Does Fluoride Varnish Waste Dental Hygienists’ Time?

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Dental offices vary widely with the use of fluoride varnish. Some offices assume adults don’t want it, taking into consideration that it is rarely covered by most insurance for adults, and it would be an out-of-pocket expense for the patient. Some offices never even ask the patient whether or not they would like to spend those $40 on their health.

Other offices do it at staggering rates. Hygienists apply fluoride varnish on more than 70% of patients, month after month. In the offices that do it most, it begs the question: Is fluoride varnish wasting our chair time?

Fluoride varnish and its efficacy have been repeatedly demonstrated in clinical studies. Yet it is still not “approved” as an anti-caries agent by the FDA, only endorsed for its ability as a desensitizing agent.1-3 Hygienists do not need a governing body to tell us whether or not a product actually works. We see incipient lesions remineralize on radiographs with three-month applications of fluoride varnish, and that is all the proof we need.

We know that the American Dental Association, The American Academy of Pediatric Dentistry, and the American Academy of Pediatrics all set standards of care in agreement with three- to six-month fluoride varnish applications, depending on caries risk.2

Why am I Doing this Task?

As a hygienist who spends a great deal of time applying fluoride varnish, the invention of new varnishes that can be applied to wet teeth makes me wonder: Why am I still applying this?4 With all the things that require high levels of technical skill in the field of dental hygiene — local anesthesia, sealants, scaling the base of a 7mm pocket with a curette — let’s admit that the application of fluoride varnish is not one of them. With this fabulous invention of wet-application varnish, any sort of technique-sensitive administration has flown right out the window.

Representatives from companies that sell those wet-application varnishes boast that the varnish only needs to be applied on the buccal surface in one swipe across the mandible, then the maxilla. After that, the saliva will allow it to seep onto the other surfaces of the teeth, providing 360-degree protection that way.4

The varnish still requires prolonged contact with the teeth exceeding four hours, and the dietary restrictions include refraining from hot or crunchy foods for the duration of those hours. It has been demonstrated that prolonged application at high concentrations is necessary for the slow binding of fluoride to enamel sites; the duration cannot be interrupted nor shortened with the same effect.5

This adds the question: Is applying it in the middle of the day at their appointment ideal?

The Varnish Appointment, or Maybe Home?

Additionally, let’s talk about the elephant in the room. Many offices across the country are production-based, and, in those offices, chair time matters. Scheduling someone to come in for a 10-minute, three-month fluoride varnish application not only wastes the patient’s time in their drive to and from the office, but it also decreases compliance and potentially thwarts other appointments from being added into our schedules. Perhaps the 20 minutes after that 10-minute varnish appointment went unfilled, whereas the lack of that appointment could have allowed for a child cleaning to be scheduled in that 30-minute slot.

The bottom line is that “professionally-applied fluoride” is outdated. “Professionally-dispensed fluoride” — in the same way we dole out 5000 parts per million toothpastes — can and should be applied to the way in which fluoride varnish is sold.

After all, patients decline fluoride all the time because they are “going out to eat” after the appointment or “meeting a friend for coffee” and can’t have that sticky stuff on their teeth. Not only is that a failed sale of fluoride varnish, something that the patient desperately needs, but applying it even on a compliant patient who is going out to dinner (avoid hot and crunchy!) will get less of an effective application than if that person applied it right before they went to bed.

Home application would allow for longer contact with the teeth for an extended period of time (greater than four hours as most varnishes require) without the interference of diet. Three-month applications would have a far greater level of compliance if they did not have to come all the way back into the office for the between-cleaning application. Hygiene scheduling would be uninterrupted and more efficient. We would be more productive, more effective, and more convenient for the patient. It’s a win-win-win.

Applying More, Not Less

The title of this article may have been misleading. The purpose of this discussion is not to apply less fluoride varnish to our patients but to offer it more — way more. It needs to be given to mothers after trying to wrestle that unruly two-year-old just to look in their mouth. Mom should be applying it for her child that night right before bed. It needs to be dispensed in multiples for those patients who are coming from a nursing home and need a ride just to make it into the office. It needs to be applied by a loved one in their nursing care facilities to make sure they have three-month protection.

We are missing a huge population of people: The kids who are not cooperative, the busy moms who have to pick their kids up from practice and can’t make it into the office for a 10-minute appointment, the geriatric population who suffers from xerostomia but doesn’t have a car. We are failing them.

It is important as a hygienist to spend time out of your day not only employing the tactics we have and know in the fight against periodontal disease and decay but analyze them. How have they evolved, and how can we evolve along with them? Are the current methods the best methods? How can we increase compliance and effectiveness? Furthermore, how can we compete with this new-age desire for things to be quick and easy? When you take a long, hard look at something that is outdated, something that compromises the level of care or the level of ease for patients, for molar’s sake: Say something!

References

  1. Bader, J.D., Rozier, R.G., Lohr, K.N., et al. Physician’s roles in preventing dental caries in preschool children. American Journal of Preventive Medicine. 2004; 26(4): 315-325.
  2. Milgrom, P., Taves, D., Kim, A.S., et al. Pharmacokinetics of fluoride in toddlers after application of 5% sodium fluoride dental varnish. Pediatrics. 2014; 134(3): e870-e874.
  3. Marinho, V., Worthington, H.V., Walsh, T., et al. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database Systematic Review. 3023; 40(7): CD002279.
  4. 3M Vanish 5% Sodium Fluoride White Varnish with Tri-Calcium Phosphate. 2019. https://www.3m.com/3M/en_US/company-us/all-3m-products/~/3M-Vanish-5-Sodium-Fluoride-White-Varnish-with-Tri-Calcium-Phosphate/?N=5002385+8710872+8713393+3290273727&preselect=5006188&rt=rud
  5. Carey, C. Focus on Fluorides: update on the use of fluoride for the prevention of dental caries. Journal of Evidence Based Dental Practices. 2014 June; 14 Suppl: 95-102.