant increase in the reversal of enamel decalcifications in children with
early childhood caries.34 Studies using 5% sodium fluoride varnish have also reported on its
effectiveness in reducing orthodontic decalcification.35
Table 4. Overview of sodium fluoride varnish clinical efficacy
Marinho et al.
Helfenstein, Steiner
Holm et al. 36
Weinstein et al.
Study
Meta-analysis
Meta-analysis
Pre-school children
Early childhood caries
(open study)
Caries reduction
33% dmfs reduction (19% to 48%)
46% DMFS reduction ( 30% to 63%)
38% reduction
44% dmft reduction
51% reversal of enamel decalcification
The high level of fluoride and prolonged fluoride release compared to other inoffice topical fluorides are factors considered to result in the high caries reductions that
have been found with this vehicle.
Gels and foams
Gels and foams are available as acidulated phosphate fluoride and as sodium fluoride.
Acidulated phosphate fluoride (APF) gels and foams contain 12,300 ppm fluoride,
and neutral sodium fluoride gels contain approximately 9,000 ppm fluoride. These are
available as either a four-minute or a one-minute application:
• There is clinical support and evidence for the efficacy of four minute gel applications
• There is insufficient evidence of caries efficacy for a one-minute application of gel or
foam
• Foam has the advantage of resulting in a lower dose of applied fluoride compared
to gel, reducing the risk of ingestion.
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The American Dental Association recommends the use of 4-minute fluoride gel in
children age 6 and older and in adults. The use of in-office fluoride gels and foams is
not recommended for children under age 6, who are at greater risk of fluoride ingestion
during application and have less ability to spit out excess afterward.
Clinical efficacy
In a meta-analysis of fluoride gels, a caries reduction average of 21% was found (range
of 14 – 28%) across 14 placebo-controlled studies.37 A separate systematic review of
23 trials (some of which did not have placebo controls) found a caries reduction (DMFS)
average of 28% (range of 19 – 37%).38 It was also concluded in these studies that there
was insufficient evidence of any effect in the primary dentition. A systematic review by
van Rijkom et al. of clinical trials using acidulated phosphate gels found an average
reduction of 22%, with greater reductions for higher caries incidence patients than for
lower caries incidence patients.39 An in vitro study by Garcia-Godoy et al. resulted in the
conclusion that APF gel treatment with a one-minute or a four-minute application resulted
in equivalent reductions in enamel lesion depths.40 A recent study conducted on 3 –
4-year-olds on the twice-annual use of in-office APF foam found a primary caries reduction (dmfs) of 24%, attributable to its effect on approximal surfaces and no effect on occlusal surfaces.41 A second study by Jiang et al. assessed the efficacy of APF foam and
gel in 6-7 year-old children in a 24-month clinical trial, and found these were equivalent
with a 41% caries reduction on smooth surfaces for each. 42 (Table 5) The ADA does not
recommend or endorse the use of one-minute gels and does not recommend the use of
fluoride foams, due to the paucity of clinical evidence.25
Table 5. Clinical efficacy of fluoride gels and foams
Marinho et al.
Study
Meta-analysis (gel)
Marinho et al.
Systematic review (gel)
v Rijkom et al.
Systematic review (gel)
Caries reduction
21% DMFS reduction
(14% to 28%)
28% DMFS reduction
(19% to 37%)
22% average reduction
Jiang et al.
APF gel and foam comparison
41% caries reduction for each
Jiang et al.
Pre-school children (foam)
24% dmfs reduction
In-office fluoride rinses
In-office topical rinses are available as 2% sodium fluoride rinses and dual rinses containing stannous fluoride and acidulated phosphate fluoride. These should not be used
in young children, due to the risk of ingestion.
• There is limited in vitro data suggesting an effect for dual rinses
• There is no clinical evidence for efficacy of these rinses
• The American Dental Association does not recommend the use of in-office fluoride
rinses.25
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Risk levels and ADA
recommendations for
in-office fluorides
Patients can be classified as being at low, moderate or high risk for caries at a given
time. Low-risk patients are those who have no factors that may increase their risk of caries and who have had no incipient, cavitated or secondary carious lesions in the prior
three years, according to the guidelines in the ADA recommendations on professionally
applied fluorides. All other patients are either moderate or high risk. (Table 6)
Table 6. Moderate- and high-risk levels
Moderate risk
High risk
< 6 years of age
No incipient/cavitated carious
lesions during the last 3 years
At least one risk factor
Any incipient/cavitated lesions
in last 3 years and/or multiple
risk factors
6+ years of age
one/two incipient/cavitated
lesions in last 3 years
and/or at least one risk factor
3 or more incipient/cavitated
carious lesions in the last 3 years
and/or multiple risk factors
Adapted from: Evidence-based Clinical Recommendations: Professionally Applied Topical Fluoride
For moderate- and high-risk patients, the American Dental Association recommendations are for the use of fluoride varnish in children under age 6 and either fluoride
varnish or a four-minute gel in patients age 6 and over. The recommended frequency
of application for these patients is two to four times per year, depending on risk level.25
The ADA recommendations do not include the use of foam specifically because there
are few clinical trials conducted on foam to demonstrate its efficacy. However, those
that were conducted, together with laboratory data, suggest that it may be equivalent to
fluoride gel. For low-risk patients, in-office topical fluorides are not recommended, and
the use of fluoride dentifrice may suffice. Professional judgment is required for individual
patients.25 (Table 7)
Risk factors are destructive factors in the caries process, while the use of fluoride
and other preventives are protective factors. (Table 8)
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Table 7. American Dental Association recommendations
Low-risk patients*
Moderate-risk patients**
High-risk patients
< 6 years
of age
Professional fluoride
may be of no benefit
Fluoride varnish
2 times per year
Fluoride varnish
2 - 4 times per year
6 - 18 years
of age
Professional fluoride
may be of no benefit
Fluoride varnish or gel
2 times per year
Fluoride varnish or gel
2 - 4 times per year
18+ years
of age
Professional fluoride
may be of no benefit
Fluoride varnish or gel
2 times per year
Fluoride varnish or gel
2 - 4 times per year
* Use professional judgment. Fluoride dentifrice may be sufficient. **Moderate-risk may benefit from up to 4 times per
year. Adapted from: Evidence-based Clinical Recommendations: Professionally Applied Topical Fluoride.
Table 8. Destructive (risk) and protective factors
Risk factors
Suboptimal fluoride exposure
Xerostomia
Poor oral hygiene
High bacterial load
Familial high caries rate
High frequency sugar and other carbohydrate
consumption
Enamel defects
Defective restorations
Tobacco use
Drug or alcohol abuse
Exposed roots
Orthodontic appliances
Low SES
Inability to perform adequate oral hygiene
Protective factors
Optimal fluoride exposure
High salivary flow
Use of xylitol
Use of antimicrobials
Home use of Recaldent-containing products
Clinical examples
Clinical examples of at-risk and high-risk patients can be found below.
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a. Patient with early childhood caries
b. Orthodontic patient
Courtesy of Dr. Michael Florman
Courtesy of Dr. N. Sue Seale
c. Patient with exposed roots
Courtesy of Dr. Scott Froum
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Considerations for in-office
and home-use fluorides
In addition to the ADA recommendations for professional fluorides, professional judgment,
efficacy and safety, and other considerations contribute to the selection of in-office and
home-use fluorides. These include pH, alcohol content, propensity for stain, and preferences.
pH of topical fluorides
The pH range of topical fluorides is approximately pH 3 – 7 (neutral). Acidulated
phosphate fluoride (acidulated sodium fluoride) topicals are formulated for rapid uptake
of fluoride; however, their use over time has the potential to etch and alter the surface
of ceramics, resin-based composites and
Table 9. pH of fluoride products
glass ionomers.43,44 In addition, acidulated
Product
pH
phosphate alters the surface of titanium
1.23% APF gel, foam
3-4
alloys, therefore caution is advised with reSodium fluoride varnish, gel, foam Neutral
spect to use of these formulations in implant
NaF and MFP dentifrices
Neutral
patients.45 In patients for whom these are
0.4% stannous dentifrice
2.8-4
Sodium fluoride pastes, gels, rinses Neutral
considerations, the use of neutral sodium
APF (Rx) paste/gel
5.1-5.6
fluoride products would be indicated.
Acidulated phosphate fluoride rinses 4
Alcohol content
While not a consideration for in-office topical fluorides or systemic fluoride, home-use
fluoride rinses are available with an alcohol content range of 0 – 21.6%. Alcohol-containing rinses can result in irritation in some patients, and a drying sensation in patients
with xerostomia, and should not be used by alcoholics or patients sensitive to alcohol.46
Rinses containing alcohol are generally not advised for use in children. The alcohol
content of rinses can be found on the label, under the inactive ingredients.
Extrinsic staining
The potential for extrinsic staining of teeth is greater in patients with poor oral hygiene,
smokers, red wine, tea and coffee drinkers, and with the use of stannous fluoride products. The staining propensity of products varies with formulation and can generally be
controlled provided the patient performs excellent oral hygiene.
Patient preferences and convenience
Patient preference and convenience play important roles in the selection of home-use products,
especially where patient compliance plays a key role. The fluoride selected must be acceptable
to the patient, with pleasant taste, texture, smell and vehicle. Patient compliance must be considered with respect to frequency and regularity of use, ease of use, and length of application.
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Home-use fluorides
Home-use fluorides include fluoride dentifrices as well as over-the-counter and prescription
gels, pastes, and rinses.
Fluoride dentifrices
The majority of over-the-counter dentifrices available in the United States and Canada
contain 1,000 – 1,100 ppm fluoride, available as sodium fluoride, sodium monofluorophosphate and stannous fluoride, and have been found to be effective with these
formulations. (Table 10)
Table 10. 1,000 – 1,100 ppm fluoride dentifrices
0.23 – 0.24% sodium fluoride
0.76% sodium monofluorophosphate
0.4% stannous fluoride
Use of fluoride dentifrice twice daily provides a regular supply of fluoride that results
in the presence of low levels of fluoride intra-orally on the teeth and soft tissues. It is
recommended to commence use of a fluoride dentifrice in children at age 2, using only
a pea-sized amount twice daily from the age of 2 and until reaching 6 years of age (due
to the risk of fluorosis with excess ingestion). Children under the age of 6 should always
be supervised while brushing (and may require supervision until 10 - 11 years of age),
and they should expectorate and rinse after brushing with fluoride dentifrices. Extensive
numbers of clinical trials on fluoride dentifrices have been conducted, documenting their
anti-caries efficacy. There is strong evidence supporting their use, based on reviews by
Twetman and by Topping and Assaf.47,48
Use of fluoride dentifrice twice daily provides a regular supply
of fluoride that results in the presence of low levels of
fluoride intra-orally on the teeth and soft tissues.
Clinical efficacy
The number of clinical trials conducted using fluoride dentifrices is extensive, with
clinical trials conducted throughout the world. These have demonstrated a substantial
anti-caries benefit with the use of fluoride dentifrices. Early studies were conducted
in urban and rural communities, in both cases demonstrating a substantial decline in
caries with the use of fluoride dentifrices.49 In one meta-analysis of 70 such trials that
were conducted in children age 16 and under, in controlled, blinded conditions, an
average reduction of 24% in DMFS was found (21% – 28%) across the studies, and
varying with caries risk levels. This caries reduction benefit was found in subjects in
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fluoridated and non-fluoridated areas, with a greater caries reduction in higher risk
individuals.50 Caries efficacy with use of fluoride dentifrices has been demonstrated
for children, adults, coronal and root caries. A root caries reduction (DFS) of 67%
was found in a one-year study with fluoride dentifrice.51 A recent study also found the
addition of calcium and phosphate to a fluoride dentifrice resulted in an incremental
reduction in root caries compared to the control fluoride dentifrice.52 A dose-response
has also been found, with higher fluoride level dentifrices conferring greater anti-caries
benefits than lower fluoride level dentifrices.53, 54 Supervised daily brushing with fluoride dentifrice in school programs has also been found to be a successful methodology
for the control of caries in school-age populations, including in high-risk children.55,56,57
Extensive numbers of clinical trials on fluoride dentifrices have been
conducted, documenting their excellent anti-caries efficacy.
Prescription pastes/gels
Prescription home-use 1.1% sodium fluoride, equivalent to 5,000 ppm fluoride, is available as pastes containing a mild abrasive and as gels/liquids containing no abrasive.
These can also be used in mouth trays for extended at-home application. Use of 1.1%
sodium fluoride gel in trays has been found to be effective as a caries preventive in
head and neck radiation (high-risk) patients suffering from xerostomia.58 Patients using
5,000 ppm fluoride gels and paste should expectorate after using them, without rinsing
with water.
Prescription pastes and gels are:
• Formulations containing 5,000 ppm fluoride
• Typically applied as brush-on pastes and gels
• Typically used in place of regular dentifrice
• Also available in an acidulated version (APF) targeting orthodontic patients.
In a small study on available fluoride in proximal saliva and plaque following use
of 5,000 ppm paste, it was found that rinsing after brushing with the paste reduced
the available fluoride 2.4-fold compared to expectorating only, underscoring the
importance of following the instructions to expectorate only when using these prescription products.59
Clinical efficacy
Use of 5,000 ppm fluoride has been found to be effective in reducing root caries. An
early study by De Paola et al. demonstrated a 91% rate of arrestment for root caries lesions following one year of use of 1.1% sodium fluoride gel in trays.60 A second study by
Baysan et al. demonstrated 57% remineralization of root caries lesions over a six-month
period of use of 5,000 ppm fluoride dentifrice.61
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Fluoride rinses
Prescription and OTC fluoride rinses are available, variously utilizing sodium fluoride,
acidulated phosphate fluoride and stannous fluoride. A dose-response relationship has
been observed, with higher ppm fluoride rinses incrementally increasing the plaque
and salivary fluoride levels.62 A separate 24-hour study by Zero et al. found that nighttime fluoride use resulted in extended fluoride retention in whole saliva.63
Prescription rinse: 0.2% sodium fluoride rinse
Prescription fluoride rinses are available as 0.2% sodium fluoride, equivalent to 920
ppm fluoride. These are intended for weekly use and have been used in children
over the age of six and in adults as caries preventives. Due to risk of ingestion, 0.2%
sodium fluoride rinse is not intended for use in children under the age of six. The anticaries efficacy of weekly rinsing with 0.2% sodium fluoride has been demonstrated in
numerous studies.
Clinical support
Heifetz et al. found significant reductions in caries in children using 0.2% sodium fluoride rinse.64 In a study by Driscoll et al., caries reduction of up to 55% was demonstrated in schoolchildren rinsing once weekly at school during a 30-month period.65 Seven
years of rinsing weekly with 0.2% sodium fluoride rinse resulted in a 57.8% reduction in
caries in the permanent dentition in another study. It was also concluded, however, that
other factors contributed to the reductions, since reduced caries in the primary dentition
was found that pre-dated rinsing.66
The anti-caries efficacy of weekly rinsing with 0.2% sodium fluoride
has been demonstrated in numerous studies.
Over-the-counter rinses
0.05% sodium fluoride rinse
Similar to the daily use of toothpaste, daily sodium fluoride rinsing has been shown in
vivo to elevate salivary fluoride levels and plaque fluoride levels, an effect that disappears after ceasing to rinse daily. Children age 6 and over can use 0.05% sodium
fluoride rinse daily; it is not recommended for use in children under age 6 due to the
risk of ingestion.
Clinical support
Significant caries reductions have been observed with daily rinsing with 0.05% sodium
fluoride in subjects living in areas with up to 0.3 ppm fluoride in the water.64 In his
assessment, Ripa cited a 31% reduction in caries in non-fluoridated communities.67 A
48-month study in an urban geriatric population compared the use of placebo rinse,
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0.05% sodium fluoride mouth rinse and APF gel twice per year plus placebo rinse. It
was found that reductions in new lesions were statistically similar for the combination
of APF gel plus placebo rinse and for 0.05% sodium fluoride rinse alone, while the
reversal of lesions was greatest using the fluoride rinse.68 A more recent study assessed
arrestment of smooth-surface carious lesions in 11 – 15-year olds with use of 0.05%
sodium fluoride rinse once daily, finding an arrestment rate of 84.4%.69 Geiger et al.
found reductions in white spot lesions (orthodontic decalcifications) following use of
0.05% sodium fluoride rinse during orthodontic treatment. While compliance issues in
this study resulted in only 13% rinsing daily with the mouth rinse, a significant reduction
in white spot lesions was found and correlated to the frequency of rinsing (daily as
recommended versus less frequently).70 In reviewing the Cochrane Database clinical
trials that addressed reductions in white spot lesions during fixed orthodontic appliance
therapy, Benson et al. concluded that rinsing daily with 0.05% sodium fluoride rinse
reduced the severity of enamel lesions adjacent to fixed appliances.71
The anti-caries efficacy of daily rinsing with 0.05% sodium fluoride
has been demonstrated in numerous studies.
0.02% sodium fluoride rinse
Sodium fluoride rinses are available at 0.02% concentrations in the United States and
Canada. These rinses should be used twice daily, given the lower concentration of fluoride, and are recommended for use in children age 6 and over. In vitro fluoride uptake
studies using 0.02% sodium fluoride rinse have shown superior fluoride uptake. No clinical trials have been published using this rinse.
Acidulated phosphate fluoride/sodium fluoride rinses
Acidulated phosphate (sodium) fluoride rinses are available in 0.044% and 0.021% concentrations, both available over-the-counter. These are also intended for use in children age
6 and older and in adults. 0.044% acidulated phosphate fluoride has been recommended
mainly for orthodontic patients, and its daily use is clinically supported. 0.021% acidulated
sodium fluoride is available for twice daily rinsing.
Clinical efficacy
One early study (1978) showed that 0.044% acidulated phosphate fluoride rinse
reduced the development of white spots in orthodontic patients by up to 58%.72
Stannous fluoride rinses
Stannous fluoride rinses at a concentration of 0.63% are available as prescription rinses,
and they are then diluted to provide a 0.1% rinse. This was shown in an early study to
be effective in reducing caries and inhibiting bacterial metabolism.73
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Table 11. Clinical support for fluoride rinses and for 5,000 ppm fluoride gel/paste
Study
Caries reduction
de Paola et al.
Root caries, 1-year
study
91% arrestment of root caries
lesions
Baysan et al.
Root caries, 6-month
study
57% remineralization of root
caries lesions
Driscoll et al.
Schoolchildren, weekly
rinsing, 30-month
Up to 55% reduction
Leverett et al.
Weekly rinsing,
7 years
57.8% reduction permanent
dentition
Ripa
Coronal caries
31% caries reduction
Wallace et al.
Root caries
Up to 71% reduction
Heifetz et al.
Coronal caries children
Up to 40% reduction
(permanent dentition)
Duarte et al.
Smooth surface, 11-15
year olds
84.4% arrestment of carious
lesions
Orthodontic patients
Up to 58% reduced
development of white spots
5,000 ppm (Rx) sodium fluoride
0.2% (Rx) sodium fluoride rinse
0.05% sodium fluoride rinse
0.044% APF rinse
Hirschfield et al.
Biofilm, rinsing and
intra-oral fluoride
Fluoride dentifrice use has greatly contributed to caries reductions for several decades and
continues to provide anti-caries benefits. The presence of moderate amounts of biofilm does
not deter fluoride from reaching the tooth surface, and fluoride has been shown to penetrate
through and concentrate in light biofilm layers, increasing the retention of intra-oral fluoride. 74
Fluoride dentifrice use has greatly contributed to caries reductions for
several decades.
Considerations include the assessed compliance of the individual patient with appropriate brushing and use of a fluoride dentifrice, as well as his or her risk level. Noncompliant patients may brush inadequately or brush for an inadequate length of time,75
reducing the effectiveness of brushing and exposure to fluoride toothpaste. Post-brushing
rinsing, which is standard practice for most patients, also removes fluoride that was
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just delivered by the dentifrice and reduces the amount of intra-oral available fluoride.
Although no controlled clinical trials are available on its impact, post-brushing rinsing has
been shown to reduce the level of intra-oral bioavailable fluoride.76
Post-brushing rinsing has been shown to reduce the level
of intra-oral bioavailable fluoride.
Zamataro et al. found a 250% reduction in intra-oral bioavailable fluoride as a
result of rinsing with 15 ml of water after use of a standard dentifrice containing 1,100
ppm fluoride.76 Adjunctive use of fluoride rinses has been advocated for moderate- and
high-risk patients, together with routine oral hygiene procedures, to increase the amount of
available fluoride and increase protection against caries.77,78 Increasing the flow rate of
fluoride rinse has also been suggested as a possible mechanism to increase the amount of
fluoride penetrating biofilm.79
Adjunctive use of fluoride rinses has been advocated for moderateand high-risk patients.
Summary
Successful fluoride preventive interventions began with the use of fluoridated water and
fluoride dentifrices, and now include the use of professional topical fluorides as well as
prescription pastes, gels and rinse and over-the-counter rinses. The individual patient’s risk
level and age, and the product’s efficacy, clinical support and safety must be considered
when determining the appropriate combination of preventives. Other factors to consider
include clinician and patient preferences and the specifics of a given formulation. The use
of fluorides has contributed greatly to reducing the level of caries seen in the population
and continues to do so.
Author Profiles
Fiona M. Collins, BDS, MBA, MA
Dr. Collins earned her dental degree from Glasgow University and holds an MBA and MA from
Boston University. She is a member of the American Dental Association and the Organization for
Asepsis and Safety Procedures.
Michael Florman, DDS
Dr. Florman received his dental degree from Ohio State University and completed his orthodontic
post graduate training at New York University. He is a member of the American Dental Association,
California Dental Association, and the American Association of Orthodontists.
Disclaimer
The authors of this course have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.
Reader Feedback
We encourage your comments on this or any PennWell course.
For your convenience, an online feedback form is available at www.ineedce.com.
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19
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Questions
1. Fluoride has been used in the United
States as an anti-caries agent since the
________.
a.
b.
c.
d.
1930s
1940s
1950s
none of the above
2. _________ an intentional source of
systemic fluoride.
a.
b.
c.
d.
Fluoridated water is
Fluoride supplements are
Fluoridated salt is
all of the above
3. The use of fluoride supplements by
pregnant women does not result in any
benefit for the baby.
a. True
b. False
4. The Centers for Disease Control and
Prevention (CDC) suggests that fluoride
supplements be given to children living in
areas with suboptimal water fluoridation
who are at high risk of caries.
a. True
b. False
5. During tooth development, the
cumulative ingestion of fluoride prior to
pre-eruptive enamel maturation results in
________.
a.
b.
c.
d.
fluoride ions replacing hydroxyl ions
iodide ions replacing hydroxyl ions
the formation of fluorapatite crystals
a and c
6. Pre-eruptively, formed enamel is bathed in
plasma that contains fluoride and contributes to the outer fluoride-rich layer.
a. True
b. False
7. Inadvertent ingestion of excessive
amounts of fluoride during enamel
development, from all sources combined,
can result in fluorosis and is dependent on
________.
a. the dose of fluoride
b. the age of the child when excessive fluoride
ingestion occurred
c. the duration of excessive fluoride ingestion
d. all of the above
8. Topical fluorides available include
________.
a.
b.
c.
d.
sodium fluoride and sodium monofluorophosphate
acidulated phosphate fluoride
stannous fluoride
all of the above
9. During acid attacks, subsurface dissolution occurs at pH 3.8 – 4.8.
a. True
b. False
10. Disease progression is more rapid in
dentin than in enamel.
a. True
b. False
11. The anti-caries benefit derived from
topical fluorides can be attributed primarily to the prevention of demineralization
and the promotion of remineralization. a. True
b. False
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12. The application of high concentrations
of topical fluoride results in _________.
a. the formation of alkali-insoluble calcium fluoridelike globules at the tooth surface
b. the formation of alkali-soluble calcium fluoride-like
globules at the tooth surface
c. the formation of acid-insoluble calcium fluoridelike globules at the tooth surface
d. none of the above
13. Topical fluorides result in the retention
of fluoride _________.
a.
b.
c.
d.
on the tooth surface
in saliva and dental plaque
on intra-oral soft tissues
all of the above
14. Topical fluoride is believed to inhibit caries activity through bacterial inhibition,
in addition to inhibiting demineralization
and aiding remineralization.
a. True
b. False
15. Most of the topical effect of fluoride is
due to the presence of available fluoride
rather than the influence of fluoride
uptake during fluoride therapy (in-office
or home-use).
a. True
b. False
16. Omitting plaque removal with a professional prophylaxis prior to the use of
in-office topical fluorides has been found
to _________.
a. result in no calcium fluoride-like globules being
formed at the tooth surface b. increase fluoride retention and the efficacy of
fluoride therapy
c. decrease the efficacy of fluoride therapy
d. a and c
17. The vast majority of clinical trials,
evidence-based studies and the major
use worldwide of fluoride varnish is as an
in-office topical fluoride for _________.
a.
b.
c.
d.
the prevention of dental caries
the relief of hypersensitivity
cavity linings
none of the above
18. Five percent sodium fluoride varnish
has been found to be effective in reducing
caries in _________.
a.
b.
c.
d.
the primary dentition
the permanent dentition
patients with root caries
all of the above
19. In a meta-analysis of fluoride gels, a
caries reduction average of 21% was
found (range of 14 – 28%) across 14
placebo-controlled studies.
a. True
b. False
20. The ADA does not recommend or
endorse the use of one-minute gels, does
not recommend the use of fluoride foams
due to the paucity of clinical evidence,
and does not recommend the use of
in-office fluoride rinses.
a. True
b. False
21. In addition to the ADA recommendations for professional fluorides, professional judgment, efficacy and safety,
and other considerations contribute to
the selection of in-office and home-use
fluorides.
a. True
b. False
22. The number of clinical trials conducted
worldwide using fluoride dentifrices is
extensive, and these have demonstrated a
substantial anti-caries benefit with the use
of fluoride dentifrices.
a. True
b. False
23. Use of 5,000 ppm fluoride prescription
paste/gel has been found to be effective in
reducing root caries.
a. True
b. False
24. The anticaries efficacy of weekly rinsing
with 0.2% sodium fluoride has been
demonstrated in numerous studies.
a. True
b. False
25. The anticaries efficacy of daily rinsing
with 0.05% sodium fluoride has been
demonstrated in numerous studies.
a. True
b. False
26. Sodium fluoride rinses are available at
0.02% concentrations in the United States
and Canada, and these rinses _________.
a. should be used twice daily given the lower
concentration of fluoride
b. have published clinical trials
c. as with 0.05% fluoride rinse, are recommended for
use in children age 6 and over
d. a and c
27. Patient preference and convenience play
important roles in the selection of homeuse products, especially where patient
compliance plays a key role.
a. True
b. False
28. Post-brushing rinsing has been shown to
reduce the level of intra-oral bioavailable
fluoride.
a. True
b. False
29. Adjunctive use of fluoride rinses has
been advocated for _________ patients,
together with routine oral hygiene
procedures, to increase the amount of
available fluoride and increase protection
against caries.
a.
b.
c.
d.
low risk
moderate risk
high risk
b and c
30. The individual patient’s risk level and
age, and the product’s efficacy, clinical
support and safety must be considered
when determining the appropriate
combination of preventives.
a. True
b. False
www.ineedce.com
ANSWER SHEET
Fluoride Guide
Name:
Title:
Address:
E-mail:
City:
State:
Telephone: Home (
)
Office (
Specialty:
ZIP:
)
Country:
Lic. Renewal Date:
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822
If not taking online, mail completed answer sheet to
Educational Objectives
Academy of Dental Therapeutics and Stomatology,
A Division of PennWell Corp.
1. List intentional and unintentional sources of systemic fluoride.
P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
2. List and describe caries risk factors and the ADA recommendations for in-office topical fluorides corresponding to
different risk levels.
For immediate results,
go to www.ineedce.com to take tests online.
Answer sheets can be faxed with credit card payment to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.
3. List and describe the considerations involved in selecting in-office and home use topical fluorides.
4 List and describe the various home use topical fluorides available and the clinical efficacy of each.
Course Evaluation
P ayment of $59.00 is enclosed.
(Checks and credit cards are accepted.)
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.
1. Were the individual course objectives met?
Objective #1: Yes No
Objective #3: Yes No
Objective #2: Yes No
Objective #4: Yes No
If paying by credit card, please complete the
following:
MC
Visa
AmEx
Discover
Acct. Number: _______________________________
2. To what extent were the course objectives accomplished overall?
5
4
3
2
1
0
3. Please rate your personal mastery of the course objectives. 5
4
3
2
1
0
4. How would you rate the objectives and educational methods?
5
4
3
2
1
0
5. How do you rate the author’s grasp of the topic? 5
4
3
2
1
0
6. Please rate the instructor’s effectiveness. 5
4
3
2
1
0
7. Was the overall administration of the course effective?
5
4
3
2
1
0
8. Do you feel that the references were adequate? Yes
No
Yes
No
9. Would you participate in a similar program on a different topic?
Exp. Date: _____________________
Charges on your statement will show up as PennWell
10. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________
11. Was there any subject matter you found confusing? Please describe.
___________________________________________________________________
___________________________________________________________________
12. What additional continuing dental education topics would you like to see?
___________________________________________________________________
___________________________________________________________________
AGD Code 258
PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
AUTHOR DISCLAIMER
The author(s) of this course has/have no commercial ties with the sponsors or the providers of
the unrestricted educational grant for this course.
SPONSOR/PROVIDER
This course was made possible through an unrestricted educational grant. No
manufacturer or third party has had any input into the development of course content.
All content has been derived from references listed, and or the opinions of clinicians.
Please direct all questions pertaining to PennWell or the administration of this course to
Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or [email protected].
COURSE EVALUATION and PARTICIPANT FEEDBACK
We encourage participant feedback pertaining to all courses. Please be sure to complete the
survey included with the course. Please e-mail all questions to: [email protected].
www.ineedce.com
INSTRUCTIONS
All questions should have only one answer. Grading of this examination is done
manually. Participants will receive confirmation of passing by receipt of a verification
form. Verification forms will be mailed within two weeks after taking an examination.
EDUCATIONAL DISCLAIMER
The opinions of efficacy or perceived value of any products or companies mentioned
in this course and expressed herein are those of the author(s) of the course and do not
necessarily reflect those of PennWell.
Completing a single continuing education course does not provide enough information
to give the participant the feeling that s/he is an expert in the field related to the course
topic. It is a combination of many educational courses and clinical experience that
allows the participant to develop skills and expertise.
COURSE CREDITS/COST
All participants scoring at least 70% (answering 21 or more questions correctly) on the
examination will receive a verification form verifying 4 CE credits. The formal continuing
education program of this sponsor is accepted by the AGD for Fellowship/Mastership
credit. Please contact PennWell for current term of acceptance. Participants are urged to
contact their state dental boards for continuing education requirements. PennWell is a
California Provider. The California Provider number is 4527. The cost for courses ranges
from $49.00 to $110.00.
Many PennWell self-study courses have been approved by the Dental Assisting National
Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet
DANB’s annual continuing education requirements. To find out if this course or any other
PennWell course has been approved by DANB, please contact DANB’s Recertification
Department at 1-800-FOR-DANB, ext. 445.
Customer Service 216.398.7822
RECORD KEEPING
PennWell maintains records of your successful completion of any exam. Please contact our
offices for a copy of your continuing education credits report. This report, which will list
all credits earned to date, will be generated and mailed to you within five business days
of receipt.
CANCELLATION/REFUND POLICY
Any participant who is not 100% satisfied with this course can request a full refund by
contacting PennWell in writing.
© 2010 by the Academy of Dental Therapeutics and Stomatology, a division
of PennWell
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