The role of chlorhexidine in caries prevention.

The use of chlorhexidine for caries prevention has been a controversial topic among dental educators and clinicians. In several reviews, it has been concluded that the most persistent reduction of mutans streptococci have been achieved by chlorhexidine varnishes, followed by gels and, lastly, mouth rinses. Also, the evidence for using different chlorhexidine modes or a combination of chlorhexidine-fluoride therapy for caries prevention has been "suggestive but incomplete". Variable study designs and lack of data in high-risk children and adults support the need to continue conducting randomized, well-controlled clinical trials and to search for a practical, effective mode of antimicrobial treatment that augments the known effect of fluoride treatments. Currently, the only chlorhexidine-containing products marketed in the United States (US) are mouthrinses containing 0.12 percent chlorhexidine. Based on the available reviews, chlorhexidine rinses have not been highly effective in preventing caries, or at least the clinical data are not convincing. Due to the current lack of long-term clinical evidence for caries prevention and reported side effects, chlorhexidine rinses should not be recommended for caries prevention. Due to the inconclusive literature and sparse clinical data on gels and varnishes, their use for caries prevention should also be studied further to develop evidence-based recommendations for their clinical role in caries prevention. Since dental caries is a disease with a multifactoral etiology, it is currently more appropriate to use other established, evidence-based prevention methods, such as fluoride applications, diet modifications and good oral hygiene practices. Recent findings also indicate that the effect of an antimicrobial agent for reducing the levels of mutans streptococci or plaque reduction may not always correlate with eventual caries reduction. The clinically important outcome is proven reductions in caries. Many advances in the treatment and prevention of dental caries have been introduced over the past century. The use of chlorhexidine in caries prevention has been referred to as a nonsurgical management of dental caries and has represented the modern medical model of caries treatment. However, there is a lack of consensus on evidence-based treatment protocols and controversy regarding the role of chlorhexidine in caries prevention among dental educators and clinicians. There is a need to standardize guidelines to optimize evidence-based non-surgical disease management to provide appropriate care. This paper reviewed the literature on the effectiveness of different modes of chlorhexidine delivery for caries prevention and provides guidelines for chlorhexidine use in caries management. A literature search was conducted using the PubMed and Evidence-Based Medicine Reviews databases and the keywords "chlorhexidine" and "caries", limiting the search to "humans", "reviews" and "English". Based on the published reviews, it was concluded that chlorhexidine rinses, gels and varnishes or combinations of these items with fluoride have variable effects. Additionally, the sparse clinical data that was reported weakens the conclusions. Due to the current lack of evidence on long-term clinical outcomes and reported side effects, chlorhexidine rinse, which is currently the only treatment mode available in the US, should not be recommended for caries prevention. Clinical evidence on gels and varnishes is also inconclusive. For the treatment of dental caries, there are alternative evidence-based prevention methods available, such as fluoride applications, diet modifications and good oral hygiene practices.

Recommendations for fluoride varnish use in caries management.

Available data suggest that fluoride varnish can be a safe and effective method for caries management. The application of varnish can be beneficial for those at risk for caries and for patients with special needs, and for those with no access to daily fluoride or other preventive methods. Even a small amount of varnish can be applied to active noncavitated lesions, assuring that a high concentration of the agent is available at the site where needed and that the total amount of active agent administered to the patient may be markedly reduced. Considering that varnish treatment is painless and can be easily performed by auxiliary dental personnel, it is a caries preventive method that can be easily applied and recommended for any age group, even young children. For high-risk caries patients with a significant cariogenic challenge, topical applications of fluoride might be insufficient and thus could be supplemented with other anticariogenic methods, such as xylitol chewing gum.

Dental students' opinions and knowledge about caries management and prevention.

Students' attitudes toward caries prevention can impact their receptivity to training and subsequent involvement in preventive services in their future practices. The aim of this study was to evaluate dental students' opinions and knowledge regarding caries management and prevention at the University of Florida College of Dentistry. A twenty-six-item written survey instrument was administered to third- and fourth-year dental students. The response rate was 92.3 percent (72/78) for third-year and 45.5 percent (35/77) for fourth-year students. In their responses, 83 percent reported they would use chlorhexidine rinses for caries control, and 51 percent would use salivary tests for detecting cariogenic bacteria. Ninety-two percent reported they would use fluoride varnishes for caries control, and 40 percent were not sure if varnishes have associated dental or medical side effects. The majority of respondents felt that training and practice on caries prevention should be increased. Favorable responses to increasing education in preventive dentistry indicate that students may be receptive to modern caries management and prevention principles. This study suggests there is a need to update and integrate a more comprehensive caries prevention program into the predoctoral dental curriculum. Such programs should stress, in addition to actual training, the importance of prevention in students' future practice.

Caries management by risk assessment: implementation guidelines.

ACT This consensus statement supports implementation of caries management by risk assessment in clinical practice by using the following principles: modification of the oral flora, patient education, remineralization, and minimal operative intervention. The statement includes a list of supporters.

Prevalence of noncavitated and cavitated carious lesions in 5-year-old head start schoolchildren in Alachua County, Florida.

PURPOSE: The diagnosis of early carious lesions is essential for nonsurgical management of dental caries. This report describes the prevalence of early noncavitated and cavitated carious lesions in the primary dentition of 5-year-old Head Start schoolchildren in Alachua, Fla. METHODS: As part of the Fluoride Varnish Study conducted at the University of Florida, modified caries diagnostic criteria-which differentiated caries lesion activity and severity-were developed for the primary teeth. Dental examinations were conducted on 221 children ages 5 years by 2 calibrated examiners. RESULTS: Overall, 86% of the children had experienced noncavitated or cavitated caries lesions in the primary dentition. Prevalence of cavitated dentinal lesions was 48%, and prevalence of active noncavitated enamel lesions was 71%. The mean number of active noncavitated enamel lesions (mean +/- SEM: 2.91 +/- 0.21) was slightly higher than the mean number of cavitated dentinal lesions (2.52 +/- 0.31). The mean number of restored surfaces was 1.24 (+/- 0.42), and only 8% of the children had 1 or more restored surfaces. Noncavitated lesions were most common on occlusal surfaces, especially in mandibular second molars. African-American children had a higher prevalence of noncavitated lesions (81%) than whites (69%) or others (33%; P<.0001). Prevalence of cavitated lesions was 49% for African Americans, 46% for whites, and 48% for others. CONCLUSIONS: This study shows that noncavitated enamel and cavitated dentinal lesions are common in this study population's primary dentition. There is a need for preventive measures and treatment of decay in these children living in low-income families.

Effect of fluoride varnishes on color stability of esthetic restorative materials.

Fluoride varnish applications were applied to two hybrid resin composite materials, Z-100 (3M Dental Products, St Paul, MN, USA) and Esthet-X (Dentsply Caulk, Milford, DE, USA), shades A1 and A2 and a glass ionomer, GC Fuji IX GP Fast (GC Corporation, Tokyo, Japan), shade A2, to evaluate color stability. Specimens (12.6-mm dia x 2.3 mm) were prepared using a polyethylene frame, light-cured and polished through a 1-microm alumina finish. After the initial baseline color measurements, the discs were suspended in Fusayama artificial saliva (FAS) solution at 37 degrees C for 48 hours. Post immersion, the specimens were divided into five groups (n=15 each). The following fluoride varnishes were applied to four groups of test specimens: Duraphat (Colgate Oral Pharmaceutical, Inc, Canton MA, USA), Cavity Shield (OMNII Oral Pharmaceuticals, West Palm Beach, FL, USA), Duraflor (Pharmascience Inc, Montreal, Canada) and Fluor Protector (Vivadent, Ivoclar North America, Amherst, NY, USA). The varnish was allowed to dry for five minutes before immersion. The control group was not coated with varnish, although the specimens were immersed in FAS. All specimens were incubated in newly prepared FAS at 37 degrees C for 24 hours, cleaned with an electric toothbrush and the process repeated using newly prepared FAS. CIE L*a*b* color measurements were recorded five times: at baseline, after 48 hours FAS immersion, after cleaning the first and second fluoride varnish applications and after the final brushing using a commercial toothpaste (Crest). A Minolta CR-300 tristimulus colorimeter with an 8-mm aperture (Ramsey, NJ, USA) was used to record color measurements with the daylight (D65) setting. Calculations were performed for using CIE parameters deltaE*, deltaL*, delta a*, delta b*. Analysis of variance (ANOVA) and post-hoc test (Fisher's PLSD) were used for statistical analysis. After immersion in saliva, the tested glass ionomer (Fuji IX) produced the most significant color changes (deltaE*=1.19 and deltaL*=-1.03), indicating the effect of the color change was due to absorption. After fluoride varnish applications, Duraphat varnish produced significant changes in all tested materials and shades, resulting in color changes with deltaE greater than (>) 1 but less than (<) 3. These color changes are considered visually perceptible, yet have been reported in dental literature as clinically acceptable. Fluoride varnishes can be used without adversely affecting the color of restorative materials.

Assessing fluoride concentration uniformity and fluoride release from three varnishes.

BACKGROUND: The authors investigated the fluoride content uniformity of three commercial fluoride varnishes, as well as their fluoride-release behaviors. METHODS: The authors examined 20 doses from each of two tubes of Duraphat (Colgate-Palmolive Co., New York) and Duraflor (Pharmascience Inc., Montreal), and 20 doses of individually packaged 0.25-milliliter and 0.40-mL units of CavityShield (OMNII Oral Pharmaceuticals, West Palm Beach, Fla.). Part of the dose was dissolved in chloroform, followed by fluoride extraction with distilled water. The authors painted the remaining varnish from five predetermined doses from each group onto plastic substrates for examination of fluoride release. Fluoride concentrations in the solutions were measured with a fluoride-selective ion electrode. RESULTS: One-way analysis of variance showed statistically significant differences between varnish groups. The fluoride content was more uniform in Duraphat and CavityShield than it was in Duraflor. The fluoride release profiles in terms of percentage of total fluoride released over time were different among different groups of varnishes and were similar among samples from the same test group. The authors found that Duraflor released consistently more fluoride in artificial saliva than did the other two varnishes. CONCLUSIONS: Fluoride content can vary between doses dispensed from the same tube. Uniformity also varies between different varnishes and affects the retention of fluoride in the varnish. CLINICAL IMPLICATIONS: Clinicians should be aware that the nonuniform appearance of fluoride varnish as squeezed out of the tube could indicate separation of ingredients, resulting in variation of fluoride content.