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Debbie Seidel Bittke

Caries Risk: Fluoride Risk and Benefits

Caries Risk: Fluoride Risk and Benefits

5/16/2019 7:21:55 AM   |   Comments: 0   |   Views: 105
This is about the “F” word. I say the “F” word because there is so much controversy around the use of fluoride. Very few dental materials have created this strong of a controversy. Much of this controversy is about fluoridated water.

This blog will talk about caries risk: Fluoride risk and benefits. Part II will be posted next week and it will cover the various caries prevention products.

Questioning isn’t wrong; good research should always stand up to scrutiny or be dismissed when discovered to have incorrect, unprovable, or unreproducible data. The public is asking questions and we must provide best answers.

Water fluoridation began about 60 years ago as an experiment and the purpose were to find out if it would reduce the amount of tooth decay.

In 1959 the study concluded that fluoride in the water reduced caries in children by 55.5%.

The CDC has stated that, “Fluoride is safe and effective in preventing and controlling dental caries when used appropriately.” The American Dental Association (ADA) endorsed water fluoridation as safe and effective in the 1950s and continues to champion the impressive results.

Many caries-risk assessment tools are available to help with the decision. The ADA offers several resources to help clinicians decide how to balance the fluorosis negatives of fluoride with the anticaries positives. They advocate frequent caries risk assessment along with analysis of overall fluoride source intake. Printable caries-risk assessment forms are available online from the ADA, AAPD, and other professional and commercial websites.
Nonfluoride therapies

Nonfluoride therapies include oral xylitol and topical chlorhexidine products. Reducing sugar consumption and placing sealants are known to be the best adjunctive services to prevent tooth decay.

The ADA Journal has printed the research on Caries Assessment by Risk Management with protocols and a wealth of information to help educate our patients and this provides information to provide our patients with the best possible care.

The journal can be accessed here.

The Caries Risk Assessment Coalition meeting frequently to collaborate on the latest research on caries and the prevention of tooth decay.

The Caries Risk Assessment Tool (CRA) is also updated frequently. This is a tool that every dental practice should use to educate their patients about their risk for caries.

The most recent ADA Journal reports that an instituted early-caries-management program includes a family meeting with a registered hygienist for 30 minutes. The dental hygienist will complete a screen and provide education which includes nutrition counseling, a toothbrush prophylaxis and a fluoride varnish application.

For the past 21 years of CAMBRA existence, there is an overwhelming evidence due to the CRA tool that results in an accurate assessment of caries risk.

This also supports the creation of effective and individualized caries management plans.

To access the CRA forms please view this CDA CAMBRA Guide by the CDA Foundation and view pages 19 and 20.



Biological risk factors contribute directly to the initiation or progression of dental caries. They include an assessment of cariogenic bacteria and fermentable carbohydrates, the two required conditions for dental caries.

Additional factors such as frequency of ingestion of fermentable carbohydrates and salivary-reducing medications have been established as important.

The following are the risk factors utilized in the updated CRA form.

1. Frequent snacking on fermentable carbohydrates at least three times daily outside of meal times.

Frequent carbohydrate intake results in a prolonged acidic environment in the plaque that dissolves the tooth mineral and can act as a driving force to reinforce the overgrowth of cariogenic bacteria and the suppression of oral commensal (beneficial) bacteria, leading to future caries development.

Fermentable carbohydrates such as sucrose, fructose (high-fructose corn syrup), glucose and cooked starch are included. Fruit juice (e.g., apple juice) is an important but often overlooked source of fermentable carbohydrates among young children.

2. Use of bottle or non-spill cup containing liquids other than water or milk.

This provides a continuous ingestion of carbohydrates, such as from fruit juices, that leads to a continual acid environment in the plaque. It should be stressed that the use of milk in a bottle overnight and nursing on demand in the presence of cariogenic bacteria provide a prolonged acid challenge that increases the risk for caries and should be strongly discouraged.

3. Mother/primary caregiver or sibling has current decay or a recent history of decay.

Presence of recent decay indicates they have high levels of cariogenic bacteria, especially mutans streptococci (MS), which can be transmitted to the child. Early colonization of MS by age 3 will increase the child’s risk for developing caries.

Current or recent decay in the parent or caregiver is an important indicator of potential high caries risk for the child. This becomes more important in infants with few teeth present, where signs of additional risk factors are not yet evident and is supported by the strong correlation found in numerous studies.

4. Family has low socioeconomic/ health literacy status.

Low socioeconomic status cannot usually be changed and is not a biological contributor to the caries process. However, as a social determinant of health for many other diseases, it is one of several statistically significant factors associated with high caries risk.

Practitioners should account for a challenging family socioeconomic context in formulating a personalized caries management plan. Similarly, low health literacy is not a biological risk factor, but it is often associated with socioeconomic levels and contributes to increased risk of disease. Importantly, it is possible to educate the parent/primary caregiver regarding caries and caries prevention.

5. Use of medications that induce hyposalivation.

Hyposalivation is a side effect of some of the most commonly prescribed medications, such as those used to treat allergies, asthma, mental disorders and cancer. The risk of dry mouth increases with the number of medications prescribed.



Protective factors are environmental factors or chemical therapy that help to swing the caries balance to caries prevention or reversal. The factors included in the newly proposed CRA form are:

1. Lives in a fluoridated drinking water area.

2. Drinks fluoridated water.

The beneficial effect of drinking fluoridated water is well established.

3. Uses a fluoride-containing toothpaste at least twice daily.

The beneficial effect of brushing with fluoridated toothpaste has been well established in numerous clinical trials and is a major factor in reductions in caries over recent decades. The American Academy of Pediatric Dentistry (AAPD) recommends the use of a smear of fluoride toothpaste for ages 0 to 2 years and a pea-sized application for ages 3 to 6 years. For children aged 0 to 6 years, it is recommended that the parent/caregiver brushes the child’s teeth or supervises toothbrushing twice a day. Parent-supervised toothbrushing with fluoride toothpaste at least twice daily provides considerable added benefit greater than once daily.

4. Has had FV applied in the last six months.

The caries-reducing benefit of FV is well established, including when used in young children.

Note: Xylitol use by the caregiver is no longer listed as a protective factor in this revised CRA version
as the evidence of its antimicrobial effects to achieve caries prevention is limited for adults or children.



Next week’s blog will continue on this topic, but I will outline some of the products to prevent caries.



Information accessed on May 6, 2019


Debbie Seidel-Bittke, RDH, BS is founder and CEO of Dental Practice Solutions. Debbie is also a former dental hygiene program director. Her expertise is optimizing the hygiene department by taking a total team approach; including the doctor as the leader.

Our Dental Practice University will launch for dentists and their team on June 6, 2019.

We are looking for ten offices to test drive (Beta-test) the university. The university has training video modules, forms and scripts for each department in your dental practice.

*For our beta-testers this includes modules for the doctor(s) about creating a culture to have a lot of new patients, keep your dental team the life-time of your dental practice, as well as re-create or create your vision and mission. Doctors receive a 90-Day goal setting journal.

The hygienists have their own training video modules that cover time management, caries risk, treating the gingivitis and perio patient.

The front office has video modules on phone calls, new patient calls, we provide job descriptions and a lot of information for hiring and keeping employees long-term.

You receive 24 AGD CE Credits. Once the University is open to all dental practices around the world, it will be FREE for the first 2 weeks and then $97.00 a month indefinitely. It includes AGD CE Credits for up to 2 employees each month. Additional employees can register and get the AGD CE Credits for $20/month.

If you would like to test drive the University over the next year, we do have a few requirements. Please text our office: 949-3551-8741 AND write DPU.

Once we receive this we will get back to you to discuss if you qualify for the “test drive” to Beta Test the Dental Practice University.

P.S. If you are chosen to test drive the DPU, two of your team members will receive the 24 AGD CE Credits.*

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