Caries Risk Assessment Clinical Case #2

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Question 1 of 3

1. Question
Mr. Tran brings in his 18 month old son Henry for a well child visit. You know the Tran family well, but see them only sporadically due to their lack of health insurance, mobility, and other life priorities. Overall, the Tran family children are quite healthy. The only significant problems have been with Henry’s older sister who has extensive dental caries, primarily related to the family’s poor understanding of the role of preventive care and appropriate diet.

On exam you note several white lines on Henry’s teeth along with a small early cavity (photo). You counsel the family about oral hygiene and dentally appropriate diet, facilitate referral to a dental home, and consider the possibility of applying fluoride varnish.

Joanna Douglass, BDS, DDS

Your decision to apply fluoride varnish should be based upon which of the following statements?
- All children should have fluoride varnish applied at their well child visits. Many medical practices integrate oral health services into well child visits. However, not all children should receive fluoride varnish. USPSTF recommends fluoride varnish application be offered in the medical home to all children ages 5 and under.
- Fluoride varnish will cure Henry’s cavity. Fluoride varnish, along with behavioral changes such as appropriate use of fluoridated toothpaste and a dentally appropriate diet will decrease the likelihood of a child developing future dental caries. The varnish can “cure” or remineralize the white spots (they will remain white but will have a normal, healthy mineral content). However, the varnish cannot cure or fully treat an actual cavity. Fluoride can, with other preventive strategies, slow or arrest the growth of the cavity but a dental restoration is typically needed to fill established cavities and provide long term protection of the pulp and improved aesthetics.
- The white spots on Henry's teeth are an indication for varnish application.
- Fluoride varnish application can be an important source of revenue for your practice. In the majority of states, Medicaid does reimburse medical providers for applying fluoride varnish. However, as for any treatment in medicine there needs to be a clear medical indication and evidence of efficacy present before treatment is provided. While fluoride varnish treatments may generate additional revenue for a practice, it is unethical to provide treatments solely based on reimbursement.
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Question 2 of 3

2. Question
After consideration, you make the decision to apply fluoride varnish to Henry’s teeth. While discussing Henry’s treatment plan and obtaining informed consent, Mr. Tran raises concerns about the safety of fluoride varnish.

Which of the following statements about the safety of fluoride varnish is most correct?
- As safe as riding in his car seat Communicating risk with patients is always a difficult problem. Using common analogies is helpful. However, the analogy in this answer is a poor one. Car seats and fluoride varnish are dissimilar and improve health in completely different ways. It is better to avoid the analogy in this case and simply explain the low risk.
- As safe as taking a multivitamin pill
- It is risky, but the benefits outweigh the risks Fluoride varnish has little risk associated with it. The benefit, based on meta-analysis of randomized controlled trials, is a 38% reduction in caries. There are no published reports of fluorosis associated with its use. Analyses of plasma fluoride concentrations in children after varnish was applied showed rapid decrease of fluoride plasma concentrations with peak and waning levels comparable with those found after brushing with fluoridated toothpaste.
- It can cause fluorosis, a serious tooth abnormality Fluorosis does not occur from fluoride varnish. It occurs as a result of sustained exposure to fluoride over a long period of time. There are no published reports of fluorosis from fluoride varnish. Children are more apt to get fluorosis from excessive use of fluoridated toothpaste at each brushing. Furthermore, fluorosis is typically a mild cosmetic issue and not a serious or functional one.
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Question 3 of 3

3. Question
Once reassured as to the safety of fluoride varnish, Mr. Tran then inquires, “How does fluoride help to protect Henry’s teeth?”

The most appropriate response to Mr. Tran’s question is:
- Fluoride binds sugars so that they cannot be digested by bacteria in the mouth to create acid. Fluoride does not have an effect on dietary sugars. Fluoride is actually incorporated into the mineral matrix of the outer surface of the enamel producing a more acid resistant tooth surface.
- Fluoride varnish forms an impenetrable barrier coating teeth similar to wood varnish on a wooden door. Although fluoride’s primary action is topical, it does not work like a resin coat. The varnish in fluoride varnish is simply the vehicle for fluoride ions. As the teeth remineralize, fluoride is incorporated into the outer surface of the enamel producing a harder tooth that is more resistant to demineralization.
- Fluoride varnish eradicates strep mutans bacteria from the mouth. Although fluoride does reduce bacterial levels to some degree, primarily by reducing their growth rate, it is not directly bactericidal in the concentrations reached on teeth and cannot eliminate strep mutans completely. Its primary effect is through strengthening the outer surface of the enamel producing a more acid resistant tooth surface.
- The fluoride contained in varnish becomes incorporated into tooth enamel and makes it more resistant to acid demineralization.
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Caries Risk Assessment, Fluoride Varnish, and Counseling

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