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.
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
Apply varnish three times in one week, for
example, Monday, Wednesday and Friday, once per year, or
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
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
Fluoride Rinses: This is
an optional choice for:
All people over the age of 6 years who can
safely rinse and expectorate without ingestion
People who are not able to fully use the
first two interventions above, or
People with persistent decay.
(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
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,