Chlorhexidine, fluoride varnish, and xylitol chewing gum: underutilized preventive therapies?

The successful implementation of a preventive dentistry program depends, to a large extent, on the compliance of the patient. The scheduled program would include: recall appointments, all instructions relative to oral hygiene, use of nightly fluoride rinses, and control of diet. To ensure that high-risk patients who have cariogenic bacteria are adequately treated, chlorhexidine rinses may be required on a periodic basis. The patient's level of risk must determine all treatment decisions. For low-risk patients, the times between recall appointments can be extended when evidence of caries arrest and remineralization can be documented. High-risk patients should be recalled at least every three months, until evidence of lesion arrest and/or remineralization has been documented. For patients with extremely low saliva flow rates, the combined chlorhexidine and fluoride method may be required. If the caries risk is still judged to be high according to bacteria counts and/or evidence of further lesion development or progression, more frequent applications of chlorhexidine may be required. Because fluoride varnish is generally more effective on smooth surfaces than on fissure sites, moderate caries-risk patients should receive fluoride varnish on smooth surfaces, and sealants, when indicated, on fissure sites. As the caries risk of the patient is reduced to a low-risk level, less frequent use of fluoride-containing or fluoride releasing products is indicated, and there can be longer periods between recall examinations. Three applications of fluoride varnish, applied to a single week, appear to provide greater caries protection than two applications per year. Attempts should be made to ensure that the varnish is applied immediately after cleaning the teeth and protected as long as possible after the varnish has been applied (preferably at least 10 hours). Fluoride varnish appears to be as effective as topical fluoride gel and may be safer. Thus, a greater frequently of application is permitted without a significant risk of fluorosis. Prevention is more cost effective as the patient shifts from a high-risk level to a low-risk level. Recall appointments can subsequently be extended and more conservative prevention treatments are warranted. Over an extended treatment period, the cost for the preservative dentistry option should be comparable to and perhaps less than the cost of placing and replacing dental restorations.