Fluoride Varnish Application

Learning outcomes Describe the properties of fluoride varnish and how fluoride varnish helps to reduce dental decay. Identify the areas of competency required in the Direct Observational Procedure (DOP) DN only Apply knowledge of the risk assessment protocol prior to application of fluoride varnish DN only Practice the safe use and application of fluoride varnish DN only

Session outline Why apply fluoride varnish and how does it reduce caries Fluoride varnish properties Fluoride varnish safety Completing the reflective journal and DOP How to apply fluoride varnish (DVD) Practical session

Programme Manual The web address is: www.child-smile.org.uk Follow links: Professional > Childsmile manuals Programme Manual for Childsmile Staff March 2014

Why apply fluoride? High quality evidence of the caries-preventive effectiveness of fluoride varnish in both permanent and primary dentitions is available

Standard Prevention for all children Apply sodium fluoride varnish (5%) twice a year to children over 2 years of age Enhanced Prevention for children at increased risk of caries Apply sodium fluoride varnish (5%) an additional 1-2 times per year to children over 2 years of age

The SIGN 183 Guideline found fluoride varnish to be effective in the prevention of decay in permanent teeth and advised that it should be applied to the teeth at least twice yearly for all children.

Marinho VCC, Worthington HV, Walsh T, Clarkson JE Marinho VCC, Worthington HV, Walsh T, Clarkson JE. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2013, Issue 7 www.thecochranelibrary.com

How does fluoride work Topical effect which; Slows down the development of decay by stopping demineralisation Makes enamel more resistant to acid attack and speeds up remineralisation Can stop bacterial metabolism and reduce acid production.

Chronic fluoride ingestion causes fluorosis

Fluoride Varnish Application Duraphat®

Fluoride varnish resources

Fluoride Varnish Safety The dose for a child aged two to six years is 0.25ml Dose for child over six years ( mixed dentition) is 0.40ml. Children should not take fluoride supplements for two days after the fluoride varnish application Ensure Childsmile aftercare instruction/leaflet is given FVAftercareInstructions.pdf [764 Kb]

Toxic dose Acute fluoride toxicity causes nausea and vomiting If a child is suspected of ingesting more than one dose they should be given milk to drink and quickly transferred to A&E There should be no opportunity for a child to ingest more than a single 0.25ml (0.4ml) dose. Acute fluoride toxicity causes nausea and vomiting

Toxic Dose Estimated toxic dose of fluoride ingestion is 5mg of fluoride per kg of child body weight The dose of 0.25 ml of Duraphat® contains 5.6mg of fluoride, well below the toxic dose. If the average 3 year old weighs 11-20kg. What would be the toxic dose ?

An 11Kg child would need to swallow 55mg of fluoride to be considered to have ingested a toxic amount and a 20Kg child would need to ingest 100mg of fluoride. 11Kg = 55/5.6 x 0.25ml = 2.5ml 20Kg =100/5.6 x 0.25ml = 4.5ml

The Collapsed Child Duraphat® applied in the correct dose is not associated with any adverse reactions Every parent is asked about allergies and asthma, and children who have been hospitalised due to severe asthma or allergy or who are allergic to sticking plaster should not have Duraphat applied. Duraphat –Safety Issues information sheet Childsmile Website http://www.child-smile.org.uk/professionals/information-for-dental-practice-staff/practice-documents.aspx Prescribing Duraphat is the DENTIST’S responsibility

The Collapsed Child Protocol Stop the procedure and summon help from the rest of the team/teacher Call 999 and note the time Remove all equipment from the vicinity of the child Put the child in the recovery position Make sure all other children are kept safe and away from the incident

Reporting adverse reactions protocol Remove product by tooth brushing and rinsing and follow local protocol Complete and submit a BNF yellow card as per local procedure If there are any adverse reactions to the fluoride varnish (e.g. mucositis, allergy etc.) then these must be reported, by either the DHSW or the EDDN, to the prescribing dentist http://yellowcard.mhra.gov.uk/

Reflective Diary and Direct Observational Procedure Firstly observe and assist a trainer apply varnish in five cases. Write a reflective statement detailing your learning during observation. Apply varnish to at least 10 children approx age under 10 years with the majority being under 6 years it should be supervised and documented in the reflective diaries Undergo 1 Direct Observational Procedure (DOP). If you are successful then the diary is sent to NES Oral Health Improvement Tutors and you will receive your certificate

Direct Observational Procedure You must be assessed as competent in areas 1-7 to complete the DOP satisfactorily If you do not complete one of the cases satisfactorily the area should be identified and addressed and the DOP re-taken

Competencies Taking a relevant history and risk-assessing for fluoride varnish application Clinical Judgment Technical Ability & Manual Dexterity Communication Skills Professionalism Knowledge Organisation

Child Protection There are many forms of abuse: physical, emotional, sexual, neglect. Everyone has a part to play in making sure children are safe from harm 60% of cases of physical abuse have orofacial signs

Gaining consent Nursery/school programme Follow Childsmile consent protocol for the supply and application of Duraphat Dental practice Follow consent protocol as per local general practice guidelines

Communicating with children What can we do well?

Verbal and non-verbal behaviours Behave Project Verbal and non-verbal behaviours

Training DVD

Practical session

Learning Points Feedback from practical session

Appropriate preventative care Group work In addition to application of fluoride what other simple preventative interventions are available? Discuss what your responsibilities are in terms of preventive advice.

Caries Prevention http://www.sdcep.org.uk/index.aspx?o=2858

Summary

Evidence Scottish Dental Clinical Effectiveness Programme www.sdcep.org.uk The Scottish Intercollegiate Guidelines Network (SIGN) www.sign.ac.uk The Cochrane library www.thecochranelibrary.com Childsmile Programme www.childsmile.org.uk The yellow card scheme http://yellowcard.mhra.gov.uk/