Earn2 CE creditsThis course was

written for dentists, dental hygienists,

and assistants.

Supplement to PennWell Publications

Go Green, Go Online to take your course

AbstractFluoride has demonstrated its use in assisting caries prevention in children. Over the years it has evolved and has current modalities for adults as well. Fluoride options include systemic uptake via water and foods, and by topical applications such as gels, foams, varnishes, dentifrices, and mouth rinses. The highest levels of fluoride are stored on the tooth surface. Topical applications are most successful if they have a high fluoride release and fluoride uptake. Traditionally the tray method has been in use in dental offices since the 1940’s. More current application of fluoride includes a fluoride varnish method which uses a less amount of fluoride per application than the tray method. Varnish sets quickly and remains on the teeth releasing fluoride hours after it has been applied. Candidates for topical fluoride include patients with orthodontics, restorations, and exposed root surfaces, thus an adult population can benefit from fluoride. The use and ease of a fluoride varnish is a universal and modern approach to treating caries risk in children and adults.

Educational ObjectivesThe goal of this course is to provide the reader with contemporary information on intraoral digital radiography to optimize results. Upon completion of Part II of this course, the reader will be able to:1. Discuss topical fluoride options

available to patients.2. Explain the preventive outcomes

of topical fluoride.3. Identify the differences in

fluoride application modalities of gel, foam, and varnish.

4. Describe the key factors of a quality varnish.

Author ProfileTrish Jones, RDH, BS has been passionate about dentistry for over 25 years. With degrees in Dental Hygiene and a Bachelor of Science in Health Care Management from Southern Illinois University in Carbondale, she loves to speak and write about topics that have practical impact on dental offices. Trish is honored to be an Executive Coach with Fortune Management in San Antonio, Texas. She can be reached at gotrishjones@gmail.com

Author DisclosureTrish Jones, RDH, BS has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

Publication date: Nov. 2016 Expiration date: Oct. 2019

This educational activity has been made possible through an unrestricted grant from Ultradent Products, Inc.This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content.Requirements for Successful Completion: To obtain 2 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%.CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products or services discussed in this educational activity. Heather can be reached at hhodges@pennwell.comEducational Disclaimer: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.Image Authenticity Statement: The images in this educational activity have not been altered.Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents the most current information available from evidence based dentistry. Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient and improvements in oral health. Registration: The cost of this CE course is $49.00 for 2 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

PennWell designates this activity for 2 continuing educational credits.

Dental Board of California: Provider 4527, course registration number CA# 02-4527-15143“This course meets the Dental Board of California’s requirements for 3 units of continuing education.”

The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to (10/31/2019) Provider ID# 320452.

INSTANT EXAM CODE 15143

The Modern Approaches to Fluoride: Applications for All AgesA Peer-Reviewed Publication Written by Trish Jones, RDH, BS

2 www.DentalAcademyOfCE.com

Educational ObjectivesAt the conclusion of this educational activity participants will be able to:1. Discuss topical fluoride options available to patients.2. Explain the preventive outcomes of topical fluoride.3. Identify the differences in fluoride application modali-

ties of gel, foam, and varnish.4. Describe the key factors of a quality varnish.

AbstractFluoride has demonstrated its use in assisting caries prevention in children. Over the years it has evolved and has current modalities for adults as well. Fluoride options include systemic uptake via water and foods, and by topi-cal applications such as gels, foams, varnishes, dentifrices, and mouth rinses. The highest levels of fluoride are stored on the tooth surface. Topical applications are most suc-cessful if they have a high fluoride release and fluoride uptake. Traditionally the tray method has been in use in dental offices since the 1940’s. More current application of fluoride includes a fluoride varnish method which uses a smaller amount of fluoride per application than the tray method, thereby maximizing the clinical benefits of topi-cal fluoride application while minimizing ingestion that may cause gastric upset issues or in younger children other systemic issues. Varnish sets quickly and remains on the teeth releasing fluoride hours after it has been applied. Tooth structure benefits are dependant on contact time between the fluoride and enamel/dentin. Candidates for topical fluoride include patients with orthodontics, restorations, and exposed root surfaces, thus an adult population can benefit from fluoride. The use and ease of a fluoride varnish is a universal and modern approach to treating caries risk in children and adults and treat hyper-sensitive root surfaces.

Introduction It was once thought that fluoride only assisted with caries prevention in growing children. Over the years, fluoride in various treatment modalities has been demonstrated to help children; and adults in prevention of the progression of dental caries. Fluoride now has additional, current applications ben-eficial for all ages.

Dental caries or cavities are caused by a breakdown of the tooth enamel and dentin. This breakdown is the result of bacteria on teeth that breakdown carbohydrates in the foods consumed and produce acid that destroys tooth enamel and dentin, resulting in tooth decay. The bacteria associated with the etiology of this disease are Streptococcus mutans, Lactoba-cillus, and Actinomyces viscosus and odontolyticus.8,12,22

These organisms act upon fermentable carbohydrates such as sucrose, glucose, and fructose to produce acid by-products, reducing the pH of the associated oral structure.

A more acidic environment begins the process of enamel demineralization. If frequency of ingestion of fermentable carbohydrates increases, so does the risk of demineralization of the enamel, increasing the risk of caries. Other factors that can affect the process include fluoride exposure, pH level, and salivary flow.1, 7, 8, 9

Dental caries remains the most common chronic dis-ease of children aged 6 to 11 years and adolescents aged 12 to 19 years. Tooth decay is four times more common than asthma among adolescents aged 14 to 17 years. Den-tal caries also affects adults with nine out of ten over the age of 20 having some degree of tooth-root decay.1,2 Car-ies, especially of the root surface is a common occurrence in patients over age 60 and may be related to decreased salivary flow as well as less hand dexterity making home care less effective. With the increasing demographic of the aging population who are retaining teeth, the challenge is preventing and treating root caries in this older age group who may exhibit gingival recession and root exposure. It is estimated there will be 7.5 million older patients via the “baby boomer” generation (1946-1964) by year 2030. 19,21,22 With a greater awareness of their health and a longer retention of their natural teeth, dental caries is likely to be a concern with this generation.

Fluoridation has been a proven method to prevent cavities. Named by the Centers for Disease Control and Prevention (CDC) as one of the ten great public health achievements of the 20th century, water fluoridation has been a major contributor to the decline of the rate of tooth decay.2 Studies have shown that water fluoridation can reduce the amount of decay in children’s teeth by 18-40%.3

Fluoride optionsFluoride can help achieve optimum oral health by two gen-eral routes. One route is systemic ingestion, specifically, fluoride in water, foods, and beverages, or by fluoride sup-plements to meet optimal levels for developing teeth. The other route is topical fluoride. Topical fluoride is placed directly on exposed surfaces of the teeth for uptake. Topical fluoride includes gels, foams, varnishes, dentifrices, and mouth rinses.7,8,9

Systemic application: water fluoridationFluoride research had its beginnings in 1901, when a young dental school graduate named Frederick McKay opened a dental practice in Colorado Springs, Colorado. He was as-tounded to find scores of Colorado Springs natives with brown stains on their teeth. McKay searched for information on this bizarre disorder. He found no mention of brown-stained teeth in any of the dental literature of the day.6

McKay’s break came in 1909, when renowned dental re-searcher Dr. G. V. Black agreed to come to Colorado Springs and collaborate with him on the mysterious ailment.

www.DentalAcademyOfCE.com 3

Black investigated fluorosis for six years, until his death in 1915. He and McKay made two crucial discoveries. First, mottled enamel (as Black referred to the condition) resulted from developmental imperfections in children’s teeth. Second, teeth afflicted by Colorado Brown Stain were surprisingly and inexplicably resistant to decay.6

The architect of the first fluoride studies in the 1930s was Dr. H. Trendley Dean. Dr. Dean concluded that the optimal level of fluoride in the water to minimize the risk of dental caries was 1 ppm.6

Fluoridation of water in communities first occurred in 1945. After much research in 2015, the US Department of Health and Human Services (HHS) updated the optimal concentration of water fluoridation to be 0. 7 ppm.4 This level provides an effective level of fluoride to reduce the incidence of dental caries while minimizing the risk of fluorosis.4

Fluoride is an important part of the crystal lattice of teeth and bones. Structurally, fluoride and calcium can both occupy the same molecular position in the enamel or den-tin. But higher amounts of acid are required to remove the fluoride from the tooth structure then calcium. Incorpora-tion of fluoride into the enamel during tooth development results in the formation of fluorhydroxyapatite, which is more resistant to the acid attacks of the decay process and is a systemic benefit.3,7,9

Certain foods such as tea, fish, meat, eggs, vegetables, fruits, and cereals contain fluoride, which alone is not enough to provide for caries prevention. Bottled water normally does not contain fluoride unless indicated. In re-gards to water filters, reverse osmosis and water distillation systems remove the fluoride, whereas water softeners do not. Fluoride can be removed from treated water by carbon filters containing activated alumina.7

In communities with no water fluoridation, fluoride supplements may be prescribed in forms of tablets, loz-enges, drops, and a swish/swallow rinse.7

Homes using well water may contain anywhere from no or low levels of fluoride to very high levels depending on the location. it is recommended that these water sources be checked for fluoride levels and either supplemental fluoride be added to the diet or in the case of excessive levels filtered to lower the level to an accepted level.

Over-the-counter toothpastes and mouth rinses may contain fluoride and can be recommended to patients as well.

Topical application of fluorideThe highest levels of fluoride are stored on the tooth sur-face. Topical application of fluoride has been mainstream in dental offices since the 1940s as part of the oral prophy-laxis. Topical fluoride helps prevent dental caries in three different ways. These include inhibiting demineralization,

enhancing remineralization of incipient caries lesions, and glycolysis inhibition. Fluoride enhances remineraliza-tion by combining with the tooth and making the coronal enamel and root surfaces more resistant to decay. The more resistant remineralized enamel in turn serves as a deterrent to acid, which acts to remove minerals from the tooth sur-face.3,6-10 Fluoride inhibits bacterial activity by inhibiting enolase, which is an enzyme needed by bacteria to metabo-lize carbohydrates.8

Topical fluoride modalities include 2.0% sodium fluo-ride (NaF) or 1.23% acidulated phosphate fluoride (APF) gel or foam in a tray delivery method. Another more mod-ern method is 5% neutral sodium fluoride (NaF) varnish.

ToxicityAcute fluoride toxicity results from short-term ingestion of higher concentrations of fluoride. Symptoms can range from mild nausea to more severe GI symptoms and, in extremely rare cases, death.7,9 The severity of symptoms is affected by the amount of fluoride ingested, the patient’s weight, and the patient’s health status.10,15 Mild nausea is the most common form of fluoride toxicity and is experienced when patients swallow too much topical fluoride. The fluoride reacts with the stomach acid, forming hydrogen fluoride, and produces symptoms of nausea, cramps, and vomiting, usually within 30 minutes of ingesting.10,15,16

Positive outcomes of fluoride treatmentsFluoride release is the amount of fluoride that the product unlocks as it is in contact with the tooth. A higher rate of fluoride release means that more fluoride is available for absorption. A higher rate is also more efficient than a low release rate since it provides more available fluoride per treatment. In order to be truly effective, however, a product must have both a high fluoride release and a high fluoride uptake.20

Fluoride uptake is the amount of available fluoride ions that are actually absorbed into the tooth. Without a high fluoride uptake, a fluoride treatment is largely inef-fective, as the fluoride has no opportunity to provide any benefit. It merely sits on the tooth without penetrating the enamel.20

Dental biofilm plays a part in the application of fluo-ride. Biofilm has several functions. It acts as an interface between the oral surface and its surroundings; it harbors bacteria and interacts with other bacteria; and disrupts the ph level. Remineralization of enamel is affected ad-versely by high calcium and phosphate concentrations in biofilms, saliva or artificial calcifying agents. It provides a barrier against uptake of fluoride for remineralization. It is advantageous to remove the plaque biofilm prior to any fluoride treatment modality to maximize the uptake and benefits of fluoride.8,18

4 www.DentalAcademyOfCE.com

Tray delivery systemNeutral sodium fluoride (NaF) has a pH level of 7 and is safe for porcelain and composite restorations that may be present in the oral cavity. Acidulated phosphate fluoride (APF) has a low pH of 3.5, which enhances fluoride uptake; however, it is recommended as a 4-minute application. APF can etch porcelain, composite, and sealant materials, so a thorough dental health history and evaluation should be taken into consideration in determining which tray fluoride material and method is best. Patients should be advised not to rinse, eat, or drink for 30 minutes following high-concentration fluoride applications to maximize effec-tiveness.7,9,11,13,20 In children under six, the tray method may not be ideal due to the possibility of ingestion. Additionally, patient cooperation can be a factor in these young children and fluoride varnishes are quicker to apply and require less patient cooperation during treatment.

Five percent neutral sodium varnish has been widely used and has proven to be safe, effective, fast, and easy, and patient compliance and acceptance is good.

Fluoride varnishes The United States Food and Drug Administration (FDA) approved fluoride varnish in 1994 for use as a cavity liner and treatment for hypersensitivity. As compared to a gel or foam, varnish has a higher concentration of fluoride. Since varnish is painted on or layered similar to a lacquer, less amount of fluoride is used per application than the tray method.13,14 A key factor in using varnish is that is sets quickly and remains on the teeth, releasing fluoride hours after it has been applied.7,8,9 This helps with reducing caries in pits and fissures, and in interproximal and cervical areas where it is needed the most.9 It is effective in remineralizing lesions regardless of whether the varnish is applied over or around the lesion.10 Thus, the use of varnish in orthodontics or around restorations is beneficial as it helps reduce de-mineralization around the brackets and/or the restorations present. Varnish may also help older people with exposed root surfaces as it can help diminish dentin hypersensitivity by blocking dentinal tubules.7,9,11,13,14 It has also been dem-onstrated that varnish may be indicated for those with xe-rostomia caused by factors such as head-and-neck radiation and saliva-depressing drug therapy.10 Proper application technique reduces the possibility that a patient will swallow varnish during its application as compared to the traditional tray method.17,18

High-frequency beverage consumption of sodas, citrus juices, sports drinks, tea, coffee, and wine provides an acidic environment that exposes teeth to an acidic pH for longer periods of time, thus increasing the risk of demineralization. Normal pH of the oral cavity is 7. A pH of 5.5 provides an environment in which hydroxyapatite dissolves. Fluorapatite begins to demineralize/dissolve in an environment of 4.5.7,8,9

Figure 1.

123456789

10111213

lemon juicediet soft drinks

apple juice

rainwater

freshly distilled waterseawater

baking soda

household bleach

gastric fluidcarbonated beverages sports drinksvinegarorange juicebeer soda watercoffeeegg yolkmilkblood

http://www.health.govt.nz/sites/default/files/images/yourhealth/page-images/teeth-and-gums/ph-chart.png

Table 1. Topical Fluoride Concentrations7,9,13,20

NaF 9,000 ppm

APF 12,300 ppm

Varnish 22,600 ppmDentifrice 1,000- 1,500 ppm

Varnishes are becoming a popular option for topical fluoride. They are ideal for children under six due to the decreased risk of swallowing the fluoride. Varnishes are also recommended for children and adults with orthodontics, adults with sensitivity and/or root exposure, and children and adults who have xerostomia due to factors such as medi-cation.7,8,9,10,11,17

Patients with xerostomia or chronic root sensitivity and increased caries potential can be trained to apply fluoride varnishes at home under dental professionals guidance.

Before recommending a product, in addition to noting the ingredients, it is ideal to learn more about the product’s fluoride release and uptake as this assures the most efficient and effective product is used.

The Caries Management Risk Assessment Survey helps clinicians decide on the best treatment modality for a fluoride plan of action.23,24 This survey is available at http://www.ada.org/en/member-center/oral-health-topics/caries-risk-assessment-and-management.

This survey provides effective management of dental car-ies based on assessment of the caries risk level. There are two surveys available: one for 6 years old and under and another for 6 years old and older.

Benefits of a fluoride varnish include taste; color (clear); lack of gritty texture; patient acceptance, espe-cially with adults; uptake and release of fluoride; contact time; and multifunctional use on children, orthodontic patients, and adult patients.12

www.DentalAcademyOfCE.com 5

Modern choiceFluoride varnish is a more modern approach to treating caries risk. Its ease of use and universal application in regard to treat-ing young patients, adults with restorations and/or recession, and orthodontic patients of all ages make it a popular choice. Evaluation of the quality of fluoride, its availability to adhere to the teeth, and the uptake and release of the fluoride maxi-mizes its benefits to the patient.

References1. Dye BA, Tan S, Smith V, Lewis BG, Barker LK,

Thornton-Evans G, Eke PI, Beltrán-Aguilar ED, Horowitz AM, Li CH. Trends in oral health status, United States, 1988-1994 and 1999-2004. Vital Health Stat 11. 2007;(248):1-92.

2. U.S. Department of Health and Human Services (2000) Oral Health in America: A Report of the Surgeon General. National Institute of Dental Craniofacial Research, National Institutes of Health. Rockville, MD.

3. www.cdc.gov/healthywater/hygiene/disease/dental_caries.html. Accessed July 17, 2016

4. www.publichealthreports.org/documnets/PHS2015Fluoride_Guidelines.pdf. Accessed July 17, 2016

5. www.nidcr.nih.gov/oralhealth/Topics/Fluoride/TheStoryofFluoridation.htm. Accessed July 15, 2016

6. Mattana DJ, Relich, EE. Fluorides in Clinical Practice of the Dental Hygienist. Wilkins E., editor. Philadelphia: Lippincott Williams and Wilkins; 12th edition. 2017 593-618.

7. Featherstone, JDB. The science and practice of caries prevention. Journal of the American Dental Association, 2000; 131,887

8. Darby M, Walsh M. Dental Hygiene Theory and Practice 3rd edition. St. Louis: Elsevier. 2010.

9. Autio-Gold JT, Courts F. Assessing the effect of fluoride varnish on early enamel carious lesions in the primary dentition. Journal of the American Dental Association 2001; 132, 1247.

10. Stephenson R. Causes of xerostomia. RDH J. 2008 March; 60-66.

11. Centers for Disease Control and Prevention. “Recommendations for using fluoride to prevent and control dental caries in the United States.” MMWR Recomm Rep. 2001; 50(RR-14):1–42. PMID 11521913. Lay summary: CDC, Web. 2007-08-09. Web. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1htm. Accessed 7/12/12

12. Wilkins E. Editor. Clinical Practice of the Dental Hygienist. 11th edition. Philadelphia: Lippincott Williams & Wilkins. 2013.

13. Beltrán-Aguilar E, Goldstein J, Lockwood S. Fluoride varnishes: A review of their clinical use,

cariostatic mechanism, efficacy, and safety. JADA 2000; 131(5): 589-596. Web http://www.ncbi.nlm.nih.gov/pubmed/10832252. Accessed July 19, 2016.

14. Marinho VCC, Higgins JPT, Logan S, Sheiham A. “Fluoride varnishes for preventing dental caries in children and adolescents.” Cochrane Summaries. 1/21/2009. Web. http://summaries. cochrane.org/CD002279/fluoride-varnishes-for-preventing-dentalcaries-in-children-and-adolescents. Accessed August 3, 2012.

15. American Association of Poison Control Centers. Web. http.//www.aapcc.org. Accessed September 3, 2012

16. American Academy of Pediatric Dentistry. Policy statement on the use of fluoride. Adopted 1967. Reaffirmed 1977. Revised 2013. Available from: http://www.aapd.org/media/Policies_Guidelines/P_FluorideUse.pdf.

17. American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride: Evidence-based clinical recommendations. J Am Dent Assoc. 2006; 137(8):1151-9.

18. García-Godoy F., Hicks MJ. Maintaining the integrity of the enamel surface. JADA, Vol. 139, 2008; 25-34.

19. US Department of Health and Human Services; 2013. http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf. Accessed July 18, 2016.

20. http://mchb.hrsa.gov/whusa11/hstat/hshi/downloads/pdf/w11hshi.pdf. Accessed July 20,2016

21. Murphy SL, Kochanek KD, Xu J, Arias E. Mortality in the United States, 2014 NCHS Data Brief No. 229, Decemberwww.cdc.gov/nchs/data/databriefs/db229.pdf. Accessed July 20, 2016Jensen L., Budenz AW, Featherstone JDB, Ramos-Gomez FJ, Spolsky VW, Young DA. Clinical protocols for caries management by risk assessment. CDA Journal, Vol 35, No 10, 2007; 714-723.

22. Schemerhorn BR. Sound enamel fluoride uptake from a fluoride varnish. 2013. Ultradent Data on file.

Author ProfileTrish Jones, RDH, BS has been passionate about den-tistry for over 25 years. With degrees in Dental Hygiene and a Bachelor of Science in Health Care Management from Southern Illinois University in Carbondale, she loves to speak and write about topics that have practical impact on dental of-fices. Trish is honored to be an Executive Coach with Fortune Management in San Antonio, Texas. She can be reached at gotrishjones@gmail.com

Author DisclosureTrish Jones, RDH, BS has no commercial ties with the spon-sors or the providers of the unrestricted educational grant for this course.

INSTANT EXAM CODE 15143

1. What is the revised ppm fluoride that is recommended currently for community water fluoridation?a. 0.5 ppmb. 0.7 ppm c. 1 ppmd. 2 ppm

2. Which of the following topical fluorides has the lo west risk for swallowing?a. Dentifricesb. Mouth rinsesc. Gelsd. Varnishes

3. Which fluoride is best for patients with porcelain and composite restora-tions present?a. 2.0% fluoride gelb. 5% neutral fluoride varnishc. 1.23% acidulated phosphate fluoride d. Both a and b

4. Fluoride release is:a. The amount of fluoride that the product

unlocks as it is in contact with the tooth. b. When the tray is in contact with the teethc. The same as fluoride uptaked. Not as important as the uptake of fluoride

5. The normal pH level is 7 for the oral cavity. At what level does hydroxy-apatite dissolve?a. 6b. 4c. 5d. 3.5

6. Topical fluoride applications may be indicated for:a. Children over 6 with a high caries riskb. Adults with hypersensitivityc. Orthodontics patientsd. All of the above

7. Varnish has what ppm of fluoride concentration?a. 20,000b. 21 400c. 9,000d. 22,600

8. Which beverages may affect enamel demineralization?a. Milkb. Sodac. Drinking waterd. Both a and b

9. Proper risk assessment of adults and children include:a. Taking a survey to assess sugar intake,

salivary function, and medications and creating a plan of action

b. Assessment of the gag reflex when the tray is in the oral cavity

c. Assessing nutritional intaked. Talking to the patient about the beverages

they drink

10. Benefits of fluoride varnish from the patient’s perspective include:a. Tasteb. Colorc. Textured. All of the above

11. Which of the following bacteria is associated with etiology of dental caries?a. Actinomyces colib. Streptococcus mutansc. Lactobacillus strepd. E. coli

12. Which of the following increases the risk of demineralization of the enamel?a. The frequency of intake of fermentable

carbohydratesb. Drinking bottled waterc. Decreased Salivary flowd. Both a and c

13. Which topical fluoride treatment modality delivers the highest parts per million of fluoride?a. Fluoride rinseb. APF foamc. Varnishd. NaF gel

14. Which statement is true?a. Dental caries primarily affects children

under the age of 14.b. Fluoridation has been named by the CDC

as one of the ten great public health achieve-ments of the 20th century.

c. Dr. McKay concluded the level of fluoride in water that minimizes the risk of dental caries averages 1 ppm.

d. Studies have shown that water fluoridation can reduce the amount of decay in children’s teeth by 41-50%.

15. Which statement is false?a. Certain foods such as tea, fish, meat, eggs,

vegetables, fruits, and, cereal contain enough fluoride for caries prevention.

b. In communities without water fluoridation, supplements may be indicated.

c. The highest levels of fluoride are stored on the tooth surface.

d. Fluoride enhances remineralization by combining with the tooth and making the coronal enamel and root surfaces more resistant to decay.

16. Symptoms of acute fluoride toxicity include:a. Mild nausea to more severe GI symptomsb. Cramps c. Vomitingd. All of the above

17. Fluoride uptake:a. Is the amount of available fluoride ions that

are actually absorbed into the toothb. Occurs when fluoride just sits on the toothc. Works best when fluoride release is lowd. Is largely ineffective when it is high

18. 5% neutral sodium varnish has been widely used and has been demonstrated to be:a. Safeb. Effective c. Fastd. All of the above19. The following statement is true:a. More fluoride is used in a varnish as

compared to a tray method.b. Varnish takes hours to set since it is

painted on.c. Varnish remains on the teeth, releasing

fluoride hours after it has been applied. d. Varnish does not help patients with

orthodontics or dental restorations.

20. Varnish can help:a. Reduce dentinal hypersensitivity b. Protect exposed root surfacesc. Reduce demineralization around orthodontic

brackets or dental restorationsd. All of the above

Questions

Online CompletionUse this page to review the questions and answers. Return to www.DentalAcademyOfCE.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

6 www.DentalAcademyOfCE.com

INSTANT EXAM CODE 15143

Customer Service 800-633-1681

If not taking online, mail completed answer sheet to PennWell Corp.

Attn: Dental Division, 1421 S. Sheridan Rd., Tulsa, OK, 74112

or fax to: 918-831-9804

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.COURSE EVALUATION and PARTICIPANT FEEDBACK

We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: hhodges@pennwell.com.

INSTRUCTIONSAll questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be mailed within two weeks after taking an examination.

COURSE CREDITS/COSTAll participants scoring at least 70% on the examination will receive a verification form verifying 2 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00.

PROVIDER INFORMATIONPennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, not does it imply acceptance of credit hours by boards of dentistry.

Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP ar www.ada.org/cotocerp/

The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to (10/31/2019) Provider ID# 320452

RECORD KEEPINGPennWell maintains records of your successful completion of any exam for a minimum of six years. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt.

Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.

CANCELLATION/REFUND POLICYAny participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

IMAGE AUTHENTICITYThe images provided and included in this course have not been altered.

© 2016 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell

FLUO1116DIG

For IMMEDIATE results, go to www.DentalAcademyOfCE.com to take tests online.

INSTANT EXAM CODE 15143 Answer sheets can be faxed with credit card payment to

918-831-9804.

Payment of $49.00 is enclosed. (Checks and credit cards are accepted.)

If paying by credit card, please complete the following: MC Visa AmEx Discover

Acct. Number: ______________________________

Exp. Date: _____________________

Charges on your statement will show up as PennWell

ANSWER SHEET

The Modern Approaches to Fluoride: Applications for All AgesName: Title: Specialty:

Address: E-mail:

City: State: ZIP: Country:

Telephone: Home ( ) Office ( )

Lic. Renewal Date: AGD Member ID:

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 2 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 800-633-1681

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

Educational Objectives1. Discuss topical fluoride options available to patients.

2. Explain the preventive outcomes of topical fluoride.

3. Identify the differences in fluoride application modalities of gel, foam, and varnish.

4. Describe the key factors of a quality varnish.

Course Evaluation1. Were the individual course objectives met?

Objective #1: Yes No Objective #2: Yes No

Objective #3: Yes No Objective #4: Yes No

Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.

2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0

5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0

6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0

7. Was the overall administration of the course effective? 5 4 3 2 1 0

8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0

9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0

10. Do you feel that the references were adequate? Yes No

11. Would you participate in a similar program on a different topic? Yes No

12. If any of the continuing education questions were unclear or ambiguous, please list them. ________________________________________________________________

13. Was there any subject matter you found confusing? Please describe. _________________________________________________________________

14. How long did it take you to complete this course? _________________________________________________________________

15. What additional continuing dental education topics would you like to see?

_________________________________________________________________

AGD Code 134

INSTANT EXAM CODE 15143

Questions

800.552.5512 | ultradent.com© 2016 Ultradent Products, Inc. All Rights Reserved.

No one wants to leave the dentist’s office with a gritty film masking their teeth. That’s why we developed Enamelast with an exclusive formula that provides sustained fluoride release and leaves the teeth feeling natural and smooth. Before Enamelast

After applying Enamelast

Everything you want in a fluoride varnish. At last!

Orange Cream

WalterberryBubble Gum

Cool Mint

WHAT IS

FAVORITE FLAVOR?