both. There are many different brands to suit all tastes. Child formulations contain up
to 550 ppm fluoride to limit fluoride ingestion and therefore reduce the risk of
fluorosis. There are limited studies on the efficacy of child formulations on caries. A
systematic review of low fluoride toothpastes showed a reduced efficacy of 250 ppm
fluoride in comparison to 1000 ppm fluoride. Therefore, it is advisable to recommend
toothpastes for children containing at least 500 ppm fluoride to ensure caries
preventive efficacy. It is sometimes difficult to decide which concentration of fluoride
toothpaste is to be recommended to parents for their children. There is a balance
between caries-risk and fluorosis-risk. If the child is caries-free, low fluoride (500
ppm F) children's pastes can be recommended to minimize the risk of fluorosis.
However, if a young child under 6 years presents with caries, a fluoride toothpaste of
at least 1000 ppm is indicated as these have been proven to be more efficacious for
caries prevention.
Fluoride gels
These can be applied in trays or by brush and 26% caries reductions have been
reported. They are high in fluoride (1.23% = 12,300 ppm) for professional use and
lower (1000 ppm) for home use. There is a risk of toxicity with the high fluoride
containing gels and the following safety recommendations should be followed:
(1) no more than 2 ml per tray;
(2) sit patient upright with head inclined forward;
(3) use a saliva ejector;
(4) instruct the patient to spit out for 30 s after the procedure (usually 4 mins but
newer types are for 1 min).
(5) Do not use for children under 6 years.
Home use gels contain 1000-5000 ppm fluoride for use by patients at home at bedtime
in addition to toothbrushing. Thirty-six percent caries reductions have been reported.
Fluoride mouth rinses
These can be either daily rinses containing 0.05% (225 ppm) or weekly rinses 0.20%
(900 ppm) of sodium fluoride. It is best to advise patients to use their fluoride rinses
at a different time to toothbrushing so that the number of fluoride exposures increases.
Caries reductions of 20-50% have been reported for fluoride rinse studies. The effect
of toothbrushing and rinsing with fluoride has been shown to be additive. All
orthodontic patients should be using a daily fluoride rinse to minimize the risk of
demineralization and white spot lesions. Children under the age of 6 years should not
be recommended to use fluoride mouth rinses due to the increased risk of swallowing
the product.
Varnishes
Duraphat 5% by wt fluoride = 22,600 ppm fluoride is the main fluoride varnish. This
has a very high fluoride concentration. It is supplied in a small tube, but used lavishly
by most dentists as if it were toothpaste. Again there is the possibility of toxicity with
young children. It should be used sparingly with a cotton bud, a small pea-size
amount is sufficient for a full mouth application in children up to 6 years. Caries