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Authors: John Morgan, Bonnie F. Zimble

Preventive Care in Special Care Dentistry:

Recommended Preventive Protocols

Special Care in Dentistry
John Morgan, DDS
Tufts University School of Dental Medicine, 2008


Study Question:
 

  1. List the five protocols for the prevention of dental disease.  
  2. Summarize the main points of the regimen for each.

Recommended Preventive Protocols 

Note: The following information was adapted with permission from Glassman et al (2003).*  

Protocols are listed in order of preference, and can be of benefit in addition to the practices described in the previous pages. The first two protocols, xylitol and fluoride varnishes, were shown to have additive benefits, and it is recommended that they both be used. For each intervention, regimens are described for its use.  

·       Xylitol: Products containing at least 50% by weight of xylitol should be used three times daily for five minutes each exposure. For example, xylitol chewing gum should be chewed for five minutes three times a day. For individuals who cannot chew gum, or where supervised chewing is not feasible, other xylitol-containing products can be used, such as lozenges, mints, or lollipops. For infants, there are pacifiers with xylitol reservoirs, or traditional bottles with xylitol-containing solutions. For other products see the Oral Health Products Resource List. 

·       Fluoride Varnish: Apply varnish using one of the following regimens, based on the needs of the individual:

o      Apply varnish three times in one week, for example, Monday, Wednesday and Friday, once per year, or

o      Apply varnish once every six months.

The use of fluoride varnish requires removal of food debris prior to application. There may be some individuals or circumstances where this is not possible. 

The remaining interventions below may be of additional benefit. It is important that a dental professional examine the patient and make appropriate recommendations based on the individual’s living situation, their ability to carry out activities of daily living, and the presence and quality of care-giving available on a daily basis. As always, the dental professional should work closely with the care giver to provide appropriate care. 

·       Fluoride Rinses: This is an optional choice for:

o      All people over the age of 6 years who can safely rinse and expectorate without ingestion

o      People who are not able to fully use the first two interventions above, or

o      People with persistent decay.

Sodium fluoride (0.05%) has proven anti-caries effects additive to the use of fluoride toothpaste. Use a fluoride rinse containing 230 ppm fluoride without alcohol for one minute, twice daily. If an individual cannot rinse or spit, then apply the solution with a cotton swab, sponge applicator, or toothbrush. 

·       High Concentration Fluoride Toothpaste or Gel: This is to be considered when the previous recommendations are not adequately preventing caries, for example, a patient with xerostomia resulting from medications or radiation therapy. The decision to use these products should also consider the ability of the patient to use them correctly, or the presence of caregivers who can supervise and control the application of the products (which contain 5000 ppm of fluoride and can be toxic if sufficient quantities are ingested). The recommendation is to brush with the paste or gel prior to bedtime, spit out the excess without rinsing with water, and leave the residual product on the teeth while sleeping. Water should not be consumed for one hour after the use of the toothpaste or gel. 

·       Chlorhexidine: This is for individuals who are not able to fully use the methods already described, or for those with persistent decay. In such cases, use of a chlorhexidine rinse can be of benefit. Rinse with a half-ounce of chlorhexidine solution for one minute twice daily for 2 weeks. Repeat this regimen 4 times a year. If an individual cannot rinse or expectorate the solution, apply with a cotton swab, a sponge applicator or a toothbrush. Chlorhexidine is more effective than xylitol in reducing levels of caries-producing microorganisms, and for some patients an initial course of chlorhexidine may be indicated prior to beginning a long-term regimen of xylitol exposure. 

*Glassman, P., Anderson, M., Jacobsen, P., Schonfeld, S., Weintraub, J., White, A., Gall, T. Hammersmark, S., Isman, R., Miller, C.E., Noel, D., Silverstein, S. & Young, D. (2003). Practical protocols for the prevention of dental disease in community settings for people with special needs: The protocols. Special Care Dentistry, 23(5):160-4.