2. PROFESSIONAL APPLICATION
1. Gel and Foam
• Due to the high concentration of fluoride in gels (typically 9,000 and
12,300 ppm F, respectively for neutral and acidified gels), care should be
taken when using these products to avoid side effects
• Gels are usually recommended for children older than 6 years of age.
• The patient should be seated during the application by the professional,
with the head slightly bent forward.
• Suction devices should be used during the application.
• The excess of product must be removed with gauze after application, and
the patient must be instructed to spit out several times
• Application should be avoided in patients with empty stomach, to
minimize possible systemic side effects (fluoride absorption is faster in this
condition
3. F Concentration : 12.300 – 12.500 ppm
Gel APF 1,23%
Gel APF with pH 3,5 : contraindication for composite
restoration / porcelaine
Gel NaF 2%
F Concentration : 9.000 ppm
Neutral pH so there’s no risk for restoration material
4. Individual trays for gel application. It is important to select size-appropriate trays
(left) in order to allow full coverage of all teeth. The gel must be dispensed at a
volume enough to treat the entire arch without excess (center and right), in order
to minimize fluoride ingestion
5. Application of fluoride gel using a tray (left) covering an entire arch, or with cotton
swab (right) treating each hemiarch at a time, allowing adequate moist control (to
enhance CaF2 deposition). Suction device must be used under both conditions to
minimize fluoride ing
6. After gel application, the excess of gel is gently removed with a gauze (left), and
the patient is requested to spit out for 30 s in order to minimize excessive fluoride
ingestion from the product
7. 2. Varnish
Aplikasi Profesional
• Contain 22,600 ppm F (5% NaF)
• The main advantages of varnishes are the prolonged contact time
between fluoride and tooth surfaces, which increases F uptake by
hard dental tissues and the formation of CaF2 reservoirs, and the
possibility of using very small quantities of the product, which
greatly reduces the risk of excessive intake of fluoride
• Should be applied 2–4 times/year in patients at high caries risk
• varnishes can be considered as a safer option when compared to
gels due to the small amount used during the application, since the
systemic exposure from this source is known to be transient and
below the upper limit regarded as safe
8. Fluoride varnish is indicated to arrest or reverse white spot lesions (a, c). After removal of the
dental plaque, the product (previously agitated for its homogenization) should be applied
with the aid of a brush on the caries lesions (b). The dental surface does not need to be
completely dry before application, and light humidification of the varnish after its application
helps in its adhesion to the dental structure. Following the varnish application, the child
and/or caregiver should be reminded not to allow brushing of the child’s teeth or eating
crunchy/sticky foods for the rest of the day to maximize the effect of the fluoride varnish. The
fluoride is slowly released from varnish and requires at least 6 h in contact with the surface of
the teeth
9. Varnish Natrium Fluoride 5%
• Primary tooth surfaces that exhibit active enamel
demineralization, white spot lesions, and non-cavitated
cleansable lesions
• In potentially cleansable lesions, when the caregiver does not
consent to the use of silver diamine fluoride because of the
black discoloration that it causes. It should be noted here
that NRCC using 5% sodium fluoride varnish is most effective
on enamel lesions.
• In children in whom cooperation is limited by age or
disabilities and performing conventional operative dentistry
becomes a challenge.
• A motivated caregiver being a prerequisite for the success of
NRCC using sodium fluoride varnish, a positive outcome of
the procedure is caregiver driven rather than operator
driven.
INDICATION AND
CONTRAINDICATION
10. PROCEDURE
• Plaque must be accessed and
mechanically disturbed/removed
from all tooth surfaces, and the
caregiver is advised on the correct
toothbrushing technique.
• Fluoridated toothpaste with at least
1000-ppm fluoride is recommended
in a child with active carious lesions
• The caregiver is simultaneously
educated to correct any faulty
feeding habits and regulate intake of
refined sugar
As an integral part of NRCC, the caregiver was
motivated to perform meticulous toothbrushing
twice a day with a fluoridated dentifrice. For the
purpose of demonstration, illustration of a
different case is presented here
1. Step 1: Toothbrushing
11. 2. Step 2: Oral Prophylaxis
• Mechanical disruption of plaque
through toothbrushing in
conjunction with professional oral
prophylaxis forms the basis of
NRCC. Professional oral prophylaxis
will remove mature, stubborn plaque
and suppress the activity of bacteria.
It can be done with a rotating rubber
cup or a rotating tuft along with a
light abrasive paste
In-office oral prophylaxis is recommended when
possible. For the purpose of demonstration, illustration
of a different case is presented here
PROCEDURE
12. 2. Step 3: Application of Sodium Fluoride Varnish
PROCEDURE
Following air-drying, 5% sodium fluoride varnish (NaF)
was applied once per week for 3 weeks [9] followed by a
three monthly application of NaF for 1 year. For the
purpose of demonstration, illustration of a different case
is presented here
• Though some recent evidence suggests that an
application of 5% NaF once per week for
3 weeks is favored for young children who are
available regularly for treatment to arrest
lesions, new guidelines recommend
application of 5% NaF varnish on non-cavitated
carious lesions every 3–6 months and
application of 38% SDF on cavitated lesions
biannually. Professional oral prophylaxis
should precede the application of 5% sodium
fluoride varnish. Application of high
concentrations of topical fluoride leads to
formation of a calcium fluoride reservoir in the
active lesion. Calcium fluoride release serves
to slow down the progression of lesion activity
13. Silver Diamine Fluoride ( SDF )
• Primary tooth surfaces that exhibit areas of active cavitated dentinal
lesions (frank soft carious lesions in dentin) with no signs or
symptoms of pulp involvement. These are children where
cooperation is limited by age or disabilities and performing
conventional operative dentistry becomes a challenge
• Deep active carious lesion where the clinician may want to scrub the
lesion with SDF to arrest lesion progress predictably prior to restoring
it with an intracoronal or an extra-coronal restoration.
• To arrest inaccessible proximal lesions where placing a restoration
would involve extensive tooth preparation.
• In multisurface dentinal lesions or difficult to treat cavitated carious
lesions e.g., lower anterior primary teeth where longevity of the
restoration is questionable.
• In children with limited access to dental care SDF is the preferred
choice of treatment given the evidence-based outcomes of
predictable carious lesion arrest.
INDICATION AND
CONTRAINDICATION
14. CONTOH KASUS
1 SDF Application in Posterior Carious Lesions
A deep carious lesion was seen in dentine on the
disto-occlusal surface of tooth 64. A small stained
pit was visible mesially. The occlusal grooves on
tooth 65 appeared stained
• Tooth 64 presented with an active
non-cleansable deep carious lesion in
dentine.
• The child had no signs or symptoms
of pulp pathology.
• The child was 28 months old and
would have been unable to
cooperate for operative procedures.
15. • Radiograph showed the carious
lesion in tooth 64 involving the
inner third of dentin.
• A thin layer of dentine
separated the carious lesion
from the distal pulp horn
16. PROCEDURE
Petroleum jelly was applied to the perioral
areas to prevent accidental staining
• A temporary staining or
silver tattoo occurs if SDF
comes into accidental
contact with the skin or
mucosa.
1.
Step 1: Application
of Petroleum Jelly
17. PROCEDURE
2. Step 2: SDF Application
After air-drying the lesion, SDF was scrubbed
into the lesion with a micro-brush
• One drop of SDF dispensed in a plastic dish is
sufficient to treat roughly 6 teeth
• Isolation with cotton rolls is adequate. When
required, superficial loose debris can be
removed to enable better contact of the SDF
with carious dentin
• The lesion is air-dried, SDF scrubbed on for a
minute, and gently dried
• The site of application should be isolated for
up to 3 min when possible post application
• Fluoride varnish can be applied on the lesion
post SDF application to keep the SDF in
contact with the lesion and to mask the taste
of SDF
• Patients are advised against eating or
drinking for 30 min
18. PROCEDURE
3.
Step 4: Restoration with Glass
Ionomer Cement: SMART
• Silver diamine fluoride Modified
Atraumatic Restorative Technique,
is a concept where the caries-
arresting ability of SDF is combined
with the ability of glass ionomer
cement to seal the carious lesion.
SMART is especially useful in
cavitated non-cleansable carious
lesions in posterior teeth. In this
case ideal proximal contacts could
not be established, as child
cooperation was limited and the
priority was to achieve lesion
arrest and sealing of the lesion. Tooth 64 was restored with high-viscosity glass
ionomer cement—SMART. In tooth 65, the
carious fissures were “sealed in
19. PROCEDURE
3. Step 5: Postoperative Radiograph
• A postoperative
radiograph serves to make
a comparison with future
radiographs to monitor
remineralization of the
carious lesion and lesion
arrest.
Postoperative radiograph was recorded to
compare with a future radiograph
20. PROCEDURE
3. Radiografi post operative
• (a) Eighteen-month follow-up
shows a stable restoration, and the
soft tissue appears healthy. The
dark hue of the arrested lesion
underneath is showing through the
restoration. (b) Note at the end of
eighteen months that the
restoration is stable, and
periradicular tissue is healthy.
There is an increase in the zone of
mineralization between the lesion
floor and the pulp indicating lesion
arrest and mineralization
Post operative radiograph.
