Fluoride CDH

3 conditions in order for caries to form:

  • Susceptible Host- Teeth, Xerostomia, Lack of Fluoride

  • Bacteria- Primarily Streptococcus mutans, then lactobaccillus

  • Diet- Primary Sucrose

To Reduce Decay, make an effort

  • Increase resistance of teeth- fluoride

  • Reducing Bacteria by mechanical means

  • Diet modification

Mechanisms of Action

Partial replacement of hydroxyapatite with fluorapatite

Fluorapatite crystals are larger, more perfect, LESS Soluble

Calcium, Phosphate, and fluoride are needed for crystal re-growth

  • Bacterial Metabolisms reduced

    • Bactericidal (high conc. and low pH of fluoride)

    • Bacteriostatic (low concentration)

    • Fluoride alters ability of S. mutans to produce caries-causing acid

Remineralization- low conc, used daily

fluoride increases remineal. and decreases demineral (these areas soak up more)

Remineralized areas are stronger than regular enamel

Other agents that help remineral: ACP and MI paste (minimal intervention) Has recaldent to help with remineralization, white spot lesions, sensitivity. One study found no significant differences w helping WSL from ortho between varnish, MI paste compared to standard OH with regular toothpaste

  • Modification of tooth morphology

    - teeth have slightly smaller, more shallow fissures (systemic fluoride)

  • Increased rate of post-eruptive maturation

    - Newly erupted teeth have hypomineralized areas. Fluoride helps accelerate maturation.

Effects of Water fluoridation:

  • Perm teeth: 27% caries reduct.

  • Prim teeth: 40% caries reduct.

  • Mixed (8-12yrs): 20-40% caries reduct.

  • Smooth Surface: 86% reduct.

  • Occlusal Surfaces: 37% reduct.

  • Root Caries: 50% reduct (from topical effect of water fluoridation)

  • 95% few caries in max ant. teeth

  • 75% fewer permanent 1st molars extracted

  • less malocclusion

  • the chance for kids never having a cavity in their permanent teeth is abt 6x greater in the fluo. community than a fluo. deficient one

  • Adults benefit too: lower DMFT scores, less cemental caries, possibly fewer bone fractures

Research has established that:

  • body has an efficient excretory mechanism for fluoride (ppl on renal dialysis should not have fluoridated water water)

  • no skeletal damage from f. water

  • no impairment of general health at .8ppm

  • caries inhibitory effects well documented

.7ppm f.water for all climates!

Compounds used to fluoridate water:

Sodium Silica fluoride, Sodium fluoride, fluosilicic acid

Outermost layer of enamel has the highest concentration of fluoride in enamel

- Topical Fluoride is more effective soon after tooth eruption

Pulpal surface of dentin has the Highest Concentration of fluoride in dentin (From systemic)

UPTAKE:

- depends on the level of fluoride in the oral environment and the length of time of exposure

- Hypomineralized Enamel absorbs fluoride in greater quantities than sounds enamel

Fluoride in Biofilm and Saliva

  • Saliva and biofilm are reservoirs for fluoride; saliva carries minerals available for remineralization when needed

  • Fluoride helps to inhibit demineralization when it is present at the crystal surface during an acid challenge

  • Fluoride enhances remineralization forming a condensed layer on the crystal surface, which attracts calcium and phosphate ions

  • High Concentrations of fluoride can interfere with the growth and metabolism of bacteria

  • Dental biofilm may contain 5-50ppm fluoride. Varies greatly and constantly changing

Fluoride Toxicity:

  • When ingested, 90-95% of fluoride is absorbed through the stomach

  • most common side effect is NAUSEA

  • CLD ( certain lethal dose ) is based on kilograms of body weight

  • Adulta: CLD is 5-10g of NaF at one time

  • Children CLD is .5-1g (500-1,000mg)

  • Depending on weight and size, safely tolerated dose (STD) is ¼ the CLD

  • Chronic long term: Bone fluorosis, skeletal damage, (4-8ppm over 20+ yrs) (osteosclerosis is mild form)

  • Fatal Lfuoride poisoninf: accidental ingestion from large quantities of fluoride, e,g, in insecticides

  • Fluoride in dental products can be potentially hazardous to kids

  • Acute toxic dose symptoms: nausea, vomiting, hypersalivation, abdominal pain, in severe cases : muscle cramping, bronchospasm, ventricular firbrilation and cardiac arrest. NOT HYPOTENSION OR CONSTIPATION

Tx of Fluoride Toxicity

  • Induce emesis

  • administer milk, antacids (fluoride- binding liquids)

  • Take to the hospital

  • Use mineral free water for kidney dialysis patients

  • Do not store large amounts of fluoride at home and keep out of reach of children

    MAX AMOUNT OF DIETARY FLUORIDE SUPPLEMENTS DISPENSED AT 1 TIME : 264 mG NaF, 120mg fluoride ion)

Enamel Fluorosis

  • Enamel Hypocalcification resulting from ingestion of excessive fluoride ion content during enamel calcification

  • Flurosis from excessively fluoridated water (2ppm) may require water to be defluoridated

  • Well water may have fluoride

  • Home filtrations systems may remove fluoride

  • Daily ingestion in excess of .10mg of fluoride (from all dietary and non-dietary sources) per kilogram of body weight is generally accepted to cause fluorosis

*Typical ribbon of toothpaste- 1mg of fluoride, kids 4-6 may swallow up to 50%

Grade of Fluorosis

  • Questionable: a few white specks

  • Very Mild: Small, opaque, paper white areas involving less than 25% of the surface

  • Mild: White opacities more extensive, but don’t include more than 50% of the surface

  • Moderate: Distinct brown staining, the tooth is worn and hypoplastic. All enamel surfaces are affected and discrete or confluent pitting is present

Mild Enamel Fluorosis

  • in order for hydroxyapatite to become incorporated within enamel matrix it has to degrade, then it gets rid of by-products

  • Excessive fluoride interferes with this process; crystals can’t get incorporated, accounts for white fluorosed areas

Severe Enamel Fluorosis

  • Brittle, hypoplastic

  • Toxic damage to ameloblasts

Why not fluoridated water?

  • lack of education

  • apathy. political inexperience

  • Lack of $$$ for initial set-up

  • Antifluoridatinonists’ activity

  • Violation of personal freedom

Tips for promoting water fluoridation

  • work w known officials and leaders in the health and welfare, inclu. members of professional groups.

  • Assess the leaders’ initial knowledge of and attitudes’ toward fluoridation

  • Provide needed education subtly and slowly

  • Activities should be directed toward the decision making group, rather than toward the public in general

Methods of fluoride administration

a. Community Water Fluoridation- Most cost- effective method

b. Dietary fluoride Supplements- Tablets, drops, vitamin preps (Poly-Vi-Flor and Tri-vi- Flor)

  • Dosage based on concentration of fluoride given in water and age of child

  • Supplements are not given to pregnant women

    • baby exclusively breast-fed: .25mg fl supplement starting at 6 mons

Fluoride Supplementation Chart

Birth - 6months: <0.3PPM, 0.3-0.6PPM, and >.6PPM — NONE

6mons - 3 yrs: <0.3PPM — .25mg/day ; .3- .6PPM, >.6PPM — NONE

3-6 yrs: <.3PPM — .50mg/day ; .3-.6 PPM — .25mmg/day ; >.6 PPM — NONE

6-16 yrs: <.3PPM — 1.0mg/day; .3-.6PPM — .50mg/day; >.6 PPM— NONE

School Based fluoride tablet programs

  1. provide topical and systemic benefits; -30% caries reduction

  2. inexpensive, requires little time; teachers can administer and the RDH can monitor the program

  3. RX needed

  4. Voluntary Participation

School Water Fluoridation

  1. Fluoridated at 4.5 times that of community water

  2. Disadvantage: children do not receive benefits until they begin school and while they’re in school

  3. Caries reduction - 25%

  4. Cost effective, but being replaced with fluoride mouthrinse programs for kids older than 6

Fluoride Mouthrinses

  • 20%-50% caries reduction

  • NaF (sodium fluoride)

    • .2% used weekly (900ppm)

    • 0.05% used daily (200ppm)

  • Not Rxed for kids under 6yrs

  • Rxed for pts with high caries susceptibility

  • .2% used for school-based weekly rinse program

  • low potency rinses available OTC

  • Rx for a non-fluoridated community: fluoride tablets K-8th grade; weekly fluoride rinses for grades 9-12

E. Profesional Gel Applications

  1. Least cost effective as a public health measure

  2. Neutral Sodium Fluoride (NaF)

    • 2% concentration; pH 7.0; 9,040ppm

    • applied at 4 appt.s intervals (coinciding with eruption of teeth (3, 7, 10 and 13)

    • store in polyethylene container

Neutral Na Fluoride Cont’d

  • Good for sensitivity and pts with extensive restorations

  • must be applied for 4 mintues

  • “foams” appear to not be as effective

  • Thixotropic- materials are odd solids and fluids that change their viscosity when loaded by stress by becoming less viscous

  • Amounts in trays:

    • 5ml for larger pt

    • 2ml for small kids

  • Fluoride Varnish

    • 24,000 ppm; 5% NaF or 2.26%F

    • FDA approved for desensitization but ADA endorses for caries control

    • helpful for kids at high risks for caries

    • less systemic absorption than gel trays

    • needs saliva to activate (unlike other fluroides, don’t need to dry teeth)

    • avoid hot, hard foods, alcohol, brushing, flossing 4-6 hrs after application

    • PROF. application 2x yr or every 3 months for pts. with high risk of caries NOT FOR HOME USE

Stannous Fluoride (SnF2)

  • 8% or 10% concentration require single application; 19,300ppm

  • disadvantages: short shelf life; bitter taste; staining of teeth, silicates, decalcified and carious areas; gingivsl rxns; stannous ions cause atifacts on films if given prior to radiographs

  • Bacteriostatic- 1.64% used for subgingival irrigation

  • SnF2 is a good desensitizing agent

Acidulated Phosphate Fluoride (ADF)

  • 1.23% orthophosphoric acid; 12,000 ppm pH of 3.5% (lower pH promotes uptake)

  • Store in polyethylene container

  • No clinical support for 1 minute gel of foam

  • contraindicated for porcelain, sealants, composites, implants, pts with mucositis. Note: Newer micro-filled composites are not as sensitive to APF agents

Home Fluoride Gels (tray and brushing methods)

  • Agents 1.1 NaF ex: Prevident or Fluoridex 5,000 cream

  • 0.4% SnF2 ex: Gelkam

  • 0.5% APF

  • Target Population: Kids over 6yrs w rampant caries or high risk for caries; contraindicated for kids under 6

  • also for adults with high caries susceptibility; denitinal hypersensitivity; xerostomia; root caries; ortho appliances; overdentures; recurrent decay

Fluoride Dentifrices

  • 1,000-1500ppm

  • Agents: NaF; Snf2: Na MFP (monofluorophosphate) NOT APF

  • recommended for all patients, but uses caution w kids younger than 6 (peasize) toddlers (thin film of paste)

  • 20-30% caries reduction

Other weapons for caries control

  • nanosilver rinse by elementa

  • Loloz with cavibloc

  • Xylitol products

  • Acp Amorphous, Calcoum Phosphate

  • Recaldent (in MI paste, Trident gum) ** derived from milk protein and should not be given to pts with a milk allergy

  • Basic Bites dental chews- designed to mimic saliva; arginine bicarbonate, calcium carbonate, xylitol ** offers options for those folks who oppose fluoride for whatever reason

Other therapeutic effects for plaque control

  • plaque inhibiting agents

    • chlorhexidine- .12% bacteriocidal; alters taste, stain, more calc, mucositits, inactivated by SLS, contains alcohol, Rx: rinse ½ ozfor 30 sec 2x daily (12hr substantivity) Can be used for caries control- High risk pts.

    • phenolic- related essential oils rinse (listerine)

    • sanguinarine (viadent) rinse and dentifrice

    • cetylpyridium chloride (scope, prohealth, cepacol)

    • glycine and erythritol powder- periodontal air polishing

  • Desensitising Agents

    • Fluoride! ( stannous is good for sensitivity) MOA: occludes dentinal tubules

    • Potassium Salts (potassium nirate, oxalate, chloride and citrate)

      [ Sensodyne; Crest Hypersensitivity] MOA: Reduce depolarization of nerve membrane

    • Strontium chloride: pt ed: plaque control dietary issues, avoid tartar control dentifrices

  • Professional desensitization

    • dentin bloc agents prior to instrumentation: rubber cup polishing with desentizing agent( colgate sensitive pro-relief, sensodyne or novamin technology)

    • 5% NaF Varnish application os sensitive areas at end of tx ( off label use as an anti-caries agent)

  • SDF

    • SDF (38%)-2014 approved for tx of dentinal hypersensitivity

    • SDF off label use for caries: silver (antimicrobial), Fluoride, and ammonia; arrests enamel, dentinal, and root caries

    • Dry tooth, apply for 1min, apply varnish to rest of mouth

    • Some studies suggest a 2nd application a week after inital application (1x wk for 3 wks)

    • applied every 6months for 2-3 yrs, 10 yr success and arrest rate for 90%

    • SDF plus potassium iodide solution (riva star)

  • Calculus Reducing Agents

    • Tartar control dentifrices

      • Sodium pyrophosphate salts

      • Sodium hexametaphophostae helps reduce new stain and calc formation

      • zinc salts

  • Whitening agent

    • OTC dentifrices claim whitening for removal of stained biofilm

    • some OTC dentifrices have a mild peroxide agent

    • carbamide peroxide (10%-22%)

    • Hydrogen peroxide (5-5%- 7.5%)

    • Hypersensitivity issues

    • “Bleachorexia”

  • Pit and Fissure sealants

    • Popularity in dental public health

    • mechanical barriers

    • need to be reapplied like fluoride

    • sealant tx can resutl in incipient caries reversal

    • 37-50% phosphoric acid create mechanical tags or microspores

    • success depends upon dry field

    • Triage for sealing teeth

      • right after fully erupted

      • teeth w deep occlusal surfaces

      • 6yr molars and 12 yr molars (1st grade and 7th grade)

  • Caries Risk!

    • Low SES

    • Past Caries or caries experience of mother, caregiver, or other sibs

    • low fluoride exposure

    • dietary factors: sugary foods or drinks; eating disorders— older kids

    • special health care needs

    • dental home (est. pt of record in a dental office)

    • visible plaque

    • Dental/ ortho appliances

    • salivary flow/ meds that result in xerostomia or caries

    • clinical or radiographic caries

    • restroations

    • unusual tooth morphology

    • low oral pH

    • High Microbial Count

  • CAMBRA- caries management by risk assessment

    • Rx 5,000 ppm cream: rxed for adults and children 12yrs of age older. Children 12-16 brush 2x per day, expectorate and rinse (over age 16 and adults: do not rinse) ** fluroride rinses are NOT recommended for kids under 6 yrs of age

    Supplemental dietary fluorides are indicated for kids at high caries risk living in areas of under-fluoridated drinking water

Reductions in caries for topical fluorides:

  • daily OTC toothpaste — 24%

  • daily RX (5,000 ppm) cream — 37%

  • daily fluoride rinse — 26%

  • semiannual professional gel — 21%

  • semiannual professional varnish —37%