Flouride Effects and Dental Flurosis

;At the beginning we`ll start talking about Flouride Effects The main and first most important effect of fluoride is the : Inhibition of dental caries ; Direct effect on the de elopment of the enamel -1 b! which the fluoride replaces the "# group of the h!dro$!apatite to form calcium fluroapatite which is more resistant to solution b! acid than the h!dro$!apatite : Topical Effect : fluoride in the sali a interacts with carious process in three wa!s -% a& F has antibacterial properties b& 't inhibits deminerali(ation and enhances re-minerali(ation of )a and * in the + enamel of incipient lesions during acid challenge + a better more resistant surface 'ts suggested that the fluoride reduces the tendenc! of the enamel to adsorb sali ar! -, proteins and b! this pla-ue wont build up -uickl! .it also works on affecting the & bacterial en(!mes . two of these en(!mes are : Endolase and ATPase 0ote : Endolase En(!me is related to bacterial metabolism and is important in // gl!col!sis process + 'mportant process b! which sugar in anal!(ed to use energ! to + the bacteria 'nhibiting The AT*ase will inhibit the h!drogen pump and then the *# of the cell // & becomes more acidic and then the 1acterial cell will e entuall! die : 0ow we`ll Discuss The Flouride Therap! 2 : 3ainl! two t!pes s!stemic t!pe : water fluoridation 4 supplements -1 : Topical t!pe -% & a& professionall! applied : gels . proph! pastes . F- arnishes b& 5elf- applied : dentifrices . mouthrinses -------------: 6ets start with the s!stemic t!pe : A- 7ater fluoridation most effecti e method in pre enting caries in which the patient will be getting the -1 & ma$& benefit with the least cost + 't offers caries reduction +89: - ;9:-% *age<1

doesn=t re-uire an! cooperation from the patient -, & a ailable to e er!one . safe and economical -> Discontinuation of F-water results in a return to pre ious le els of carious acti it! // + + F-protection is re ersible The range or concentration of fluoride aries between 9&; ? 19% + this depends on theclimate ; hot climate means people are drinking more water so ; it`s 9&; and ise ersa + regarding Flouride protection ; it`s higher on the anterior teeth than the posterior + because of the fluoride abilit! to to resist caries on the smooth surfaces than on the + pits and fissures F- Deficient area`s patients are at higher risk to caries + so the!`re ad ised to take + supplements which are chewed and swallowed Amman`s water suppl! contains onl! @9&1- 9&8 A ppm of fluoride while in irbid it`s near optimum + 9&B+ ppm &the highest amount of fluoride was detected in +(ai + water station in %99; Cordan water compan! +me!ahona+ has started a fluoride stud! in cooperation with & arious go ernmental and non-go ermental institutions

: 1- Fluride supplements : 1efore prescribing them . we should take in consider the following total fluoride intake + if the child is taking fluoride from other sources like F- -1 + water .dentifrices. foods or drinks )aries Disk status + we onl! prescribe them to children with high caries risk status -% + prescription are also based on the american academ! of pediatric dent& . where the 1& age . %- le el of fluoride are both in ol ed + Table in the slides + page 1B & As !ou can see . we don=t prescribe an!thing for patients up to B months we usuall! prescribe for those who ha e water fluoridation less than 9&, ppm or 9&, ? + 9&B + more than 9&B ppm we don=t prescribe supplements dosage as we pre iousl! said ; depends on the age and F-water/ : Disad antages of the 5upplements *age<%

e$pensi e -1 .poorer attitude of the parents ma! lead to less knowledge and acceptance of F -% + de elopment of enamel opacities and fluorosis + if e$cessi e -3 we should instruct the patient to first chew then swallow and we should take care in / & prescribing them to patients before +,-B !ears + because of fluorosis risk caries reduction E9: ? 89 // -----0ow we`ll discuss the second t!pe of fluoride therap! which : is the Topical type : professionall! applied -1 + a& Flouride Gel : +mostl! used easier to appl! -1 adherent to the tooth-% + wont penetrate pro$imal areas + use floss to appl! it between the tooth -, no difference in the chemical components compared to the Flouride solution . + / some preperations comes in the form of solution which is not as thick as the gel and it`s good in areas where we need fluoride to go between the teeth in the inter-pro$imal + areas Indicated in oderate ! hi"h ris# caries patients and non-flouridated *** $ co unities

: Fels- *reparations 5nF E: The bad thing about it is that it ma! cause staining of the teeth G it`s -1 + taste is not well accepted b! children +metallic taste 0aF %: + am not sure about this . in the slides it`s written 1: but during the -% + lecture the doctor mentioned that it`s %: +H IJK LMNO PQRSH+ so . 1ack to the 0aF . it has a neutral *# so it`s good in enamel erosions . carious e$posed dentines and where the enamel surface is porous + people %ith tooth $ sensiti&ity : + A*F + acidulated phosphate fluoride -, . : used in the clinic . and comes in a concentration of 1&%, &it consists of + 0aF . #!drofluric acid and orthophosphoric acid

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better taste no tooth staining low *# because of the acid in it + enhance fluoride uptake 4 because acid etched + enamel absorbs fluoride better presence of P help suppressing the enamel dissolution & 6onger lasting benefits following the termination of treatment : Degarding the application fre-uenc! // semi annual + twice a !ear + and it can be changed depending on the caries risk of the child * 'aries reduction : 3(-)( ** Thi$otropic gel + a t!pe of gel that becomes a solution upon pressure 4 no need for // + cleaning prior to application : b. Fluoridated prophyla+is paste it`s not essential before the application of fluoride because it remo es up to > micrometer of the enamel surface + which is most rich in fluoride so significant loss . + of fluoride ma! occur but if !ou ha e hea ! pla-ue or calculus then the! ha e to be remo ed before appl!ing the fluoride + if a patient cleans his mouth regularl! then !ou don=t ha e to + use a proph! paste before fluoride application : c& Fluoride ,arnishes ehicle for holding F in a close contact with the tooth for a long period of time because the! are adhesi e and efficacious in deli ering and retaining F on the tooth & structure & )aries Deduction : >9-8B// :Tses // + #igh carie risk children +speciall! to arrest incipient lesions -1 caries control in special need patients -% children with head and neck radiation and on chronic oral medications -, + ortho- patients + pre ent de-)a beneath the ortho bands -> & easy and safe Deapplication 's 0ecessar! 4 3ain cariostatic effect of the arnishes is the / & remenirali(ation of earl! carious lesions : & application fre- // 5emi annual + twice a !ear + but for high caries risk patients it should be +,-> $4 + !ear *age<>

: Fluoride Uarnishes T!pes // duraphat 8: 0aF ? 1 Fluoro ? protector 1: di ? F ?5ilane -% Durafluor + it`s nice and similar to duraphat but it has $!litol 'n addition 4 to , + impro e the taste and pt& acceptabilit! )a it! shield ? most recent t!pe ? 8: 0aF in resinous 1ase 4 a oids wastes . -> pre ents o er application because it comes in separate carpules for each patient so &less chance of to$icit! too : Application techni-ue / proh!la$is ? pla-ue remo al is`nt critical prior to application + unless oral h!giene -1 + is terribile & 'solation ? dr! the teeth . place cotton rolls -% arnish dispensed 9&8 ? 1ml for the entire dentition 4 appl! with disposable brush 4 -, dental floss for interpro$imal areas . a oid getting on 5T . sets in few sec &s &entire process takes ,- > minutes -> It ta#es one inute for -)* of fluoride in &arnish to "et absorbed **

The onl! disad antage of the arnish is that is causes !ellowish ? brown // + discoloration + temporar! !ou should instruct the parents that the staining is temporar! and that it will anish // upon brushing 4 but children should a oid brushing for the rest of the da! and also should a oid eating for % hours + in fluoride Fel . child mustnVt eat for ,9 minutes + . & also soft diet for the rest of the da! is ad ised as well F- arnishes not intended to adhere permenantl! to the tooth but to remain in close / contact with the enamel for se eral hr&s and then we end up with a F- rich tooth & surface : $ /elf ! Applied Fluoride $ Topical Type -. : 0a. Dentifrice 0T1 : )ontents Amine fluoride or 5nF @9&> : A or 9&;B : sodium 3F* @ 1: fluoride ion A -1 @ @ colgate 4 colgate ?palmoli e co 53F* better than 5nF 4 no staining 4 neutral *# -% @ )a p!rophosphate abrasi e @crest W gamble -,

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& make sure that the dentifrice used is ADA appro ed / : most appropriate F concentrations recommended b! ADA / ppm in children 889- 899 ppm in adults %899- 1899 & )orrect T1 amount is bean si(e for children and e en less for infants /// : b. 2outhrinses Indications : rampant caries 4 ortho therap! 4 sali ar! depression caused b! & pathologic conditions or medications 4 Xaw fi$ation4 dental h!persensiti it! 0aF Y agent of choice it reduces caries b! >9 : compared to A*F which reduces // onl! %9 ? ,9: : Decommended Dosage// Dail! rinsing + low conc & 9&98: + 4 1-% mins twice a da! ? 1 + weekl! rinsing : + high conc& 9&%: 4 once weekl! ? % 1ased on a stud! b! erricsson . preschool children inXested a erage of 9&> mg of F 2 per rinse because of inade-uate swallowing refle$es . that`s wh! the! decided that children below the age of B !ears shouldn=t use mouth rinse & pHdRq B ZO [\]^ _` ZMS abc defdRg . hij _NkefdRg hMc HdlMlMg _` m Hdnk\i ZoMO : other t!pes of self ? applied gels #igh concentration A*F gels for semi-manual office application 4 not found in & pharmacies there are also lower concentrations of 9&8: A*F gels or 9&8: 0aF or 9&> : 5nF or other fluoride gels wich are a ailable in the pharmacies and can be used directl! b! &the patient`s parent & we should worn the parent if their child is brone to fluorosis or staining / Dr& Asked About the t!pe of fissure sealant in the last slide in the fluoride 1 lecture / + + page %E ans & FuXii-U'' -

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Fluoride To+icity : increase in the le&els of fluoride : t%o types acute to+icity : hi"h a ount 4 e+cessi&e a ount of fluoride 4 sy pto s of -3 acute to+icity : syste ic anifestations 'hronic to+icity : hi"h a ount of fluoride for a lon" period of ti e 4 causes -. fluorosis : no% %e5ll discuss the ter fluorosis ** 6e&irsible condition 7 and it5s caused by e+posure of a de&elopin" tooth to an increased a ount of fluoride resultin" in inerali8ation defects of the ena el slide pa"e 3 9 dental fluorosis in a :-- yrs child "re% up in fluoridated * Auc#land in ne%8ealand :'linical appearance * 1ilateral opa;ue %hite areas in the ena el tooth is fully functional and resistant to acid attac# $ fluoride . $ resistant to acid attac# actually . ena el ore porous 4 can "et stained -

a#es it &ery -

: Types of fluorosis* &ery ild : s all ! paper %hite areas 7 in&ol&es less than .) * of the ena el -3 $ . ild : opa;ue areas $ )( * of the ena el -. oderate : %hole ena el ay be affected %ith paper %hite or bro%n areas -3

se&ere : ena el is "rossly defecti&e 7 opa;ue 7 pitted 7 stained 7 bro%n and -< brittle ** Please "o bac# and chec# the slides for picture althou"h they are not clear ** :=istopatholo"ic appearance * non pitted fluorotic ena el %ith subsurface porosity belo% %ell ! inerali8ed surface 8one this surface porosity is %hat creates the %hite opa;ue appearance %ith increased se&erity of fluorosis 7 porosity e+tends to%ard DE> 7 brea#do%n .and pittin" of ena el ay result A The ;uestion is ? @hen does fluorosis occur * : Ena el for ation sta"es are -

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presecretory sta"e -3 0 secretory 0 protein synthesis and secretion 7 early aturation 0 atri+ re o&al and trouble occur inerali8ation -. ost of the -3

ineral deposition B %here

7 /o presecretory sta"e 9hi"h a ount of fluoride %ill affect the a inoblast and . their differentiation to polari8ed cells secretory sta"e 9 fluoride atri+ ay affect the secretion of e+tracelluler or"anic -

Early aturation 9 the a eloblast secrets the protenase 7 the fluoride can $ inhibit the protein secretion $ increased fluoride in atri+ 2aturation 9 %hen the atri+ has to be re o&ed and the ineral deposit 7 the fluoride %ill also inhibit this process throu"h so ethin" %hich is called the $ 8one refine ent hypothesis $ 9 Decrease in the nu ber of C6 cycles 0 cycles 9 re o&al of protein and addition of inerals B chan"e in the crystal si8e and . orpholo"y in subsurface of fluorosed ena el "o bac# to the slides ** : 'ritical factors in Fluorosis for ation : Dose D Dosa"e If the dose E (.3 "4 #" 9 fluorosis ris# Duration is 9 late secretion 4 early aturation period $ aturation is $ sensiti&e . if patient e+posed to both durations then it5s ore se&ere -

ore

. per enant incisors and canines affected by fluorosis at a"e of 3.) ! ..) yrs . per enant post. Teeth affected ostly at the a"e 3-F years-

: 'haracteristics of fluorosis ** ottlin" is usually ende ic in areas %here F . . pp in drin#in" %ater $ so if you find one e ber of the fa ily affected 7 usually ost of the fa ily %ill be $ affected only those %ho li&ed in a hi"h F- area durin" dental de&elop ent sho% 7 older &isitors to the area %ont be defected Deciduous teeth are rarely effected 4if affected ottlin" -

ostly the E5s %ill "et fluorosis -

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: 6is# Factors ** $ ,ery Gon" E+posure to fluoride $duration related -3 $ Increased ris# %ith e+cessi&e use of fluoride supple ents $ dose related -. $ lo%est ris# is durin" secretory sta"e $ H 33 $ hi"hest ris# durin" both secretory and 6is# increases %ith increasin" the dose -) . /o 7 Factors : Dose 7 Duration 7 A"e 7 Ti in" 7 other F sources ** A =o% to differentiate bet%een the Fluorosis and the Ena el =ypoplasia ** Fa ily history : if fluorosis ost of the li&in" in that area should be affected =istory of trau a : hypoplasia ! . =+ of fluoride inta#e 9 fluorosis -3 Gocali8ed Defect 9 =ypoplasia ! < Generali8ed defect 9 Fluorosis -) : 2ana"e ent * : the proble is cos etic ? any options of ana"e ent e bers of the fa ily and people -3 onths of a"e -3

aturation $ birth ! < years -<

restorati&e options icroabrasion co posite resinporcelain &eneers %hen they beco e adultstooth ousse ! "ood for oderate cases: Fluoride to+icity ** 'ertainly Gethal to+ic dose 9 death -3 4 acute Gethal dose 9 sypto s of to+icityacute lethal dose of F in the for of IaF in an adult ale 3.- F< #" %ei"ht results in death %ithin .-< hrs if first aid is5nt applied i ediately 'GD for J( #" adult 9 )-3( "ra 'GD for a child 3( #" $ 3.- 3: 9 Probably to+ic dose -. 7 corresponds to F-dose for 3.-F< onth of a"e $ is 3.( " of fluoride -

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sy pto s of to+icity " F4 #" ) KLMNO P QRST : The e+a ple in the slide fluoride II pa"e 3the child is 33.3 #" PTD 9 ) " F 4 #"

? eans #" of %t ) " of fluoride 3 #" of %t U 33.3 U9 )F.) 0 appro+i ately )J B "

: This ;uantity of Fluoride is contained in " of 3((( pp F dentifrice )J -3 $half the a ount $ 3: " of a hi"her conc. $ 3)(( pp $ appro+i ately )(( + 3.( l outhrinse $ pepsi can or F dentifrice $ -. u" of a outhrinse -3

" F- tablets )J -<

l of 3..3* APF <.F -) Io clear relationship bet%een fluorosis and cancer ** : no% sy pto s of acute to+icity bloc# of celluler etabolis conduction disorders nausea -. &o itin" -3 hypersali&ation -< diarrhea -) $ abdo inal pain $ irritation of the GIT throu"h for ation of =F acid -F s%eatin" 7 headache -J yopatholo"ic si"ns ? spas s 7hypotension 7 cardio&ascular failure 7 ! : disturbance of electrolyte balance and restoration is depressed inse&ere cases and * a g e < 19 4 inhibition of "lycolysis 7 ner&e i pulse and -3

ay de&elop to respiratory acidosis and pt. disoriented patient : 2ana"e ent ** esti ate the a ount inVested -3 ini i8e further absorbtion -. re o&e Fluoride supple ents -3 support &ital si"ns -< if &o itin" hasnWt occurred "i&e il# -) =ospitali8ation -F

ay under"o unconsciousness 4

in the past the used to use e etic syrup %hich is the ipecac 4 not used no%adays because the &o itin" it induces doesnWt rid the body of the poisonin" it also causes burnin" of the esopha"us another %ay of ana"e ent is $ ana"e ent by dosa"e$ if you esti ate that the child has inVested less that ) " 4 #" then "i&e il# $ 'alciu content $ the . obser&e up to < hours if the patient has inVested if ore than 3) ore than ) -3) " 4 #" hospital ad ission ore ad&anced ana"e ent

" 4 #" hospitali8ation and

: Death 6eported due to F-to+icity ** : cases 3 years old child died because he s%allo%ed .<-3: $ after 3 hrs onths old 4

" F 4 #"$ /nF $ death 3 -3

ale 4 inVested 3(( F- tablets 4 ) days later died .J -.

yrs old inested .(( tablets 4 death occurred J hours latter 3 -3 . Ie+t Gecture 'alculations %ill be discussed Done by Ghadeer Afaneh

* a g e < 11

* a g e < 1%