Professional Documents
Culture Documents
What is fluoride?
Mechanisms of Action
Topical
Systemic
Antibacterial
Mechanisms of Action
Topical
inhibits demineralization
promotes remineralization
Mechanisms of Action
Fluorides role in remineralization
When bacteria metabolize carbohydrate and produce acid,
fluoride is released from dental plaque in response to lower
pH levels at the tooth interface (Tatevossian, 1990).
To be more acid resistant and contain more fluoride and
less carbonate, the demineralized enamel crystal structure
takes up released plaque fluoride and salivary fluoride
along with calcium phosphate.
Mechanisms of Action
Remineralization
Demineralization
Demineralization
Remineralization
Mechanisms of Action
Systemic
improves enamel crystallinity
reduces acid solubility
improves tooth morphology (controversial)
Mechanisms of Action
Several studies have reported that teeth formed in fluoridated
communities or exposed to fluoride supplements preeruptively tend to be smaller and have shallower pits and
fissures than teeth formed in non-fluoridated communities or
not exposed to pre-eruptive fluoride supplements (Lovius et al,
1969; Simpson, et al, 1969; Aasenden, et al, 1974).
These researchers believe that even if the differences are small
and do not entirely explain lower caries prevalence, the very
fact that measurable alterations in tooth morphology occur
when there is pre-eruptive exposure to fluoride indicates that
there must be some effect from exposure to fluoride during
tooth development.
Mechanisms of Action
Antibacterial
concentrates in plaque
disrupts enzyme systems
Fluoride inhibits bacterial metabolization of carbohydrates to
produce acid and affects the bacterial production of adhesive
polysaccharides (Hamilton, 1990).
When fluoride is constantly present, mutans Streptococci produce
less acid (Bowden, 1990).
HOWEVER. . .
Clinical epidemiologic data demonstrate both pre- and posteruptive caries-preventive benefits to teeth from fluoride.
Fluoride
--A Brief Glimpse into History- Fluorides ability to inhibit or even reverse the initiation and
progression of dental caries is well documented.
The first use of adjusted fluoride levels in water supplies for
caries control began in 1945 and 1946 in the United States and
Canada.
The first field study occurred in four pairs of citiesGrand
Rapids and Muskegon, MI; Newburgh and Kingston, NY;
Evanston and Oak Park, IL, and Brantford and Sarnial,
Ontario Canada.
Sequential cross-sectional surveys were conducted over the
next 13 to 15 years.
Fluoride
--A Brief Glimpse into History- The findings included:
a reduction in caries of 50 to 70% in children with fluoridated water
supplies.
Fluoride
--A Brief Glimpse into History- The success of water fluoridation in preventing and controlling
dental caries led to the development of fluoride-containing
products, including toothpaste, mouth rinse, dietary
supplements, and professionally applied or prescribed gel,
foam, or varnish.
In addition, processed beverages, which constitute an
increasing proportion of the diets of many U.S. residents, and
food can contain small amounts of fluoride, especially if they
are processed with fluoridated water.
Fluoride
--A Brief Glimpse into History- Benefits of fluoride
Fluoride helps to prevent tooth decay.
People with non-fluoridated water supplies continue to demonstrate higher
rates of decay.
A 15 year landmark study in Grand Rapids, MI showed that children who
had fluoridated water from birth had a 50 to 63% decrease in tooth decay.
In 1993, the results of 113 studies in 23 countries were compiled and
analyzed. The review included 66 studies in primary teeth and 86 studies
in permanent teeth. Together the decay reductions were:
40 to 49% for primary teeth
50 to 59% for permanent teeth
Fluoride
--A Brief Glimpse into History-A comprehensive analysis of the 50 year history of community
water fluoridation in the U.S. demonstrated that the inverse
relationship between higher fluoride concentration in drinking
water and lower levels of dental decay continues to be true
today.
Fluoride
--A Brief Glimpse into History- Water fluoridation is cost
effective.
Per person, it costs on
average $ .50-1.00 per year.
Water fluoridation is
especially beneficial for low
socioeconomic communities
where there is a
disproportionate burden of
decay and less access to
dental care and other
fluoride sources.
Water Fluoridation
Surgeon General David Satcher wrote in his report, Oral
Health in America,
Community water fluoridation is safe and effective in
preventing dental caries in both children and adults. Water
fluoridation benefits all residents served by community water
supplies regardless of their social or economic status.
*Centers for Disease Control and Prevention, Division of Oral Health Fluoridation Census, 1992
and 2000.
Fluoride
--Other Sources- Types of fluorides
In the United States, there are three types of fluorides
approved by the FDA as safe and effective for use in
dentifrices:
Sodium fluoride (for use in paste, must be bound to another
element or it will bind to the abrasive ingredient)
Sodium monofluorophosphate (holds fluoride in complex form and
is released when exposed to phosphatase enzyme in the mouth)
Stannous fluoride (was the first used in dentifrice, was previously
difficult to stabilize, has gingivitis-reduction properties, but has an
astringent taste and potential staining)
Fluoride
--Other Sources- Fluorides for Professional Use
FDA approved for professional use:
Acidulated phosphate fluoride (APF) with 1.23% (12,300 ppm)
Fluoride
--Other Sources- Fluorides for Professional Use (continued)
FDA approved for professional use:
APF
Neutral sodium fluoride (NaFl) with 2% (9,000 ppm)
Fluoride
--Other Sources- Fluorides for Professional Use (continued)
FDA approved for professional use:
APF
NaFl
Stannous fluoride (SnFl) with 8% (not used routinely for topical
semi-annual applications)
Fluoride
--Other Sources- Fluoride Varnish
There is strong evidence for the use of fluoride varnish for
caries control of permanent teeth, but the evidence for
primary teeth is, while promising, inconsistent and
incomplete (IOM Report, 2000).
NaFl varnish delivers 2.26% fluoride (22,600 ppm), the
strongest concentration of fluoride delivered.
Application stays on tooth surface 4 to 6 hours after
application (product is purposely colored to detect
presence)
Fluoride
--Other Sources- Fluoride Varnish (continued)
Effectiveness thought to be the result of substantial
increase in fluorine content of the tooth surface and
subsurface enamel
Fluoride varnish has been used since late 1960 in Europe
and Canada as a primary preventive agent, with as much as
a 75% reduction in decay (GoranKock, 1975).
Fluoride in varnish also gradually dissolves into the plaque,
saliva, and enamel providing bacteriocidal, bacteriostatic,
and remineralizing effects (Nelson, 1984).
Fluoride
--Other Sources- Fluoride Varnish (continued)
No toxic effects were found in the blood plasma levels in preschool
and school children after treatment with varnish. The use of varnishes
is, therefore, safer than gels with small children (Ekstrand, 1981).
Children younger than six years of age tend to swallow 30 to 50% of
gel products (LeCompte, 1987).
The FDA has cleared fluoride varnish as a cavity liner or root
desensitizer. All other uses are currently considered off-label!
After 2 years, fluoride varnish resulted in a higher percentage of
caries reduction than 2% NaFl solution or 1.23% APF gel (Tewart,
2000).
Fluoride
--Other Sources- Which varnish do we
currently use at UKCD?
CavityShield
Fluoride
--Other Sources- Fluoride for Home Use
Home delivery modalities
Neutral sodium fluoride
.05% (225 ppm) rinse
.2% (1,000 ppm) Rx rinse
1,000 1,500 ppm Regular over the counter paste
Fluoride
--Other Sources- Fluoride for Home Use (continued)
Home delivery modalities
Acidulated phosphate fluoride
.044% (1,100 ppm) rinse
5,000 ppm Rx gel
Stannous fluoride
3,000 ppm Rx gel
.63% --Rx rinse
Fluoride
--Other Sources- Fluoride Dentifrices
Best topical application for compliance
Ingestion: 0.2 to 0.3 mg can be swallowed by pre-school
aged children when brushing twice a day
Recommendations/instructions for use
<0.3 ppm
>0.6 ppm
6 months 3 years
0.25 mg/day
--
--
3 years 6 years
0.50 mg/day
0.25 mg/day
--
6 years 16 years
1.00 mg/day
0.50 mg/day
--
Pertinent Issues
Dose/frequencyeffectiveness (low dose, high
frequency is current best use of F)
Bottled water (variable fluoride content, may vary
seasonally and with manufacturer)
Filtration systems: point of use system can reduce
fluoride
Prenatal use (not shown effective)
Formula (0.1 0.3 ppm on average for both soy and
milk-based formulas)
Fluoride Toxicity
Symptoms of overdose
GI (nausea and vomiting)
CNS
Death in 4 hours
Probably toxic dose =
Certainly lethal dose =
5 mg F/kg
16 32 mg F/kg (Hodge
and Smith)
15 mg F/kg (Whitford)
Fluoride Toxicity
Treatment (Augenstein et al)
Determine childs weight and estimate amount ingested
<8 mg F/kg: give milk, observe > 6 hours, refer if
symptoms develop
>8 mg F/kg: give syrup of ipecac, followed by milk; refer
immediately
Unknown dose: if asymptomatic treat as <8 mg F/kg, if
symptomatic (already vomited) give milk, refer
immediately
Contact poison control center: gastric lavage, IV calcium
gluconate
Introduction
--Why do we calculate the Fluoride Ion?-