Guidelines for Use of Fluorides in Australia: Update 2019

[Complete with corrections by ‘Fluoridation Australia’]

National Oral Health Promotion Clearinghouse,
Australian Research Centre for Population Oral Health,
The University of Adelaide,
Adelaide 2019 

Corresponding author: 

Professor Loc Do, loc.do@adelaide.edu.au The University of Adelaide 

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record.
Please cite this article as doi: 10.1111/ADJ.12742 

This article is not protected by copyright it is now in the public domain.

ACKNOWLEDGEMENT 

National Oral Health Promotion Clearinghouse, Australian Research Centre for Population Oral Health Australian Dental Association
Australian Dental and Oral Health Therapists’ Association Dental Hygienists Association of Australia (DHAA Ltd) Colgate Oral Care 

J Aldis, J Miller, AJ Spencer, LG Do and D Brennan organised the Workshop. Presenters reviewed and presented evidence of specific topics for discussion. WM Thomson moderated the discussion. 

LG Do and AJ Spencer prepared the Guidelines document. Attendees provided feedback and approved the final document. 

DISCLAIMER 

These guidelines reflect the consensus [‘a generally accepted ( opinion’- not unanimous) ] among a group of people: view of the 60 attendees at the workshop, drawn from all states and territories and representing academics from Australian dental schools, jurisdictional health authorities and peak organizations in dentistry. While the guidelines reflect the views of those attending the workshop, they may not reflect the views of the organizations with which those attendees are affiliated. 

Attendees 

(P) denotes presenter at the workshop 

Jacqueline Aldis Sandra Anderson Peter Arrow (P)
Janis Baines (P)
Derek Bazen
Linda Bertram-Takacs David Brennan (P) Bijun Cai 

Lyn Carman
Susan Cartwright (P) Mikaela Chinotti 

Matthew Hopcraft Eithne Irving
Lisa Jamieson (P) Kostas Kapellas Jeroen Kroon Yvonne Lai Dianne Lantry Adrienne Lewis Liana Luzzi 

Stuart Marshall Angela Masoe 

Susanne Sofronoff Woosung Sohn (P) Youngha Song
A. John Spencer (P) Nicole Stormon 

W. Murray Thomson (Moderator) 

Frederick Wright (P) Sergio Chrisopoulos Deborah Cole
Cathy Connor (P) Stuart Dashper (P) Yvonne Dimitropoulos Loc G Do (P) 

Ian Epondulan Catherine Feeney Mario Ferrari Michael Foley (P) Ashlea Furlan Diep H Ha (P) Martin Hall 

Chris Handbury Jane Harford (P) Kelly Hennessy 

Jenny McKibben Jennifer Miller Paula Moynihan Utz Mueller (P) Rahul Nair 

Carol Nevin
Kristy Nixon
Peter Osborne
Mark Penrose
Melissa Plath
Anil Raichur
Sarah Raphael
Kaye Roberts-Thomson (P) Tanya Schinkevitsch 

John Skinner Karen Smart 

DR. LOC DO (Orcid ID : 0000-0003-3684-9949) 

Article type : Review (by invitation of Editor) 

Guidelines for Use of Fluorides in Australia: Update 2019 

Australian Research Centre for Population Oral Health, The University of Adelaide,
Adelaide 2019 

Corresponding author: 

Professor Loc Do, loc.do@adelaide.edu.au The University of Adelaide 

Running Head: Guidelines for Use of Fluorides in Australia 

Abstract: 

Fluoride use is the cornerstone of dental caries prevention.

Only a few nation fluoridate their water,

There are numerous sources of fluoride which may have different balance of risks and benefits. The first National Guidelines for Use of Fluorides in Australia were developed at a national Workshop in 2005, and updated in 2012. Since then, more evidence on the balance of risks and benefits of fluoride has become available. A third national Workshop was convened in 2019 to update the Guidelines for Use of Fluorides in Australia. 

Keywords: Fluoride, Guidelines, Australia 

Introduction 

Poor oral health is a major health issue. Oral conditions affect 3.9 billion people worldwide, with untreated decay in permanent teeth the most prevalent condition globally 

. Dental caries is the most prevalent oral disease in Australian children and Australian adults . Dental caries has significant negative impact on health, development, behaviours and quality of life of the affected widespread dental problems, dental health expenditure in Australia is large, amounting to $10.15 individuals and their surroundings, as well as economic cost on the society Consistent with billion in 2016-17

. 

While sugar consumption and dental plaque remain as key aetiological factors for dental caries, the use of fluorides has been the cornerstone of caries prevention. Research has led to the development of two central preventive programs involving water fluoridation and use of fluoridated toothpaste 6, 78 . Water fluoridation (WF) is recognized as one of the most effective public health interventions.

The efficacy of fluoridated toothpaste is well established, and while it is an individual behaviour, toothbrushing with a fluoridated toothpaste is widespread across the population.

Development of the national guidelines on fluoride use 

In October 2005, ARCPOH hosted a workshop on the Use of Fluorides in Australia aimed to update information on the nature and distribution of dental caries and fluorosis; to update information on the nature and use (or exposure) to fluorides; to consider the trade-off of the benefit of caries prevention versus the risk of dental fluorosis; to review the evidence of the efficacy/effectiveness of a range of individual fluorides in caries prevention and their risks for creation of dental fluorosis; and to develop guidelines for the use of fluorides in Australia. A second workshop was held in Adelaide in August 2012 to review those guidelines using critical reviews of the latest national and international evidence a total of 10 recommendations from the 2005 workshop remained unchanged as no new evidence was available to warrant amendment, and 6 recommendations were amended.

A third workshop on ‘The use of Fluorides in Australia’ was held in February 2019 in Adelaide, attended by 60 academic and dental health professional experts. The workshop was moderated by Professor Murray Thomson of the University of Otago. In this workshop, presentations were held on the themes of oral disease, effects of fluoridation on dental and human health, and the use of discretionary and professionally applied fluorides. This update of the fluoride guidelines reflects the presentations and consensus discussion from that workshop. 

In these 2012 fluoride guidelines for Australia, 

The workshop 

Recent evidence: oral diseases in Australia: dental caries and dental fluorosis Dental caries in children

Dental caries, the primary target condition of any dental program using fluorides, is one of the most prevalent and important chronic conditions in children. Dental caries is a serious public health their primary teeth with a mean decayed, missing or filled teeth (dmft) of 1.5

10-year-old children had untreated dental caries in their primary dentition. Just under one-quarter of children aged 6–14 years had experienced caries in their permanent teeth with a mean decayed, missing or filled permanent teeth (DMFT) of 0.5. Further, over one in ten with untreated dental caries in their permanent teeth. 

While there has been a substantial improvement in children caries experience across the years since World War II, changes in the last two decades have been more subtle. In children, there have been small improvements in dental caries experience in the primary dentition during the 1990s and 2000s. During the same period, dental caries experience in the permanent dentition has improved a little more (Do and Spencer 2016). Many children have no or minimal caries experience, but a small proportion still experience elevated levels of caries. Some 20% of children aged 5–10 years carried over 80% of the total population burden of dental caries in the primary dentition. Likewise, some 17% of children aged 11–14 years carried 80% of the total population burden of dental caries in the permanent dentition (Ha et al. 2016). 

There are strong geographical variations in child dental caries experience in Australia. Children in Queensland, mostly non-fluoridated until the late 2000s, and in the Northern Territory, with a high proportion of Indigenous children, consistently had higher prevalence and severity of dental caries than the national averages. (Not true)

Hence, there is a need to maintain the vastly lowered caries experience for most of the child population, and to intervene among individual or groups of children among with higher prevalence and severity of dental caries to further to further improve child dental health in Australia. 

problem in both developing and industrialised countries
In the 2012-14 National Child Oral Health Survey, over 40% of children aged 5–10 years had caries in 

Dental caries in adults 

Dental caries affects a large majority of Australian adults
related. Some three quarters of young adults aged 15–34 years had caries while almost all adults of older ages had dental caries experience. People aged 15–34 years had on average 4.5 teeth affected 

. Dental caries experience is strongly age- 

. Over a quarter of 5– by caries, but those 55+ years, born before the commencement of fluoride use in Australia had more than 20 teeth affected. 

Dental fluorosis 

Australia’s approach to the use of fluorides has given primacy to achieving a near maximal reduction in dental caries without an unacceptable level of dental fluorosis. Nearly 90% of Australians live in areas with fluoridated drinking water. In addition, most Australian children and adults brush with a fluoridated toothpaste. Water fluoridation, toothpaste use and other fluoride sources are associated 

12-15
discretionary fluorides from the early 1990s have resulted in significant reduction in the prevalence 

with an increase in the prevalence of any fluorosis 

. Measures aiming at reducing exposure to 

16
few children were found with mild or more severe fluorosis. Similar findings were reported in a large 

18 

and severity of dental fluorosis in both fluoridated and non-fluoridated areas in WA 

and SA 

17 

. Very 

population-based survey in NSW in 2007 

. 

The National Child Oral Health Study 2012-14 provided the first ever national snapshot of the prevalence and severity of dental fluorosis in Australian children. Any level of fluorosis experience (a Thylstrup and Fejerskov (TF) score of 1+) was found in one in six Australian children. However, just under one per cent of children had more definitive dental fluorosis (having a TF 3+ score). Very few children were observed with moderate to severe dental fluorosis (TF scores of 4 or 5). 

Research on the natural history of dental fluorosis and its long-term impact has indicated that very mild to mild fluorosis as observed in Australian children diminished over time (Do et al 2016). Dental fluorosis was not found to have long term negative impacts on oral health-related quality of life. 

Recent evidence: Update on Nutrient Reference Values for fluorides 

Nutrient Reference Values (NRVs) may be established to represent an estimated average requirement (EAR) or an adequate intake (AI) intended to cover average nutrient requirements and/or an upper level (UL) of intake, above which the risk of adverse effects increases. In 2007 an AI and UL were established for fluoride. In 2017, the National Health and Medical Research Council 

19 

(NHMRC) revised the UL for fluoride for infants and young children up to 8 years of age 

. 

Two biomarkers were selected for the evidence review for infants and young children; dental caries and dental fluorosis, as measured by the dmf/DMF index and Dean’s index respectively. Eight critical reports were identified (1997-2010); a database search of 977 papers revealed further information 

20 

from three studies that met the search criteria (GRADE assessment)
referred to the Dean studies in US cities during 1936-42 linking dental health and natural fluoride levels in water supplies. An Expert Working Group concluded there were no better data to use as a 

. The critical reports all 

basis for establishing fluoride NRVs, as contemporary population studies were confounded by fluoridated toothpastes and/or products containing fluoride. 

The AI is based on a mean fluoride intake from the diet (including drinking water with NHMRC Drinking Water Guideline of 1.0 mg F/L) that effectively minimises dental caries. The previous AI (0.05 mg/kg body weight (bw)/day) for infants and children up to 8 years old age group was maintained. A change was made in 2017 in that the AI is not considered applicable to infants aged 0-6 months, as breast feeding is assumed for most infants. A new UL of 0.2 mg/kg bw/day, which minimises dental fluorosis of concern, was based on the 95th percentile of fluoride dietary intake assuming fluoridation of water at 1.9 mg/L. Estimated fluoride intakes from all sources (i.e., diet including water and other beverages, fluoridated toothpaste and/or supplements) in Australia and New Zealand for infants and children up to 8 years old were distributed around the AI but less than this new UL. This supports the continued use of fluorides in Australia including the fluoride level for drinking water and widespread use of low fluoride toothpaste from the age of 18 months and regular toothpaste from 6 years. 

The National Guidelines on Fluoride Use 2019 

A. CommunityWaterFluoridation 

Community water fluoridation has been the cornerstone of efforts to prevent caries in Australia since the 1970s. This position has been underpinned by population oral health research and reaffirmed across several generations of NHMRC reviews including reviews in 1991 and 2007. Previous iterations of these guidelines have had access to these reviews and contemporary research 

9, 10
had access to the most recent NHMRC review and even more recent contemporary research. 

Effectiveness of water fluoridation 

In 2017 the NHMRC conducted an extensive review of the evidence on the effectiveness and safety 

in arriving at its position on community water fluoridation 

. This iteration of the guidelines again 

15
York Review 6 and an update conducted by NHMRC in 2007 21 were used as a background. NHMRC 

of community water fluoridation
then considered the Cochrane Review of the Effectiveness of Water Fluoridation 

. In assessing the evidence on water fluoridation and caries, the 

22 

shortcomings of the Cochrane Review were noted
the included evidence to before and after non-randomised controlled studies. This had the effect of limiting the evidence to studies predominantly conducted prior to 1975. 

NHMRC set about collecting further evidence. Evidence on water fluoridation and dental caries was collected through a review of reviews which included a wider range of study designs and the 23 

. Some
. Most prominent of these was the restriction of 

collection of primary studies published after those reviews across the period 2012-15, with an emphasis on Australian research. The 2017 NHMRC Review found consistent evidence that water fluoridation at current Australian levels is associated with decreased prevalence and severity of tooth decay in children and adults. 

Research published post 2015 from Australia’s National Child Oral Health Study (NCOHS) 24, 25 and the National Survey of Adult Oral Health (NSAOH) 26 extended evidence available on the effectiveness of water fluoridation in reducing dental caries. 

Two recent studies among specific sub-populations also added support to the benefits of community water fluoridation. These were conducted in NSW and in a remote Indigenous community in far 

27, 28 

north Queensland 

. 

Safety of water fluoridation 

The NHMRC Review searched the post-2006 literature for evidence of possible harmful effects of 

15 

The evidence reviewed by the UK York Review 6 and the Cochrane Review 22 confirmed the dose- response relationship between fluoride levels occurring naturally in drinking water and dental fluorosis. However, most of the studies behind this association were from countries where the levels of naturally occurring fluoride in water supplies are up to five times greater than levels used in Australia for water fluoridation. There have also been concerns over confounding by exposure to other fluorides and the threshold for dental fluorosis of aesthetic concern. Therefore, other literature, predominantly from Australian studies were also considered by the NHMRC Review . In Australia dental fluorosis has declined over a time when the extent of fluoridation in Australia has expanded. Most of the dental fluorosis in Australia is very mild or mild. Research suggests that this level of dental fluorosis is not of aesthetic concern to affected children and adolescents or their parents. Moderate dental fluorosis is uncommon and severe dental fluorosis is rare in Australia. 

The prevalence of fluorosis in Australia was well below that documented in the USA which led to the reduction in the US recommended level of fluoride in drinking water to 0.7 mg F/L in draft 

29
either from an aesthetic perspective alone or from a community perspective on the impact of both 

water fluoridation on human health
current Australian levels is not associated with cognitive dysfunction, lowered IQ, cancer, hip fracture and Down syndrome. There was no reliable evidence of an association between water fluoridation at current Australian levels and other human health outcomes. 

form in 2011 

and formally in 2015 

30 

. Further, the prevalence of fluorosis of concern in Australia, 

. The NHMRC Review concluded that water fluoridation at 

15 

caries and fluorosis through ratings of oral health, was low
considered for the revision of the Use of Fluorides in Australia guidelines in 2012 and no change was made in the fluoride level in drinking water for fluoridation as practised in Australia. This was rationalised on the basis of Australia’s success in maintaining caries prevention in children while simultaneously reducing the prevalence and severity of dental fluorosis since the early 1990s through a range of measures targeting critical exposures in early childhood from the use of 

16, 17, 32 fluoridated toothpaste and other discretionary fluorides . 

Impact on social and racial inequalities in childhood caries 

The NHMRC Review 2007 21 noted commentary evidence that water fluoridation reduces the 

inequalities between socioeconomic groups. However, a lack of high-quality, relevant evidence was 

also noted. The York review, in England, reported “some evidence that water fluoridation reduces 

6
reported “insufficient evidence to determine whether WF results in a change in disparities in caries 

22 

the inequalities in dental health across social classes in 5–12-year olds.” 

2, 31 

. A Cochrane review
. The recent NHMRC Review found additional evidence suggesting that WF 

across levels of SES.”
reduces decay for lower socioeconomic groups and regional areas limited, with studies of low quality. 

15 

. However, evidence was 

Race- and income-related inequalities in oral health in Australian children by fluoridation were 

33 

A secondary analysis of a nation-wide longitudinal birth cohort study of Australian children also 

contributed evidence of impact of water fluoridation on socioeconomic inequalities in child oral 

34 health . 

The 2019 Guidelines on water fluoridation 

Therefore, the Workshop supported the continuation of water fluoridation at current Australian levels and recommended: 

1. Water fluoridation should be continued as an effective, efficient, socially equitable and safe population approach to the prevention of caries in Australia. 

examined recently using national data
Water fluoridation was associated with lower caries experience in nearly all race and income stratifications of this population-based study. Indexes of inequality indicated that caries experience was concentrated among lower income groups. Absolute inequalities were consistently lower in fluoridated than non-fluoridated areas. Income-related inequality in caries was also lower in fluoridated than in non-fluoridated areas for both Indigenous and non-Indigenous children. 

. The US recommendation was 

. Caries was socially patterned, both by race and income. 

2. Water fluoridation should be extended to as many non-fluoridated areas of Australia as possible, supported by all levels of Government.

3. The level of fluoride in the water supply should be within the range 0.6–1.1 mg/L.

4. For people who choose to consume bottled or filtered water containing fluoride, manufacturers should be encouraged to market bottled water containing approximately 1.0 mg/L fluoride and water filters that do not remove fluoride. All bottled water and water filters should be clearly labelled to indicate the concentration of fluoride in water consumed or resulting from the use of such products.

5. People in non-fluoridated areas should obtain the benefits of fluoride in drinking water by using bottled water with fluoride at approximately 1 mg/L.

   Note to Recommendation # 3: Individual states and territories have set targets and tolerances for fluoride in their water supplies with all being within the range 0.6–1.1 mg/L. 

B. Self-usefluorideproducts–fluoridatedtoothpaste 

Toothpaste for children and adults 

The use of fluoridated toothpaste by children under the age of 6 years has been the focus of guidelines in Australia since 1993. Two strands of action have been pursued: changed practices by children and their parents in the use of fluoridated toothpaste (age of commencement, amount of toothpaste applied to a brush, the size of the working head of the brush, spitting out toothpaste foam and not rinsing, and not eating or licking toothpaste directly from the toothpaste tube) 16, 17; and the availability and recommended use of a low fluoride children’s toothpaste. The reported behaviour of children in toothbrushing indicates that most brush in line with guidelines, apart from about one third of children commencing brushing with fluoridated toothpaste before the recommended age of 18 months. Market leaders in toothpaste products have also supplied low fluoride children’s toothpaste with appropriate labelling on use, something for which they are commended. 

The topic of what the concentration of fluoride should be in children’s toothpaste has been visited 

several times in Australia. In 2012 further consideration was stimulated by the availability of two 

Cochrane systematic reviews of the efficacy of fluoridated toothpaste of different fluoride 

35, 36 

concentrations
in toothpaste. Most evidence was on the immature permanent dentition which is erupting from age 6 years. Only four studies were available on the primary dentition. The effect of low fluoride toothpaste compared to a placebo 35 on the primary dentition was limited to one trial in children 6 to 9 years of age. This age range of participants raises the issue of relevancy. Head-to-head 

. The reviews examined efficacy in caries prevention in children by fluoride dose 

comparisons between active interventions were limited to 3 interventions in children with a primary 

36
significant differences in caries outcomes by fluoride concentration. This evidence was considered 

dentition up to the age of 5 years old with mixed results 

. Two of these studies reported non- 

equivocal at the 2012 Workshop
and is discussed in Appendix 2, Addendum # 1. 

10 37 . Further evidence has become available after the Workshop 

Evidence of clinical trials assessed in these Cochrane Reviews was therefore in line with the 

population level evidence, particularly that from Australian research. This includes the lack of 

significant change in caries in young children after the introduction of low fluoride children’s 

toothpaste and other alterations to tooth brushing behaviour in Western Australia 16 and in South 

12, 17 

Australia 

. 

Toothpastes – older adults. 

As Australia’s population ages, there is an increasing necessity to ensure that the prevention of the major oral diseases affecting older Australians is evidence-based, relevant and accessible to all. The home use of toothpastes by adult Australians is pervasive, with most older Australians using the standard products available which contain 1–1.45 mg/g fluoride (or 1000–1450 ppm). For older Australians with a high risk of root caries (as well as coronal caries) toothpastes containing up to 5 mg/g fluoride (or 5000 ppm) have been available for use. 

The international evidence for adult use of 1.5 mg/g fluoride (or 1500 ppm) toothpaste is supportive 

of the benefits to adults and older persons, but care should be taken in the interpretation of the 

effectiveness and efficiency given the variability of populations and the scarcity of dedicated, 

longitudinal clinical trials specifically controlling for enumerable confounding factors. Evidence for 

the use of 5 mg/g fluoride (5000 ppm) toothpaste, specifically in populations at high risk is more 

compelling and could guide good practice in most situations specific to older dentitions at elevated 

38, 39 

The 2019 Guidelines on fluoridated toothpaste 

6. From the time that teeth first erupt (about six months of age) to the age of 17 months, children’s teeth should be cleaned by a responsible adult, but not with toothpaste.

7. For children aged 18 months to five years (inclusive), the teeth should be cleaned twice a day with toothpaste containing 0.5–0.55mg/g fluoride (500–550ppm). Toothpaste should always be used under the supervision of a responsible adult. A small pea-sized amount should be applied to a child-sized soft toothbrush and children should spit out, not swallow,

risk to caries
workers who have been trained and are competent may engage provision of toothbrushing and toothpaste advice to individuals and groups of older Australians. 

. Allied health practitioners, registered or enrolled nurses and Indigenous health 

and not rinse. Young children should not be permitted to lick or eat toothpaste. Standard toothpaste is not recommended for children under six years of age unless on the advice of a dental professional or a trained health professional. 

8. For people aged six years or more, the teeth should be cleaned twice a day or more frequently with standard fluoride toothpaste containing 1–1.5mg/g fluoride (1000– 1500ppm). People aged six years or more should spit out, not swallow, and not rinse.

9. For people who do not consume fluoridated water or who are at elevated risk of developing caries for any other reason, guidelines about toothpaste usage should be varied, as needed, based on dental professional or trained health professional advice. Variations could include more frequent use of fluoridated toothpaste, commencement of toothpaste use at a younger age, or earlier commencement of use of standard toothpaste. This guideline may apply particularly to preschool children at elevated risk of caries.

10. For teenagers, adults and older adults who are at elevated risk of developing caries, dental professional or trained health professional advice should be sought to determine if they should use toothpaste containing a higher concentration (5 mg/g or 5000 ppm) of fluoride.

C. Self-usefluorideproducts–fluoridesupplements 

There has been no updated evidence on the effectiveness and safety of fluoride supplements since the last Workshop. 

The 2019 Guidelines on fluoride supplements 

11. Fluoride supplements in the form of drops or tablets to be chewed and/or swallowed, should not be used. 

D. Self-usefluorideproducts–fluoridemouthrinses 

A minority of mouth rinse products purchased by Australian consumers contain fluoride ion at the recommended concentration of 200–900mg/L for daily and weekly use respectively. Some overseas research has examined daily or weekly supervised fluoride mouth rinse programmes as a strategy for sub-populations such as school children. However, no such programmes are being pursued in Australia. Instead, fluoride mouth rinses offer an additional fluoride vehicle for individuals with elevated risk of caries. Population data reveal that the use of fluoride mouth rinse increases among adolescents (Do and Spencer 2016). This suggests that it may represent an appealing additional source of fluoride among adolescents deemed to be at elevated risk of developing caries. However, it would be important to ensure that any such use of mouth rinse would not substitute for toothbrushing with fluoridated toothpaste. Children aged less than six years should not use fluoride mouth rinses because of the probability of its ingestion and risk of dental fluorosis. 

The 2019 Guideline on fluoride mouth rinses 

12. Children below the age of six years should not use fluoride mouth rinse.

13. Fluoride mouth rinse may be used by people aged six years or more who have an elevated risk of developing caries. Fluoride mouth rinse should be used at a time of day when toothpaste is not used, and it should not be a substitute for brushing with fluoridated toothpaste. After rinsing, mouth rinse should be spat out, not swallowed.

E. Professionallyappliedfluorideproducts 

Fluoride varnishes 

Fluoride varnish contains 22.6mg/ml fluoride ion suspended in an alcohol and resin base. The most common product available in Australia is Duraphat. It is applied by dental and other health professionals directly to dried teeth where it forms a waxy film that adheres to the teeth until it is worn off by chewing or brushing. There are other fluoride-containing varnish products on market today, with varying compositions and delivery systems. However, most are registered for use with dentine hypersensitivity not for the prevention of caries. 

Fluoride varnish is effective in reducing caries in young children, adolescents and adults; for the 

40 

prevention of coronal caries on all surfaces of the teeth; and for the prevention of root caries 

. 

Their application up to four times a year has not been linked to an increased risk of dental fluorosis 

41 . 

There are provisions in place in most Australian jurisdictions for application of topical fluoride 

42 

The 2019 Guideline on fluoride varnishes 

14. Fluoride varnish should be used for people who have an elevated risk of developing caries, including children under the age of 10 years. 

varnish by non-dental professionals
with appropriate training may be involved in applying fluoride varnish. Other non-dental professionals who may be involved are usually registered or enrolled nurses, rural/remote health workers or Aboriginal health workers who have undergone specific training overseen by dental professionals. There is also scope for non-dental professionals use of fluoride varnish to be included in the remit of residential aged care workers and others who work with vulnerable populations. 

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. This broadens the opportunity for their use. Dental assistants 

Fluoride gel and foam 

Fluoride gels contain a high concentration of fluoride, typically up to 12.3mg/g fluoride. They are applied by dental professionals using trays that retain the material on the teeth for several minutes. After removal of trays, patients must spit out the residual gel. There is evidence of their effectiveness in children, however, they are contra-indicated for use in children under the age of 10 because large amounts of fluoride can be ingested. Further, fluoride gels appear more efficacious in 

43, 44 

The 2019 Guideline on fluoride gel 

15. High concentration fluoride gels (those containing more than 1.5mg/g fluoride ion) may be used for people aged 10 years or more who are at an elevated risk of developing caries. 

Silver diamine fluoride 

Since its development in the late 1960s silver diamine fluoride (SDF) has been used widely in several countries. The US Food and Drug Administration (FDA) granted its breakthrough therapy designation to silver diamine fluoride 38% for use in arresting dental caries in children and adults in 2016. In Australia, SDF is approved by the Therapeutics Goods Administration (TGA) to treat dentinal hypersensitivity. 

46 47 

the permanent dentition
frequency of applications. Like all forms of professionally provided fluoride, gels offer an alternative vehicle for caries prevention for individuals deemed to be at an elevated risk and in whom other fluoride modalities are not available or suitable.
There is no evidence to support the use of foam 

. 

. The reviews found no evidence that the effect was dependent on 

Studies have tested SDF, using different concentrations and varying application regimes 

. There 

45 

has been a resurgence of interest since its large-scale use, in the form of silver fluoride (SF), in public 

dental service for children in Australia in the 1980s. The findings to date suggest that the application 

of 38% SDF twice yearly is effective in arresting active carious lesions in primary teeth and root 

caries in permanent teeth among the elderly, and its major side effect is the black staining of the 

carious lesion. SF has been found comparable to atraumatic restorations with GIC in very remote 

48 

The 2019 Guideline on silver diamine fluoride 

16. Silver diamine fluoride or silver fluoride may be used for people with caries in situations where traditional treatment approaches to caries management may not be possible. 

Indigenous children
to caries management may not be possible due to behavioural or medical management challenges, or where access to care is difficult or not available. 

. Its use may be indicated in situations where traditional treatment approaches 

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F. Monitoring and developing caries prevention strategies in the population 

The use of fluoride for promoting oral health has always involved a balance between the protective benefit against caries and the risk of developing fluorosis when used in young children. Monitoring fluoride exposure in childhood continues to be important in preserving the effectiveness of fluorides in caries prevention while limiting the risk of fluorosis. Appropriate guidelines that are based on evaluation of risk and benefit of each component of fluoride use can lead to a more beneficial outcome. 

There will be a continuing need to review and revise guidelines for the best strategies to prevent dental caries. As noted above in the review of several fluoride vehicles, modifications of the existing guidelines become necessary for reasons including new evidence from clinical trials, changing patterns of behaviour that alter the nature and amount of exposure to fluoride, and emergence of new evidence about the epidemiology of caries and fluorosis. In anticipation of the need for future revisions to these guidelines, it will be important, as in the present instance, to strengthen the evidence-base about individual fluoride vehicles, dental clinical practice, population exposures, and the distribution of oral conditions, particularly the prevalence of caries and fluorosis and the psychosocial impact of both conditions. 

Concurrently, it is important to identify and evaluate all preventive strategies, including caries- preventive agents that are not based on fluoride, such as calcium-phosphate caries preventive agents, xylitol and chlorhexidine. Dental professionals, their patients and the community need to be informed about the potential advantages and disadvantages of new interventions, and whether those new interventions should be used in addition to, or as a substitute for, existing preventive interventions. Interventions that appear promising need to be subjected to clinical trials among the target populations in whom they would be intended for use. Any new preventive agents should be adopted only if they are shown to be at least as effective as existing preventive strategies. It is not enough to adopt interventions merely because they appear promising, even if they are known to cause no harm, because their use may forego opportunities to provide other care that is effective. After the adoption of efficacious interventions in clinical practice or public health settings, their community effectiveness should be monitored through population-based studies. 

Therefore, 

17. There is a need to support further studies that examine the impact of fluoride vehicles in the Australian population including: studies of the epidemiology of dental caries and dental fluorosis; investigations of the impact of both conditions on people’s well-being and quality of life; risk factors for dental caries and dental fluorosis; use of fluoride vehicles in dental 

practice and the population; and the efficacy, effectiveness and cost effectiveness of fluoride vehicles. 

18. Research is needed to develop new preventive interventions including new vehicles for fluoride delivery as well as other preventive strategies that are not based on fluoride. New interventions should be judged for their equivalency or superiority to existing preventive approaches that have documented efficacy. 

Note to Recommendation # 18: Further discussion is provided in Appendix 2, Addendum # 2. Note: All Recommendations are listed in Appendix 1. 

ACKNOWLEDGEMENT 

National Oral Health Promotion Clearinghouse, Australian Research Centre for Population Oral Health Australian Dental Association
Australian Dental and Oral Health Therapists’ Association Dental Hygienists Association of Australia (DHAA Ltd) Colgate Oral Care 

J Aldis, J Miller, AJ Spencer, LG Do and D Brennan organised the Workshop. Presenters reviewed and presented evidence of specific topics for discussion. WM Thomson moderated the discussion. 

LG Do and AJ Spencer prepared the Guidelines document. Attendees provided feedback and approved the final document. 

DISCLAIMER 

These guidelines reflect the consensus view of the 60 attendees at the workshop, drawn from all states and territories and representing academics from Australian dental schools, jurisdictional health authorities and peak organizations in dentistry. While the guidelines reflect the views of those attending the workshop, they may not reflect the views of the organizations with which those attendees are affiliated. 

Attendees 

(P) denotes presenter at the workshop 

Jacqueline Aldis Sandra Anderson Peter Arrow (P)
Janis Baines (P)
Derek Bazen
Linda Bertram-Takacs David Brennan (P) Bijun Cai 

Lyn Carman
Susan Cartwright (P) 

Matthew Hopcraft Eithne Irving
Lisa Jamieson (P) Kostas Kapellas Jeroen Kroon Yvonne Lai Dianne Lantry Adrienne Lewis Liana Luzzi 

Stuart Marshall 

Susanne Sofronoff Woosung Sohn (P) Youngha Song
A. John Spencer (P) Nicole Stormon 

W. Murray Thomson (Moderator) 

Frederick Wright (P) 

Mikaela Chinotti Sergio Chrisopoulos Deborah Cole
Cathy Connor (P) Stuart Dashper (P) Yvonne Dimitropoulos Loc G Do (P) 

Ian Epondulan Catherine Feeney Mario Ferrari Michael Foley (P) Ashlea Furlan Diep H Ha (P) Martin Hall 

Chris Handbury Jane Harford (P) Kelly Hennessy 

Angela Masoe Jenny McKibben Jennifer Miller Paula Moynihan Utz Mueller (P) Rahul Nair 

Carol Nevin
Kristy Nixon
Peter Osborne
Mark Penrose
Melissa Plath
Anil Raichur
Sarah Raphael
Kaye Roberts-Thomson (P) Tanya Schinkevitsch 

John Skinner Karen Smart 

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The above document is public property.