Anti-Caries Agent

Mechanisms of Fluoride Cariostatic actions

Anticariogenic effect

-crystal solubility

-Crystal demineralization / remineralization

Antimicrobial effect

2 mechanisms in which Fluoride gets incorporated into hydroxyapatite crystal

1. Replacement of OH group --> FA

2. Formation of hydrogen bond with OH (OH-F)

3. substitute for carbonate groups

How does forming Fluorapatite affect the crystal structure compared to HA?

-contraction of a-axis

-Fluoride is more electronegative and smaller as ions, so the tighter ionic interaction (Ca-F) will lead to more compact crystal structure.

Overall effect of incorporation of Fluoride to HA:

-increased stability of lattice

-reduction in number of imperfections / dislocations within crystals

-Larger crystal presenting SMALLER surface area/volume ratio --> less reactivity

--> low acid solubility

--> decreased rate of demineralization

--> Less susceptible to caries

Fluorapatite has a (smaller/larger) crystal presenting (smaller/larger) surface area/volume ration compared to HA.

Larger ;

smaller

Anti-bacterial effect of fluoride is _______________ -dependent.

concentration & pH

How does concentration and pH determine the antibacterial effect of fluoride?

at pH 7, 12,000 ppm is required to be bactericidal;

at pH 5, only 6-8 ppm is required.

Reducing the pH increases the sensitivity of plaque bacteria to Fluoride.

At neutral pH, _______ ppm of fluoride is required for it to become bactericidal

> 1000 ppm

What occurs on the surface of plaque and tooth surface at high fluoride concentration?

1. Release of Calcium from enamel

2. calcium reacts with fluoride

--> Formation of CaF2 globules

--> These globules are popped and contents released under acidic conditions

Describe systemic vs. Topical Fluoride application

Systemic

-fluoride ingested (prescription, fluids) during developmental stage of tooth

-can cause fluorosis if ingested too much

Topical

-rinses, dentirifices, toothpaste, etc

-does NOT cause fluorosis

Critical age of baby to ingest fluoride (systemically) :

birth to 8 years

(critical 1~2.5 year old)

Can Topical fluoride application cause fluorosis?

NO ; only systemic fluoride will cause it.

List types of Fluorides

-Sodium Monofluorophosphate

-NaF

-Stannous fluoride

-Amine Fluoride

-Titanium (IV) fluoride

-38% silver diamine fluoride

-Zinc fluoride

____________ is a type of fluoride specifically found in toothpaste

Sodium monofluorophosphate

Sodium monofluorophosphate

-found in toothpaste

-1000~1200 ppm of fluoride

-water soluble

e.g. Colgate toothpaste

Sodium fluoride (NaF)

-Attraction to calcium

-small ion - cannot occlude tubules

-water soluble

-Used professionally in dental office.

e.g. Rinses, gels, foams, dentifrices, varnishes

(NaF/ sodium monofluorophosphate) delivers the fluoride ions much more immediately upon applying.

NaF

Stannous fluoride (SnF2)

-Used professionally

-e.g. gels and rinses (dentifrices)

-2 active ions - attracts both calcium and phosphate

-Water-insoluble

-may cause SURFACE DISCOLORATION

-bactericidal/antimicrobial --> used to cure gingivitis

-alters electromagnetic charge of cell wall

-penetrates bacterial cell wall, interrupting formation of plaque

-Capable of BLOCKING dentinal tubules --> good for hypersensitive gum

-prevents lamination of lesion surface (inhibits surface arrest)

_______________ fluoride alters the bacterial cell wall, interrupting the formation of plaque

Stannous fluoride (SnF2)

____________ fluoride is bactericidal, good for treating gingivitis

Stannous fluoride (SnF2)

_____________ fluoride uniquely has 2 active ions, enabling to attract both calcium and phosphates

Stannous fluoride (SnF2)

_______________ fluoride may cause surface discoloration

Stannous fluoride

_______________ fluoride is insoluble, so it will not be washed away like other fluoride ions

Stannous fluoride (SnF2)

______________ fluoride ions are big enough to occlude the dentinal tubules --> good for hypersensitivity

Stannous fluoride (SnF2)

_______________ fluoride inhibits lamination of lesion surface

stannous fluoride

_____________ fluoride helps with slow, gradual, homogenous remineralization, preventing surface arrest.

Stannous fluoride (SnF2)

Composition of Silver diamine fluoride

-Water

-silver (25%) - kill bacteria & react w/ dentin proteins to form protective layer

-ammonium - high pH

-fluoride (5%) - remineralization

Properties of Advantage arrest

This is a type of Silver diamine fluoride

____________ fluoride is specifically good for arresting caries

silver diamine fluoride

_____________ arrests caries more effectively than fluoride varnish

Silver diamine fluoride (Advantage arrest)

38% Silver diamine fluoride

-Arrests caries (even cavitated ones)

-relieves sensitivity

-Antimicrobial activity

-silver ions are bactericidal metal cations --> inhibit biofilm formation

e.g. Advantage arrest

What is the function of Silver ions in silver diamine fluoride?

-Antimicrobial

-Bactericidal

-inhibition of biofilm formation

____________ fluoride serves as a cavity liner for deep restoration

38% silver diamine fluoride

Post-Silver diamine fluoride application treatment options

(SDF turns the arrested lesion to black)

-excavate the lesion and restore

-partial removal of arrested lesion and restore

-SMART- Silver modified atruamatic restorative treatment

-leave the SDF reservoir and reapply every 6 months

____________ fluoride is recommended to be used in management of caries in primary dentition

38% silver diamine fluoride

Side effects of application of 39% silver diamine fluoride

-Black staining (ONLY on demineralized area, not on sound enamel)

-discolors the soft tissue as well - temporarily

-mucosal irritation

Fluoride varnish effectiveness on enamel and dentin

-reverses 2/3 of enamel lesions

-No effect on dentin lesions

____________ fluoride lasts up to 3 months

5% NaF Varnish

Advantages vs. Disadvantages of 5% Sodium fluoride varnish (NaF)

Advantages

-caries reduction

-easy to apply

-prolonged fluoride uptake

-small amount ingested

Disadvantages

-taste

-yellow layer

Fluoride varnish applied 2-4 times a year prevent caries in children/adolescents by up to ______%

40%

Fluoride varnish uses are for (low/moderate/high) caries risk group

only LOW (sometimes moderate)

(for moderate and high caries risk group- no point in attempting to arrest caries when they have bad habits already)

Acidulated phosphate fluoride

-NaF with phosphoric acid

-prevents caries

-provides greater fluoride uptake

-pH 3~4

-water soluble

-1 active oin

-professionally available

e.g. gels, foams, rinses, dentifrices

____________ fluoride reduces caries up to about 40%

5% NaF varnish

What is a Dentifrice?

TOOTHPASTE (or powder)

____________ fluoride has pH 3~4 (slightly acidic), helps with whole lesion remineralization instead of just surface arrest

Acidulated phosphate fluoride

____________ fluoride causes etching on the surface, increasing Fluoride diffusion/uptake

Acidulated phosphate fluoride

Advantages vs. Disadvantages of Acidulated phosphate fluoride

Advantages

-caries reduction

-acceptable taste

-stable gel/foam for Tray application

Disadvantages

-possible excessive ingestion causing GI upset

-intolerance to trays

-porcelain/veneer etching

____________ fluoride is the one that can be applied with Tray

Acidulated phosphate fluoride

Protocol of Acidulated phosphate fluoride is _____-minute application

4

(the longer it's left, the more absorbed)

____________ fluoride is to be avoided w/ porcelain crowns and veneers, because they tend to degrade them.

Acidic topical fluoride

esp. Acidulated phosphate fluoride

Which 2 types of fluoride have antimicrobial effects?

SnF2 (stannous fluoride)

Silver diamine fluoride

which 3 types of fluoride are good for controlling sensitivity?

SnF2 (stannous fluoride)

Silver diamine fluoride

Varnish

which 3 types of fluoride are good for controlling inflammation?

SnF2 (stannous fluoride)

Silver diamine fluoride

How does Fluoride help with Remineralization?

-induces precipitation of calcium/phosphate

For the ingredients of Anticaries agent, Fluoride important, but _________ is also important

Calcium

(and phosphates)

(and HAP)

_____________ calcium technology allows high fluoride availability

Tri-calcium phosphate technology

Toothpaste with high content calcium:

MI toothpaste

CPP -ACP (Casein Phosphopeptide-stabilized Amorphous Calcium Phosphate)

Casein phosphopeptide

-cow's milk

-binds Ca and P --> bind to tooth surface and plaque.

Amorphous calcium phosphate

-Free & available to be incorporated into tooth structure

List the 2 Calcium-phosphate delivery system (often used in toothpaste)

-Tri-calcium phosphate technology

-CPP-ACP (Casein phosphopeptide amorphous calcium phosphate)

____________ fluoride works with ACP (amorphous calcium phosphate) to increase fluoride uptake and reduce enamel solubility

SnF2 (stannous fluoride)

SnF2 delivering ACP

-increases fluoride release and uptake

-helps to occlude dentinal tubules

-reduce enamel solubility

For high risk patients, they are recommended to apply ______________ with brush 1/day in evening before bedtime

Enamelon gel

__________ is a bioactive ingredient applied in microcluster or nanocrystalline forms in oral care products

Hydroxyapatite (HAP)

Function of Hydroxyapatite in oral care products:

-strong adherence to tooth tissue

-strongly adsorb on enamel/dentin crystal surfaces

-induce remineralization/demineralization

-relief hypersensitivity

-controls biofilm to reduce gingivitis

How does Hydroxyapatite in oral care products help with demineralization and remineralization?

-enters & directly FILL micropores in demineralized area

-act as crystal nucleus inside the tooth--> promote crystal deposition and growth by attracting Calcium and phosphate ions

-Calcium and phosphate ions reservoir - maintain topical state of supersaturation

Inside the tooth tissue _______________ acts as a crystal nucleus and template, promoting crystal deposition/growth

Hydroxyapatite

HAP oral care products elevate ___________ concentrations in saliva and plaque

calcium + phosphates

________________ act as a calcium and phosphate ions reservoir helping to maintain topical supersaturation of these ions

Hydroxyapatite (in toothpastes)

_____________ bind to phosphate sites on enamel surface, to form a protective layer and limit acid diffusion of ions during caries attack

Phosphate systems

Phosphate system

-strongly binds to phosphate sites on enamel --> formation of protective layer that limits acid diffusion

-ENHANCES remineralization when polyphosphates are added in fluoride toothpaste

Addition of ___________ in conventional fluoride toothpaste enhances remineralization

Polyphosphates

Why are biofilm modifiers important?

-Killing the bacteria gives change for opportunistic oral disease. --> so rather than eliminating the biofilm, it's important to modify/control biofilm bacterial behavior.

Arginine technology

Ammonia production from Deamination of amino acids (in biofilm)

--> ammonia is highly alkaline, causes a rise in pH

______________ technology is used to modify biofilm

Arginine technology

Combining ____________ and fluoride enhances the efficacy of fluoride to promote remineralization compared to fluoride alone

Strontium

____________ is a filler that incorporates strontium w/ fluoride to enhance remineralization, acid resistance, anti-plaque effect during restorative procedures.

Surface pre-reacted glass ionomer filler

___________ is implanted in host's microflora to maintain / restore natural microbiome to interfere w/ other harmful microorganisms

Probiotics

Name 2 species of bacteria used as Probiotics

Bifidobacterium

Lactobacillus

There is an immediate drop of _____________ bacteria in plaque/saliva after bcteriotherapy

S. mutans

name some NATURAL examples of probiotics

Dairy products (yogurt)

probiotic pills

define Bioactive and Biomimetic agent

any material that can actively stimulate or direct specific cellular or tissue responses & can control interactions with microbiological species

Example of Bioactive and Biomimetic agent:

Self-assembling peptides

self-assembling peptides

-Bioactive and biomimetic agent

-diffuse into subsurface of initial caries lesion --> attract calcium phosphate from saliva --> enhance REGENERATION OF ENAMEL /DENTIN