Fluoride Guide - IneedCE.com

Fluoride 

Guide 

Earn 

3 CE credits 

This course was 

written for dentists, 

dental hygienists, 

and assistants. 

Written by Fiona M. Collins, BDS, MBA, MA 

and Michael Florman, DDS 

$49.00 

www.ineedce.com 1

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. 

2 www.ineedce.com

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 months 3,4 (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 caries 5 

• 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 


Figure 1. Crystal formation and fluoride substitution 

Hydroxyapatite 

Ca ++ 

O – 

– O P O – 

OHCa ++ O 

Substitution 

of fluoride 

Fluorapatite 

Ca ++ 

O – 

– 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 attacks 10 

• 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 mild 12 

• 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. 


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) 


Figure 2. Caries process: demineralization and remineralization 

pH 

Demineralization 

pH 

Remineralization 

Ca ++ 

PO 4 

PO 4 

Ca ++ PO 4 

Acid Attack 

Ca ++ 

Ca ++ PO 4 

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 ++ 

PO 4 

+ 

Ca ++ 

PO 4 

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 


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- 

F- 

Ca ++ PO 4 

PO 4 

F- 

Acid Attack 

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. 


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 22,600 ppm 

APF gels and foams 

12,300 ppm 

Sodium fluoride gels and foams 9,050 ppm 

Dual rinses 

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 


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 

Study 

Caries reduction 

Marinho et al. Meta-analysis 33% dmfs reduction (19% to 48%) 

46% DMFS reduction ( 30% to 63%) 

Helfenstein, Steiner Meta-analysis 38% reduction 

Holm et al. 36 Pre-school children 44% dmft reduction 

Weinstein et al. Early childhood caries 51% reversal of enamel decalcification 

(open study) 

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. 


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 

Study 


Marinho et al. Meta-analysis (gel) 21% DMFS reduction 

(14% to 28%) 

Marinho et al. Systematic review (gel) 28% DMFS reduction 

(19% to 37%) 

v Rijkom et al. Systematic review (gel) 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 


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 

< 6 years of age No incipient/cavitated carious 

lesions during the last 3 years 

At least one risk factor 

6+ years of age one/two incipient/cavitated 

lesions in last 3 years 

and/or at least one risk factor 

High risk 

Any incipient/cavitated lesions 

in last 3 years and/or multiple 

risk factors 

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) 


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 



Fluoride varnish or gel 




18+ years 

of age 







* 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 

Poor oral hygiene 

Familial high caries rate 

Enamel defects 

Tobacco use 

Exposed roots 

Low SES 

Xerostomia 

High bacterial load 

High frequency sugar and other carbohydrate 

consumption 

Defective restorations 

Drug or alcohol abuse 

Orthodontic appliances 

Inability to perform adequate oral hygiene 

Protective factors 

Optimal fluoride exposure 

Use of xylitol 

High salivary flow 

Use of antimicrobials 

Home use of Recaldent-containing products 

Clinical examples 

Clinical examples of at-risk and high-risk patients can be found below. 

a. Patient with early childhood caries b. Orthodontic patient c. Patient with exposed roots 

Courtesy of Dr. N. Sue Seale Courtesy of Dr. Michael Florman Courtesy of Dr. Scott Froum 


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 

glass ionomers. 43,44 Table 9. pH of fluoride products 

In addition, acidulated 

Product 

pH 

phosphate alters the surface of titanium 

1.23% APF gel, foam 3-4 

alloys, therefore caution is advised with respect 

Sodium fluoride varnish, gel, foam 

to use of these formulations in implant 

patients. 45 In patients for whom these are 

considerations, the use of neutral sodium 

fluoride products would be indicated. 

NaF and MFP dentifrices 

0.4% stannous dentifrice 

Sodium fluoride pastes, gels, rinses 

2.8-4 

Neutral 

Neutral 

Neutral 

APF (Rx) paste/gel 5.1-5.6 

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. 


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. 


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 


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 


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 


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, 


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. 


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. 


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 


Table 11. Clinical support for fluoride rinses and for 5,000 ppm fluoride gel/paste 

5,000 ppm (Rx) sodium fluoride 

de Paola et al. 

Baysan et al. 

0.2% (Rx) sodium fluoride rinse 

Driscoll et al. 

Leverett et al. 

Study 

Root caries, 1-year 

study 

Root caries, 6-month 

study 

Schoolchildren, weekly 

rinsing, 30-month 

Weekly rinsing, 

7 years 


91% arrestment of root caries 

lesions 

57% remineralization of root 

caries lesions 

Up to 55% reduction 

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 

0.044% APF rinse 

84.4% arrestment of carious 

lesions 

Hirschfield et al. Orthodontic patients Up to 58% reduced 

development of white spots 

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 


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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Questions 

1. Fluoride has been used in the United 

States as an anti-caries agent since the 

________. 

a. 1930s 

b. 1940s 

c. 1950s 

d. none of the above 

2. _________ an intentional source of 

systemic fluoride. 

a. Fluoridated water is 

b. Fluoride supplements are 

c. Fluoridated salt is 

d. all of the above 

3. The use of fluoride supplements by 

pregnant women _________. 

a. results in no benefit for the baby 

b. results in a moderate benefit for the baby 

c. results in a moderate benefit for the mother and the 

baby 

d. results in a great benefit for the baby and a moderate 

benefit for the mother 

4. The Centers for Disease Control and 

Prevention (CDC) suggests that fluoride 

supplements be given to children living in 

areas with _________. 

a. suboptimal water fluoridation who are at low risk of 

caries 

b. suboptimal water fluoridation who are at moderate 

risk of caries 

c. suboptimal water fluoridation who are at high risk 

of caries 


5. Current recommendations are to start 

fluoride supplements, if required, at 

_________. 

a. birth 

b. 3 months 

c. 6 months 

d. 12 months 

6. The recommended fluoride supplement 

dose for a child age 6-16 years living in an 

area with 0.3 ppm – 0.6 ppm fluoride in 

the water is _________. 

a. 0.25 mg per day 

b. 0.5 mg per day 

c. 0.75 mg per day 

d. 1 mg per day 

7. During tooth development, the 

cumulative ingestion of fluoride prior to 

pre-eruptive enamel maturation results in 

________. 

a. fluoride ions replacing hydroxyl ions 

b. iodide ions replacing hydroxyl ions 

c. the formation of fluorapatite crystals 

d. a and c 

8. Pre-eruptively, formed enamel is bathed 

in plasma that contains fluoride and 

contributes to the _________. 

a. outer fluoride-rich layer 

b. inner fluoride-rich layer 

c. inner and outer fluoride-rich layers 


9. Fluorapatite crystals formed during tooth 

development are _________. 

a. smaller than hydroxyapatite crystals 

b. stronger than hydroxyapatite crystals 

c. more resistant to demineralization associated with 

the dental caries process 


10. Systemic fluoride use during tooth 

development results in a concentration of 

fluoride of _________ in the outer layer of 

the enamel. 

a. 250 – 500 ppm 

b. 500 – 1,000 ppm 

c. 1,000 – 2,000 ppm 


11. 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 excessive fluoride 

b. the age of the child when excessive fluoride 

ingestion occurred 

c. the duration of excessive fluoride ingestion 


12. Topical fluorides available in the United 

States include ________. 

a. sodium fluoride and sodium monofluorophosphate 

b. acidulated phosphate fluoride 

c. stannous fluoride 


13. Topical fluorides act intra-orally by 

________. 

a. providing periodic high doses of fluoride (in-office) 

b. providing low regular doses of fluoride (home-use) 

c. providing low periodic doses of fluoride (in-office) 

d. a and b 

14. During acid attacks, subsurface dissolution 

occurs at ________. 

a. pH 1.8 - 2.8 

b. pH 2.8 - 3.8 

c. pH 3.8 - 4.8 

d. pH 4.8 - 5.8 

15. The intra-oral pH rebounds approximately________ 

after an acid attack. 

a. 15 minutes 

b. 30 minutes 

c. 45 minutes 

d. 60 minutes 

16. Disease progression is more rapid in 

dentin than in enamel due to ________. 

a. the presence of tubules 

b. the presence of pulpal tissue 

c. the degradation of collagen fibrils 


17. The application of high concentrations 

of topical fluoride results in the formation 

of ________ at the tooth surface. 

a. acid-soluble calcium phosphate-like globules 

b. alkali-soluble calcium phosphate-like globules 

c. acid-soluble calcium fluoride-like globules 

d. alkali-soluble calcium fluoride-like globules 

18. Topical fluoride is believed to inhibit 

caries activity through _________. 

a. bacterial inhibition 

b. inhibition of demineralization 

c. promotion of remineralization 


19. Topical fluorides result in the retention 

of fluoride _________. 

a. on the tooth surface 

b. in saliva and dental plaque 

c. on intra-oral soft tissues 


20. Inhibition of the enzyme _________ impacts 

the ability of bacteria to metabolize 

fermentable carbohydrates. 

a. amelase 

b. enolase 

c. dentolase 


21. Most of the topical effect of fluoride is 

due to _________. 

a. the presence of available fluoride 

b. the influence of fluoride uptake during in-office 

fluoride therapy 

c. the influence of fluoride uptake during home-use 



22. 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 


c. decrease the efficacy of fluoride therapy 

d. a and c 

23. Available in-office topical fluorides 

range from _________. 

a. 2,500 ppm – 20,000 ppm fluoride 

b. 3,300 ppm – 21,600 ppm fluoride 

c. 3,300 ppm – 22,600 ppm fluoride 

d. 9,500 ppm – 22,600 ppm fluoride 

24. The vast majority of clinical trials, 

evidence-based studies and the major use 

worldwide of fluoride varnish are as an 

in-office topical fluoride for _________. 

a. the prevention of dental caries 

b. the relief of hypersensitivity 

c. cavity linings 


25. Five percent sodium fluoride varnish 

has been found to be effective in reducing 

caries in _________. 

a. the primary dentition 

b. the permanent dentition 

c. patients with root caries 


26. Clinicians have found the use of fluoride 

varnish unit doses _________. 

a. simplifies application 

b. results in the use of a defined amount of varnish 

c. reduces any risk of cross-contamination 



Questions (continued) 

27. One meta-analysis by Marinho et al. 

found an overall caries reduction in the 

primary dentition of _________ and 

_________ in the permanent dentition. 

a. 23%; 26% 

b. 28%; 36% 

c. 33%; 46% 

d. 38%; 56% 

28. Acidulated phosphate fluoride (APF) 

gels and foams contain _________ ppm 

fluoride,and neutral sodium fluoride gels 

contain approximately _________ ppm 

fluoride. 

a. 9,000; 12,300 

b. 9,000; 22,600 

c. 12,300; 9,000 

d. 12,300; 22,600 

29. In a meta-analysis of fluoride gels, a 

caries reduction average of _________ 

was found across 14 placebo-controlled 

studies. 

a. 15% 

b. 21% 

c. 25% 

d. 31% 

30. The ADA recommends the use of 

_________. 

a. one-minute gels 

b. four-minute gels 

c. fluoride varnish 

d. b and c 

31. In addition to the ADA recommendations 

for professional fluorides, _________ 

contributes to the selection of in-office 

and home-use fluorides. 

a. professional judgment 

b. product efficacy and safety 

c. other considerations 


32. A patient 6 years of age or older with 

one/two incipient/cavitated lesions in the 

previous 3 years and/or at least one risk 

factor would be defined as _________. 

a. low risk 

b. moderate risk 

c. high risk 


33. _________ is a protective factor against 

caries. 

a. Use of xylitol 

b. Use of antimicrobials 

c. Optimal fluoride exposure 


34. Alcohol-containing rinses _________. 

a. can result in irritation in some patients 

b. can result in a drying sensation in patients with 

xerostomia 

c. should not be used by alcoholics 


35. It is recommended to commence use 

of a fluoride dentifrice in children at 

_________. 

a. 6 months of age 

b. 1 year of age 

c. 18 months of age 

d. 2 years of age 

36. In one meta-analysis of 70 dentifrice 

trials conducted in children age 16 and 

under, an average reduction of _________ 

in DMFS was found. 

a. 19% 

b. 24% 

c. 29% 

d. 34% 

37. One study of 5,000 ppm fluoride 

prescription paste/gel found a _________ 

of root caries. 

a. 37% remineralization 

b. 47% remineralization 

c. 57% remineralization 


38. A 24-hour study by _________ et al. 

found that nighttime fluoride use resulted 

in extended fluoride retention in whole 

saliva. 

a. Hero 

b. Nero 

c. Pero 

d. Zero 

39. In a study by Driscoll et al., a caries 

reduction of up to _________was 

demonstrated in schoolchildren rinsing 

once weekly at school during a 30-month 

period with 0.2% sodium fluoride. 

a. 35% 

b. 45% 

c. 55% 

d. 65% 

40. A study on the arrestment of smoothsurface 

carious lesions in 11 – 15-year 

olds, with use of 0.05% sodium fluoride 

rinse once daily, found an arrestment rate 

of _________. 

a. 74.4% 

b. 78.4% 

c. 84.4% 

d. 88.4% 

41. 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 

42. A study on daily use of 0.05% sodium 

fluoride rinse in older adults found a root 

caries reduction of up to _________. 

a. 51% 

b. 61% 

c. 71% 

d. 81% 

43. A study on daily use of 0.05% sodium 

fluoride rinse in children found a coronal 

caries reduction of up to _________. 

a. 30% 

b. 35% 

c. 40% 

d. 45% 

44. A study on daily use of 0.044% 

acidulated phosphate fluoride rinse in 

orthodontic patients found a _________ 

reduction in the development of white 

spots. 

a. 38% 

b. 48% 

c. 58% 

d. 68% 

45. The presence of moderate amounts of 

biofilm _________. 

a. deters fluoride from reaching the tooth surface 

b. repels fluoride from the biofilm 

c. increases the retention of intra-oral fluoride 


46. Post-brushing rinsing _________. 

a. reduces the level of intra-oral bioavailable fluoride 

b. removes fluoride that was just delivered by the 

dentifrice 

c. is standard practice for most patients 


47. Increasing the flow rate of fluoride 

rinse has been suggested as a possible 

mechanism to _________. 

a. increase the amount of fluoride penetrating biofilm 

b. increase the amount of fluoride penetrating the 

teeth 

c. decrease the amount of fluoride ingested 


48. 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. low risk 

b. moderate risk 

c. high risk 

d. b and c 

49. Successful fluoride preventive interventions 

include the use of_________. 

a. fluoridated water and fluoride dentifrices 

b. professional topical fluorides 

c. home use over-the-counter rinses, prescription 

pastes, gel and rinses 


50. _________must be considered when 

determining the appropriate combination 

of preventives. 

a. The individual patient’s risk level and age 

b. A product’s efficacy and clinical support 

c. A product’s safety 



ANSWER SHEET 

Fluoride Guide 

Name: Title: Specialty: 

Address: 

E-mail: 

City: State: ZIP: Country: 

Telephone: Home ( ) Office ( ) 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 3 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822 

Educational Objectives 

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. 

Course Evaluation 

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 

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. 

Payment of $49.00 is enclosed. 

(Checks and credit cards are accepted.) 

If paying by credit card, please complete the 

following: MC Visa AmEx Discover 

Acct. Number: ______________________________ 

Exp. Date: _____________________ 

Charges on your statement will show up as PennWell 

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 

9. Would you participate in a similar program on a different topic? Yes No 

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? 

___________________________________________________________________ 

___________________________________________________________________ 

If not taking online, mail completed answer sheet to 

Academy of Dental Therapeutics and Stomatology, 

A Division of PennWell Corp. 

P.O. Box 116, Chesterland, OH 44026 

or fax to: (440) 845-3447 

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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 macheleg@pennwell.com. 

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: macheleg@pennwell.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% on the examination will receive a verification 

form verifying 3 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 $39.00 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. 

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 

24 Customer Service 216.398.7822 www.ineedce.com

Fluoride Guide - IneedCE.com

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