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Ola
Batayneh
Abeer Al Najjar
بسم الله الرحمن الرحيم
Fluoride 2
Dental fluorosis
The Dr insisted on the oral hygiene instructions and she wanted them to be
written (actually printed ) and before u give it to the patient u should show it
to the Dr to get mark on it .. you also should do the diet analysis and give diet
instruction these two things are a requirement of the pedo clinic …
Clinical appearance :
1- Bilateral opaque white area’s in enamel is opaque and chalky and white ,
bcoz it’s a systemic condition so it has to be bilateral its happening a
very where in the jaw , so if you only see its unilaterally you exclude
fluorosis from your diagnosis .
3- The fluorosis teeth are still fully functional .. the patient can still eat with
them , they don’t have reduced function or wearing in the teeth and they
are more resistant to acid attack than normal teeth coz there is fluoride
in the tooth (coz when we do acid etching we are demineralization the
tooth so if the tooth is already hypomineralized so what the acid can do ..
not much)
4- Coz enamel is more porous it may be stained easily , some cases are
yellowish and some are brownish especially in sever fluorosis and they
become more prone to fracture and wearing coz the enamel is brittle ,
and easily going out ..
Pedo lec.# 4 Dr. Ola
Batayneh
Abeer Al Najjar
5- You might have dental caries , coz you have porous and the bacteria may
perforate and coz caries ..
- Very mild : very small white pits on the surface of the enamel and it
involves less than 25% of there surface ..
Moderate type : 50% or more or the whole enamel surface is affected and you
can notice some discoloration ..
Fluorosis patient mainly from esthetics otherwise they will have no caries
risks (except for the sever case )
The dr started showing us pic and define them to the fluorosis classification
and the dr started talking about the table which tells us the dates of eruption
and enamel formation and we should memorize it …. And from this table we
can tell at which age the child started the fluoride exposure …
You have to know when the enamel formation begins and when root
formation ends , and when the tooth erupts , so in this case (I don’t know
exactly which one )the central incisor developing is a little pit delayed than the
six’s and they start formation at 3 – 4 months after birth .. so we can tell from
the incisal edge which are affected by fluorosis by fluorosis that this defect
was their when the patient was 3-4 months old , the laterals start formation10-
12 months and they are affected so it did continue tell the patient is 10-12
months , canine starts formation 4-5 months , premolar 1.5-2 years , so we can
tell that this patient was exposed to fluoride from 2 months up to 2 years
(these are permanent teeth .. I mean we are talking about permanent teeth
formation) , how did he got the fluoride ?? could be by breast milk ….
Pedo lec.# 4 Dr. Ola
Batayneh
Abeer Al Najjar
So as the Dr said you should ask where the patient was living and what’s the
fluoride concentration in that area and you should be able to estimate at which
age these teeth subjected to fluoride …
How do we restore these teeth ??? by composite or veneers (the sever cases
that got caries )we do acid itching but not with phosphoric acid maybe with
sodium hypocloride…
The stain on the fluorolized tooth : that happens coz the tooth is so porous so
its like a sponge it absorbs any stains ..
So you will see pitted enamel showing surface porosity below a well
mineralized surface , but how this surface become well mineralized ?? bcoz of
post eruption maturation at least , and coz of fluoride gel and dental past that
makes it mineralized …
So the porosity cozes the white appearance of the enamel , the well
mineralized surface zone is normal , its normally mineralized so you got
normal enamel which is translucent but the white discoloration that you see its
not from this layer its actually from the layer underneath which is porous ..
With increase severity of the fluorosis the porosity extends towards the
dentino-enamel , and this what cozes the pitted enamel appearance . so why
do we see it in sever forms ..?? coz the fluoride was extended to the dentino-
enamel junction where the enamel and dentine meet , so this layer is affected
here then you see some pitting in the surface , some areas where enamel and
dentine are not well adherent ..
- Presecretory : when the cells are preparing them selves for the secretory
stage , the cells become more elongated they become columnar , the
nucleus become prominent , the cytoplasm become more stained all of the
structures that are involved in the secretory stage become prepared ..
- Maturation : means if there is any protein remains then its removed and
minerals are incorporated in the surface .
Now with high fluoride level at this stage there is an inhibited protein
secretion and there for the fluoride increases in the matrix ..
The protein is increased , not removed probably from the matrix and the
fluoride will be in high amounts ..
Why does the fluoride inhibits it ?? coz fluoride is a very good enzyme
inhibitors , remember with bacteria it inhibits glycolsis and the H+ pump ..
and inhibits the ATP some times and now its working on the proteinases
enzyme it inhibits the protein degradation so if you put fluoride with any
enzyme it will inhibit it …
The fluoride affects the tooth when its in the maturation phase more that if
its in the secretory phase .. but when we have the fluoride in both stages it
sure has a higher risk of having fluorosis
At maturation level which is a very important stage and the fluoride affects it
very very much more them the secretory phase ..
What happens here is the matrix is removed and the minerals are deposited
now this is called cycle , when the protein is synthesis then proteinases
remove it and then the minerals get deposited now this is a whole cycle these
cycles are called zone refinement hypothesis , what fluoride do is decreases
the number of these cycles , which means it decreases the protein removal and
the deposition of minerals .
So the matrix will become high protein and less minerals so the enamel
becomes mushy and soft .
So there is a change in the size of the crystal and the morphology of the
enamel and we will have increase in the fluoride and magnesium levels .
First thing .. the does of fluoride threshold is 0.1 mg/kg and a later study said
its 0.03-0.1 mg/kg.
Pedo lec.# 4 Dr. Ola
Batayneh
Abeer Al Najjar
Critical period for fluoride exposure is late secretory or first maturation
period , but maturation stage is more sensitive that the secretory , the
permanent incisors and canines they are affected at age 1.5-2.5 permanent
posterior teeth can be affected up to age 6 (now I’m confused by these num
but I think now she is talking about the maturation but we should look to the
table and memorize it and remember this is what the Dr said)
Permanent teeth are affected but deciduous teeth are less affected , and in
primary dentition the most affected teeth are the E’s , coz there develop is
later than the others , and when affected mainly in the gingival third (the
latest part to be developed)
The risk increase the longer you exposed to fluoride and that’s what is called
chronic exposed , if the child swallow a tooth past then this is acute exposure
he will not get fluorosis but he will got acute symptoms of fluoride toxicity .
Most of the risks comes from increase the exposure to fluoride thinking its
better and when the water is fluoridated they will also get fluoride supplement
and then it causes fluorosis , and now we are very conscious in describing
fluoride supplement coz we have fluoride in food and tooth past .
How do you differentiate between fluorosis and enamel hypoplasia they are
similar in appearance some times , the first thing you will be asked about is
fluoride history , where do they live is it fluoridated area or not ?? any history
of trauma ?? why?? bcoz of trauma permanent tooth will be affected by this
trauma and it will cause an enamel hypoplasia on the permanent tooth ,
history of fluoride intake ?? some people take tooth past or supplement or
other source then you might think of fluorosis is it localized or generalized
defect ?? why?? Coz fluorosis is bilateral its not in a localized area ..
What’s the problem of fluorosis is the esthetics defects there is too much
chipping of the teeth especially the molars we place crowns on them in
anterior teeth we do esthetics management such as composites resin veneers
specially during childhood and then when the patient grows up
we put porcelain veneers , it might require microabrasion and its only on the
very mild cases to clean the defects …
Recently tooth mousse has been used by walsh 2007 (not sure about the
name)you will be taking about in the chemotherapeutic agents its cream which
is made of calcium and phosphate its actually derived from cazyeen (not sure
about the name) ?? which is a protein found in milk and cheese , you put in on
the tooth and it will mineralized it by the ca+ and phosphate content of it ..
From you clinical experience you will know that the mousse in some cases will
remove it totally others will have minimal effect and in others it will be
moderate ..
Fluoride toxicity you have to know the toxic level of fluoride , the certainly
lethal does is the dose when you will see certainly die , and this does for the
adults its 32-64 mg/kg according to body weight and this does results in death
within 2-4 hours if first aid is not applied immediately so they conclude that
CLD for a 70 kg is 5-10 g .
From that lower limit of 32 mg/kg the estimated equivalent CLD for a child is
320 mg ..
Probably toxic dose (PTD )is the dose where toxic symptoms appear .. it will
do toxicity and some times it could kill and it should trigger immediate
therapeutic intervention and hospitalization .
The symptoms of fluoride toxicity are related to the GI system coz its
ingested and they are:
- Nausea
- Vomiting
- Hypersalivation
Management of toxicity :
Pedo lec.# 4 Dr. Ola
Batayneh
Abeer Al Najjar
- Recommendation to induce vomiting ..
These calculations are for you at home , I just want you to know how do
they calculate the amount of fluoride ..
The first two of these conversation factors you have to know by heart
1% = 10000 ppm
1st ex .
SnF
You take the weight of fluoride which is 19*2 then divide it by 119 (the mw
for sn+ the mw for F)
AFP it’s the only product that u got 1% of AFP and that’s mean1% of F
concentration ..
ThE eNd
Actually this was a very boring lec im sorry but its not my fault , allah y3nene w
y3enkom 3aleha ;-)
Abeer Al Najjar