206 Part IV Prevention and Practice
advised for high cariesrisk adults with root caries; how-
PREVENTIVE AGENTS
FOR SELF-APPLICATION:
CHEMOPREVENTION
Several products are available for personal use as prescrip-
tion items or over the counter. The prescription items
generally have a higher concentration of fluoride and
therefore have a greater potential for toxicity. Fluoride is
a pharmaceutical and the potential for overexposure in
higher strength products requires that care be taken
to inform patients about the risks and for dental
professionals to prescribe and use them appropriately.
Dental professionals should understand fluoride metab-
olism and toxicology and be able to calculate the dose
administered either by design or inadvertently. Also, the
provider should be able to diagnose and appropriately
treat overdosage.20
Fluoride gels by prescription. These items are recom-
mended for patients who are at high or moderate caries
risk and would experience beneficial effects from addi-
tional exposure to fluoride. Prevident is a 1.1% neutral
NaF (5000 ppm F) gel. This product is prescribed for
high-risk patients and should be applied daily with a
toothbrush. The patient should be instructed not to
swallow the gel and to expectorate the excess gel after
brushing, and to avoid rinsing with water immediately
after use. Application before bedtime is recommended for
maximum effectiveness.
GelKam and OmniGel (0.4% SnF2, 960 ppm F) are
available by prescription. The strength of these products
is equal to that in toothpastes. These products are self-
applied either in custom trays or by toothbrush. Evidence
for efficacy for the use of 0.4% SnF2 in patients under-
going head and neck irradiation and in those wearing
orthodontic bands has been documented; however, their
general efficacy is not well established. The recommenda-
tion is to apply the product immediately before bedtime
for maximum contact. After application, the patient
should expectorate any residual gel, and should avoid
rinsing with water. These products have also been shown
to reduce dentinal hypersensitivity. The mechanism of
action is the deposition of stannous fluorophosphate into
the dentinal tubules.
Two products are routinely recommended for root
sensitivity. Products that contain 0.4% SnF2 are often
ever, questions remain about the scientific evidence to
support this application. In addition to these gels, 0.717%
F (DentinBloc) is an effective desensitizing agent for
exposed root surfaces. Protect is a potassium oxalate solu-
tion that is available for root sensitivity. These agents are
professionally applied and come in a 0.6-mL unit dose.
These agents should be applied to saliva-moistened teeth
at the sensitive sites, where gingival recession and
exposed root surfaces are evident.
Fluoride rinses without prescription. Of all self-
applied agents other than toothpaste, NaF (0.05%) daily
rinses have the best evidence of efficacy. These over-
the-counter rinses have been shown to be effective in reduc-
ing caries in moderate-risk or high-risk patients. These
products come in several brand and generic forms and are
found in the dental products section of pharmacies (see
Table 15-1). Although the concentration of the over-
the-counter products is less than prescription items, the
lower cost, ease of availability, palatable taste, and low
strength contribute to efficacy and adherence. A 10-ml
rinse for 30 seconds daily is recommended for these
products. Again, as with all fluoride products, the rinse
should be expectorated. Caries reduction has been shown
to range from 30 to 50%.21 The use of a 0.05% daily rinse
should routinely be advised for moderate or high caries
risk patients over the age of 5 years.
Dentifrices. Early clinical trials of fluoridated tooth-
pastes conducted in the late 1940s were ineffective,
because calcium-based abrasives interfered with avail-
ability of fluoride ion when it was added to toothpaste
that contained sodium fluoride.22 In 1960, Crest was
given provisional acceptance, and in 1964 was given
full acceptance by the ADA Council on Dental
Therapeutics as the first toothpaste containing fluoride
as a preventive agent. Crest used a concentration of 0.4%
SnF2 and heat-treated calcium pyrophosphate as the
abrasive. Today, the standard fluoride concentration is
0.15% weight/volume (approximately 1000 ppm) of
fluoride ion.
At present, more than 95% of all toothpastes in the
U.S. market are fluoridated.23 Fluoridated toothpaste is
recommended for all dentate persons, along with com-
munity water fluoridation, for the primary prevention of
dental caries. All caries risk groups should brush with a
fluoridated toothpaste twice daily. For young children,
care should be taken to minimize the amount of tooth-
paste placed on the toothbrush. Young children have a
tendency to swallow, rather than spit toothpaste, and are
at greater risk for experiencing very mild or mild fluorosis.
Currently, the recommendation is to use a pea-sized or
smear of toothpaste for preschool children. An adult
should supervise tooth brushing for preschool children,
and should encourage the child to spit, not swallow, the
toothpaste.
 Chapter 15
Over the years, the most common active agent transi-
tioned from stannous fluoride (SnF2) to sodium mono-
fluorophosphate (MFP) (Na2PO3F) to sodium fluoride
(NaF) as the preferred agent. Toothpastes contain one of
the fluoride formulations as the active ingredient and
an abrasive to assist with plaque removal and fluoride
uptake. Three ADA-accepted fluoride agents are used in
toothpastes.
Sodium fluoride is in toothpaste at a concentration of
0.24% NaF (1100 ppm of fluoride ion). Abrasives can
include calcium pyrophosphate (Ca2P2O7), insoluble
sodium metaphosphate (NaPO3), and silica (SiO2).
Toothpastes using this formulation include Crest, Colgate
Tartar Control Gel, Mentadent, and Colgate Total. NaF
pastes show marginally better caries reductions than other
fluoride formulations.
Sodium monofluorphosphate (Na2PO3F), or MPF,
is compatible with conventional calcium containing abra-
sives and contains 0.15% or 1100 ppm F-. Abrasives
include aluminum oxide (Al2O3), dicalcium phosphate
(CaHPO4), and calcium carbonate (CaCO3). Both
Colgate MFP and Aquafresh contain this formulation.
Stannous fluoride (SnF2) at a concentration of 0.4%
(960 ppm fluoride ion) was previously used as the active
ingredient in some toothpaste brands. Stannous fluoride
has several properties that make it less attractive commer-
cially. These properties include staining, alteration of
taste, and incompatibility with some abrasives, especially
dicalcium phosphate (CaHPO4). Abrasives used with
stannous fluoride toothpastes include calcium pyrophos-
phate (Ca2P2O7) and insoluble sodium metaphosphate
(NaPO3) with silica (SiO2). The use of SnF2 in toothpaste
has been largely discontinued.
Fluoridated toothpastes account for caries reductions
in the range of 17% to 35%.24 The preventive effectiveness
of toothpaste is lower in fluoridated areas. Caries reduc-
tions are greatest for approximal surfaces of posterior
teeth and for newly erupted teeth, which are undergoing
posteruptive maturation of enamel. The greatest caries-
preventive effect of fluoride is on smooth surfaces. Research
established that the preventive effect of toothpastes is
TABLE 15-3
FLUORIDE SUPPLEMENT DOSAGE SCHEDULE
Amount of Fluoride (F ion) by Water F Level
AGE <0.3 PPM
Birth-6 mos 0 0
6 mos-3 yr 0.25 mg F
3-6 yr 0.5 mg F
6-at least 16 yr 1.0 mg F
(2.2 mg NaF =1.0 mg F ion.)
(Adapted from the ADA Guide to Dental Therapeutics, Chicago, IL, 1998.)
Prevention Strategies for Dental Caries 207
shown to be a dose-response relationship. Persons should
be advised to look for the ADA Seal of Acceptance when
selecting a brand of toothpaste, which indicates the active
agent, efficacy or fluoride uptake, and method for use.
The preventive action of toothpastes is to increase the
bioavailability of fluoride when the enamel is under acid
challenge. Toothpastes also increase the fluoride content
of the surface enamel.25,26 Fluoridated toothpastes have
preferential uptake in demineralized areas. By forming
a less soluble, more resistant apatite crystal in enamel,
fluoridated toothpastes limit demineralization and pro-
mote remineralization. Although fluorides have been
shown to have an antibacterial property, the lower con-
centration of fluoride present in toothpaste is not likely to
have antibacterial action. Some brands, such as Colgate
Total, have formulations that provide some antibacterial
action. This product, which contains Triclosan, for anti-
bacterial action is used to prevent gingivitis (Chapter 16).
Fluoride supplements by prescription. Fluoride
supplements or dietary fluoride supplements are recom-
mended for children and adolescents who live in areas
that do not have access to the benefits of community
water fluoridation.27 These products are prescribed in
tablet or drop form. Supplements are effective if continu-
ity of administration is achieved, with reduction in dental
caries ranging from 11% to 80%, depending on the age of
the patient when the regimen is initiated.28 The prescrip-
tion guidelines (Table 15-3) are based on the amount of
fluoride in the drinking water and the age of the child.
Because the level of exposure to fluoride in drinking
water is a consideration when prescribing fluoride
supplements, the dental provider must know the fluoride
concentration in the water consumed. Fluoride levels
for water systems are available from utilities and at
http://apps.nccd.cdc.gov/MWF/Index.asp. This resource,
My Waters Fluoride, is available on the CDCs website,
as reported by state health departments. Families that
obtain water from a private well will need to have the levels
of fluoride measured before prescribing supplements.
A State or Local Health Department or Dental School
0.3-0.6 PPM >0.6 PPM
0
0 0
0.25 mg F 0
0.5 mg F 0
208 Part IV Prevention and Practice
can assist with measuring fluoride levels for private well
water supplies.
Fluoride drops are recommended for children younger
than 2 years. The drops are supplied as 0.5, 2.0, 2.5, and
5.0 mg/mL of fluoride. Product names include Fluoritab,
Pediaflor, and Luride. Dental professionals should not
dispense more than 60 to 115 mg depending on the
concentration, because a concentration of fluoride greater
than 50 mg is the acute toxic dose of fluoride for a
1-year-old weighing approximately 10 kg.
Fluoride tablets are often prescribed for older children
and adolescents by using the guidelines in Table 15-3.
The following brands of tablets are available: Fluoritab,
Flura-loz, Flura-tablets (1 mg fluoride), and Luride
(0.25, 0.5, or 1.0 mg fluoride). Dental professionals
should be careful not to prescribe more than 120 tablets
at one time, each containing 1.0 mg of fluoride to reduce
the risk of toxicity.
Antimicrobials by prescription. Because dental
caries is a diet-dependent, vertically transmissible,
infectious, bacterial disease, an antimicrobial approach
to control the cariogenic bacteria is logical. One of the
key determinants of caries development in children is
the acquisition of the cariogenic flora from the mother.
A window of infectivity occurs before 3 years of age.29
Evidence suggests that when the mothers level of
mutans streptococci is low, the incorporation of mutans
streptococci into the infants normal oral flora is delayed
and reduced in intensity and the caries experience in
these children is minimized. These findings can be
implemented to reduce the burden of early childhood
caries. Long-term effectiveness of antimicrobials on
caries control in older children and adults is less clear,
because by then, all have acquired mutans streptococci.
Differences in the virulence of cariogenic bacteria are
important. For adults, the application of antimicrobial
therapy can be best used as a second line of prevention.
If a reduction in a high count of cariogenic indicator
organisms can not be achieved by behavioral and other
preventive approaches, the use of antimicrobials may
then be warranted.
Chlorhexidine gluconate (Peridex, 0.12%) is the anti-
bacterial agent of choice to control oral pathogens. Other
essential oil-based products are available, but are far less
effective. Although chlorhexidine gluconate is effective
in reducing the burden of oral bacteria, it has significant
negative side effects, including staining of the teeth
and alteration of taste. Adherence to the protocol can be
problematic.
Chlorhexidine gluconate is only available by prescrip-
tion. Patients should be advised to rinse twice per day
with 0.5 oz (one capful) for 30 seconds per rinse. This
product should be used only for a 30-day period, every
3 months, because substantivity provides ongoing action.
Substantivity refers to the persistence of the active ingredi-
ent after application of the agent has ceased. This regimen
will suppress the load of mutans streptococci when
oral hygiene and dietary intervention are insufficiently
applied.
Xylitol and sorbitol. Xylitol (C5H12O5) is a 5-carbon
(pentose) sugar alcohol. Sorbitol is a polyol found in
many fruits and berries. Termed a natural sugar, xylitol is
found in low levels in certain fruits, and may also be
referred to as birch sugar from which it was derived.
In 2001, an NIH consensus statement promoted the use
of products containing noncariogenic sweeteners as one
method to prevent caries initiation.30 These sweeteners
include xylitol, sorbitol, other nonnutritive sugars,
sucralose (chlorinated sucrose), and aspartame (aspartic
acid and phenylalanine). These sweeteners are included
in a growing number of foods, including candies,
gums, and drinks. The actual content of noncariogenic
sweeteners may not be explicitly stated on the label, but
ingredients are listed on product packaging in order of
content percent.
The mechanism of action of xylitol in the oral cavity
differs from other sugar alcohols. Xylitol cannot be
metabolized by the typical acid-forming bacteria found
in dental plaque, and bacteria cannot use xylitol as a
nutrient. Xylitol is converted into xylitol 5-phosphate
(X5P) after its uptake into bacterial cells and X5P may
inhibit bacterial metabolism, including acid production.
Thus, xylitol retards growth of S. mutans and S. sobrinus
and inhibits acid production by these organisms in the
presence of other sugars.31 Observations of reduced plaque
mass in subjects consuming xylitol suggest an effect of
xylitol on the process of polysaccharide production that
causes decreased bulk and stickiness of the plaque biofilm.
Xylitol in the growth medium both reduced polysaccha-
rides produced by S. mutans to a greater extent than
sorbitol and decreased cell-cell (aggregation) and adhesiv-
ity of the bacteria.32
Xylitol and sorbitol chewing gums promote saliva
stimulation and an increase in the plaque pH or a more
rapid return to neutrality after a sugar challenge, or
both.33,34,35 Park et al. tested 5 commercially available
gums and found no statistically significant differences in
plaque pH between any of the sugar-free gums.36 Scheie
et al. were unable to detect any differences in plaque
quantity or acidogenic potential after chewing either
xylitol or sorbitol gums.37 These studies suggest no
increased benefit from xylitol over sorbitol in salivary
stimulation or in plaque quantity and acidogenicity.
The role of xylitol in remineralization of demineral-
ized enamel was raised by observations that xylitol can
form complexes with calcium ions and may penetrate
dental enamel during demineralization in vitro.38 It also
inhibited demineralization (lesion depth) directly and
was shown to reduce free Ca2+ ion activity when added
to saturated hydroxyapatite solutions. Amaechi et al.
tested the in vitro demineralization and remineralization
effects of xylitol solutions, and found no specific effect of
 Chapter 15 Prevention Strategies for Dental Caries 209

the xylitol on either process.39 The current science is
equivocal about the specific effectiveness of xylitol in
caries control versus sorbitol. The sucrose substitution
effect and salivary stimulation effect by cleansing are not
in question. Although some of the clinical trials support
the remineralization properties of xylitol, the data provide
limited evidence of efficacy.40,41 Remineralization studies
do not confirm any superiority of xylitol. The demon-
strated effectiveness of salivary stimulation in caries pre-
vention does not appear any greater for xylitol than for
sorbitol. Thus, despite strong biological plausibility, the
specific anticaries effect of xylitol has not been clearly
established.
caries risk is to examine the frequency of sugar consump-
tion, total sugar consumption, combinations of snacking
and meals that exceed six times per day, the total quality
of the diet as defined by variety and balance, and the
introduction of anticariogenic and cariostatic foods in the
daily dietary pattern.42
Oral health beliefs and practices are important in
caries prevention. Health behaviors, including diet, oral
hygiene, and use of smokeless tobacco, are integral to the
caries process. Behavior modification, education, and
counseling are important to dental caries prevention.
These topics are addressed in chapters 10 and 11.

Diet and plaque control. In Chapters 4 and 8, dietary RISK-BASED PREVENTION

factors are discussed relative to caries risk and prevention.
Table 8-4 provides a list of questions that are tied to the
algorithm in Figure 8-2 that is designed to guide deci-
sion-making about more in-depth nutritional assess-
ment. Ultimately, the data gathered through the
nutritional assessment methods should lead to the devel-
opment of a dietary education, counseling, and follow-up
plan. Table 8-12 provides a rationale that explains dietary
behaviors in the context of oral health.
Throughout this book reference is made to the role of
fermentable carbohydrates as a primary substrate for
the initiation of dental caries. Terms used to characterize
foods by specific response to cariogenic bacteria are
listed in Table 15-4. The primary purpose of a preventive
plan designed to address dietary variables associated with
The hallmark of risk-based prevention strategies
is to identify risk factors integral to the disease process for
individual patients and to modulate those factors by using
appropriate preventive strategies (Table 15-1).
Low Caries Risk
Patients who are at low risk for caries are successful in self-
management of their oral health. Prevention strategies for
both children and adults should focus on reinforcement of
oral hygiene and dietary practices and the use of fluori-
dated toothpastes two times per day. Individuals in this
risk category should be encouraged to drink fluoridated
water and brush with fluoridated toothpastes. These
patients should be recalled annually for risk reevaluation.

TABLE 15-4

DESCRIPTIVE RESPONSE ASSOCIATED WITH TERMS USED TO DESCRIBE FOODS AND BEVERAGES AND THEIR
ROLE IN THE PROGRESSION OF CARIES

TERM DESCRIPTION EXAMPLES

Acidogenic Foods/beverages that readily cause a drop in Sweet pastries, sweetened cereals.
plaque pH to <5.5 within 30 minutes.
Cariogenic Foods/beverages that contain fermentable Sugar-sweetened beverages sipped during
carbohydrates that can be metabolized by oral an extended period.
bacteria to cause a decrease in bacteria to cause Sticky, sugary foods.
a decrease in plaque pH to <5.5 and Highly processed starchy foods.
demineralization of tooth enamel.
Anticariogenic Foods/beverages that can prevent cariogenic Xylitol gums and candies.
activity when eaten with/before an Beverages sweetened with sugar
acidogenic product. substitutes/alcohols.
Hard cheese.
Nuts and seeds.
Cariostatic Foods/beverages that cannot be easily metabolized High-quality proteins.
by dental plaque. Bacteria, and therefore do not Dairy foods.
cause a significant drop in salivary pH.