1. Fluoride Varnish Application

2. 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

3. 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

4. Programme Manual
The web address is: Follow links: Professional > Childsmile manuals
Programme Manual
for Childsmile Staff
March 2014

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

6. 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

7. 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.

8. 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

9. 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.

10. Chronic fluoride ingestion causes fluorosis

11. Fluoride Varnish Application Duraphat®

12. Fluoride varnish resources

13. 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]

14. 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

15. 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 ?

16. 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

17. 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
Prescribing Duraphat is the DENTIST’S responsibility

18. 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

19. 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

20. 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

21. 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

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

23. 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

24. 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

25. Communicating with children
What can we do well?

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

27. Training DVD

28. Practical session

29. Learning Points
Feedback from practical session

30. 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.

31. Caries Prevention

32. Summary

33. Evidence
Scottish Dental Clinical Effectiveness Programme The Scottish Intercollegiate Guidelines Network (SIGN) The Cochrane library Childsmile Programme The yellow card scheme