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fluorides

Presented by: rahel charikar

4/23/12

Dental diseases most prevalent chronic diseases industrialized countries decline in dental caries responsible factors changes in sugar consumption ,improved oral hygiene ,and use of fluorides through systemic and topical routes including fluorides in tooth paste ,fluoride in mouth rinsing ,and other school based preventive programs. countries increase in dental caries responsible factors urbanization ,rural immigrants adopting 4/23/12 the behavior of modern society and

Western

Developing

Fluorides is a double edged sword???? at optimal level- not only decreases the incidence of dental caries but is also necessary for maintaining the integrity of oral tissues the same time at higher levels that too if taken excess during the developmental stages can cause adverse effects like dental 4/23/12 fluorosis and skeletal fluorosis.

Coz

at

1934

Dean developed a standard system for classification of dental fluorosis the `mottling index `. (Deans index for fluorosis). Dean et al discovered that at 1ppm F in drinking water ,a 60 % reduction in caries experience was observed. worlds first artificial fluoridation plant was started at Grand Rapids,U.S.A.
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1942

1945

Estimated

daily intake of fluoride

Average daily intake of fluoride from dry food substance is in the range of 0.2 to 1.8 mg and the average daily intake from water containing 1ppm fluoride is about 1.5 mg ,the total daily intake for adults being in the 1.7-3.3 mg range. The total fluoride intake in children is about 0.7 mg/day for the younger ,bottle fed group of 4/23/12

99%

of all the fluoride in the human body is found in calcified tissues process where most of the fluoride is buried within the mineral crystallites during the period of crystal growth. of fluoride in the outer enamel: 2200-3200 ppm. of fluoride in cementum: 45oo ppm. of fluoride in cementum is
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Accretion:

Amt. Amt Amt

Fluoride and Dental Plaque

Fluoride

ppm

content ranges from 15-64

Ionic

fluoride activity is between 0.08 and 0.8 ppm- too low to inhibit metabolism of plaque bacteria. fluoride originates from prolonged day to day contact with the low levels of fluoride in the saliva and gingival fluid
FIRMLY BOUND FLUORIDE IN PLAQUE IS MORE STABLE THAN FLUORHYDROXYAPATITE
4/23/12 plaque is exposed to high conc. Of

Plaque

When

Chief organ of excretion of fluoride is kidney. clearance rate: 30-50 ml/min analysis:

Renal

Fluoride 1. 2. . 1.

Ionic fluoride: isotachophoresis and ion chromatography Bound fluoride: distillation, wet and dry ashing, acid extraction Fluoride analysis in food: Water and beverages: potentiometric measurements with aid of fluoride ion specific electrode Foods: micro diffusion technique
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2.

Mechanism of action of fluorides

1.

Increases enamel resistance or Reduction in enamel solubility:

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Mechanism of action of fluorides

Increases

enamel resistance/improving crystallinity:

hydroxyapatite crystals are small and contain several impurities. Fluorine ion even in low concentrations increases crystallinity of hydroxyapatite . This is based on void theory
void

theory: association of hydroxyl ions with calcium ions in unit cell.

fluoride ions replace the occasional voids and replace missing hydroxyl ions4/23/12 effectively stabilize crystal structure by

2.

Remineralization of incipient lesions.

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Plaque bacteria

Fermentable carbohydrates(sucrose) Organic acids remineralisati on

Fluoride Good oral hygiene practices Change in sugar consumption

demineraliza tion

White spot lesions

remineralisati 4/23/12 on

3. . .

Fluoride and oral bacteria: saliva is source of fluoride. Topical application of fluoride increases salivary fluoride levels more than ingested fluoride. Affects microorganisms in several ways: low conc.-inhibits acid formation higher conc.-affects growth and metabolism even higher conc.-bactericidal

Fluoride acts on enolase enzyme and prevents conversion of glucose to lactic acid
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4. .

Increased rate of post eruptive maturation: Newly erupted teeth have hypo mineralized areas that are prone to dental caries Fluoride increases rate of mineralization, or post eruptive maturation Organic material deposited on enamel surface further increases its resistance to dental caries Modification in tooth morphology: Fluoride action on tooth morphology is 4/23/12 entirely by systemic route.

5. .

Classification of fluoride therapy fluorides 1. Systemic

a. b. c. d. e.

Community water fluoridation Salt fluoridation School water fluoridation Milk fluoridation Fluoride supplements Topical fluorides Professionally applied Sodium fluoride preparation
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2. i. i.

Community water fluoridation

Water

fluoridation is defined as the upward adjustment of the concentration of fluoride ion in public water supply in such a way that concentration of fluoride ion in the water may be consistently maintained at 1 parts per million by weight is hot-maintain slightly less than 1 ppm to compensate for excess consumption of water 4/23/12 during summer. In winter conc. is

Climate

Chemicals 1. 2. 3. 4. 5.

used for fluoridation

Sodium fluoride(powder): most expensive source Sodium silicofluoride(powder): corrosive in nature Hydroxyfluorosilicic acid Fluorspar Ammonium silicofluoride: of equipment used: Saturator system 4/23/12

. Types 1.

Limitations of community water fluoridation

Centralized

piped water distribution is crucial requirement for community water fluoridation

Lacking in most developing countries

introduction requires support of top health authorities and of the government in the form of laws, decrees, 4/23/12 regulations and budget

Salt Fluoridation
Is

the controlled addition of fluoride, usually sodium or potassium fluoride, during the manufacture of salt for human consumption. by Wespi in Switzerland in 1955 concentration is 250 mg of fluoride/kg salt salt:
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Introduced

Recommended Methods

of addition of fluoride in

Advantages: Economical: as does not require community water supply. Caries reduction:40-50% Permits individuals to accept or reject it Limitations: Consumption of salt negligible till age of 4-5yrs, so its of no use in smaller children
4/23/12 Not useful in medically

School water fluoridation

Suitable

alternative in communities with no central water supply dental caries by 40% effects are systemic and also topical effects concentration-4.5 ppm

Reduces Primary

Recommended Reasons

for recommending high 4/23/12 concentration:

Advantages: 1. 2. 3.

target population is school children Caries experience is high during developmental period Quite economical Need for co-operation from school authorities All children may not attend the school all days 4/23/12

.Limitations: 1. 2.

Milk fluoridation
Is

the addition of a measured quantity of fluoride to bottled or packaged milk to be drunk by children of milk fluoridation: Nutritional value of milk is well documented Milk is available to children through school and nutritional programs and the use of such 4/23/12 distribution systems provide

Rationale 1. 2.

1st

project began in the Swiss city Winterthur in 1955. is 2.2mg of sodium fluoride added to 1/4th liter of milk. Since children from lower socioeconomic groups tend to drink less amount of milk or no milk at all, hence they would be benefited least. Costly
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Concentration

Limitations: 1.

2.

Fluoride tablets/drops/lozenges
Alternate

source of systemic

fluoride
It

is given in the form of fluoride tablets, fluoride drops and lozenges effect ranges from 3070%

Cariostatic Fluoride

supplements are taken on daily basis from 6months to 14 years of age

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Most

tablets contain neutral NaF.

Factors i. ii. iii. .

to be considered for the correct dosage are: Age of child Existing fluoride concentration in the water supply Climatic conditions Trade names are Fluoriday, Tymafluor, Luride
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Topical fluorides
Topically

applied fluorides are used to describe those delivery systems which provide fluoride for a local chemical reaction to exposed surfaces of the erupted dentition. systems include: prophylactic pastes, solutions, gels and varnishes, fluoride dentifrices and rinses.
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Delivery

Indications

for topical fluoride

use,
1. 2. 3.

Caries active individuals Children shortly after periods of tooth eruption On medications that reduce salivary flow, or have received radiation to head and neck. After periodontal surgery when roots of teeth have been exposed
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4.

Topical 1.

fluoride products divided into 2 broad categories: Professionally applied products: high fluoride concentration products, ranging from 5000 and 19000 ppm, which is equivalent to 5-19 F/ml. Self applied products: low fluoride concentration products ranging from 200 to 1000 ppm or 0.2-1 mg fluoride/ml.
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2.

Professionally applied topical fluorides

1. q. q.

The fluoride vehicles used are: Aqueous solutions and gelsGel adheres to tooth for considerable amount of time When trays are used, it is possible to treat two or four quadrants simultaneously Available as sodium fluoride, stannous fluoride, acidulated 4/23/12 phosphate fluoride

q.

2. q.

Fluoridated prophylactic pastesSurface enamel contains higher levels of fluoride than internal layers. Prophylaxis if performed removes the fluoride rich layer If prophylaxis pastes containing fluorides are used, then the lost fluoride is replenished with added small net gain in the concentration
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q. q.

3.

Foam so as to minimize the risk of fluoride over dosage as well as to maintain the efficacy of topical fluoride treatment. lighter than conventional gel so only small amount of agent is needed for topical application in foaming agent has cleansing action by lowering the surface 4/23/12 tension

. Developed

. Much

. Surfactant

4.

Fluoride varnish compound is incorporated directly into varnish like coating material. increases the time of contact between the enamel surface and topical fluoride agents Duraphat fluoride varnish material,

. Fluoride

. This

5.

. First

. Viscous 4/23/12 yellowish

6.

Fluorprotector polyurethane based product containing 7000 ppm fluoride from an organic compound , difluorosilane Carex varnish fluoride
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. Clear

7.

. Fluoride . 1.8%

 1. .

Agents used for topical application are: Neutral sodium fluoride First fluoride compound to be used for topical application Minimum of four applications with 2% sodium fluoride Advantages: relatively stable, no need to prepare fresh solution for each patient Taste well accepted by patients Solution is non-irritating to the gingiva It does not cause discoloration of tooth structure Applied in age range 3 to 13 rather at annual 4/23/12 or semiannual intervals.

. q.

q. q. q.

q.

Method of application- Knutsons technique(four appointments) initial appointment, teeth cleaned with aqueous pumice slurry-isolated with cotton rollsdried with compressed air. Teeth isolated by quadrant or half mouth. cotton tipped applicator sticks,2% sodium fluoride solution is painted on air dried teeth. Solution is allowed to dry 4/23/12 for 3 to 4 mins

v At

v Using

2. . . v.

Stannous fluoride Most commonly used is 8% stannous fluoride preparation Technique of application(Muhlers technique) Each tooth surface cleaned with pumice or other dental cleaning agent for 5 to 10 seconds Unwaxed dental floss passed between the interproximal areas. Waxed floss may coat the 4/23/12 tooth surface and adversely

v.

Advantages: months recall conforms to the practicing dentists usual patientrecall system difficulties, particularly in public health programs created by need to arrange four appointments is avoided Disadvantages:
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v6

v Administrative

3. . v. v. v.

Acidulated phosphate fluoride Method of application Oral prophylaxis Isolation APF solution applied continuously and teeth are kept moist for 4 mins Semiannual or annual application In case of gel application, disposable trays of various sizes 4/23/12

v. v.

Advantages: only 2 applications in a year

v Requires v Gel

preparation can be self applied ability to deposit fluoride in enamel to deeper depth than neutral sodium fluoride or stannous fluoride is stable
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v Has

v APF

Self Applied Topical fluorides

1.

Dentifrices: compounds used in dentifrices are: Sodium fluoride Stannous fluoride: not used as it causes staining of teeth, pigmentation of hypo plastic areas and margins of restorations. Also has metallic, 4/23/12 astringent taste.

. Fluoride . .

Adverse

effects of dentifrices are:

Single brushing with full ribbon of paste will expose individual to approx. 1 mg F. risk of children under 6 yrs of age developing dental fluorosis from regular ingestions of large amounts. Detergents and flavoring oils irritate stomach when ingested in large amounts and cause vomiting. Abrasives may interfere with 4/23/12

2. Fluoride mouthrinses
Sodium

fluoride mouthrinses:

v Formulated

at conc. of either 0.2% for weekly use or 0.05% for daily use. are intended to be used by forcefully swishing 10ml of the liquid around the mouth for 60 seconds before expectorating it. mouthrinses used are stannous fluoride rinses, amine 4/23/12 fluoride rinses and ammonium

v Rinses

Other

Recommendations

for fluoride

mouthrinses:
v

Rinse and expectorate technique can be used for patients in fluoride deficient communities Swish and swallow technique employed when conc. of fluoride in drinking water is 0.3 ppm or lesser. Beneficial for patients with increased caries risk. 4/23/12

3. Fluoride gels
Include

neutral sodium fluoride and acidulated phosphate fluoride with a fluoride conc. of 5000 ppm and stannous fluoride which has conc. of 1000 ppm applied on trays or brushed on teeth once a day or more brush their teeth for 1 min with the gel or if trays are 4/23/12 used several drops are placed in

Either

Applied

Patients

Defluoridation
Defined

as downward displacement of level of fluoride in drinking water to optimal level of 1 ppm used are of two types: Based upon ion exchange process or adsorption Based on addition of chemicals to water during treatment.
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Methods i. ii.

Ion exchange resins

Are

commercially produced resins which are expensive and uneconomical in most circumstances Carbion Defluoron 1 Defluoron 2

a. b. c.

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Nalgonda technique
Equipment:

FC/RCC setting tank, flash mix and pump, flocculator, rapid gravity sand filter and disinfection unit materials: high fluoride raw water, alum, lime and bleaching powder container of 20-50 liters- adequate amt of lime water(30 mg/liter of water) and bleaching powder are added to 4/23/12

Raw

Procedure:

Acute Fluoride Toxicity

Occurs

when dose of fluoride intake starts from 32-64 mg/kg of body weight in one single retained dose. Safely tolerated dose is 8-16 mg of fluoride per kg body weight History Physical signs: nausea, abdominal cramps, vomiting, 4/23/12 diarrhea, increased salivation and

Management:

Dental Fluorosis
Is

a hypoplasia or hypomineralisation of tooth enamel or dentine, produced by chronic ingestion of excessive amounts of fluoride during the period when teeth are developing by lusterless, opaque, white patches in the enamel which may become mottled, stained, pitted
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Characterized

Skeletal fluorosis
Occurs

from ingestion of very high amounts of fluorides for long periods of time pain in backbone, hips, joints, hips, stiffness in joints and spine bending of legs and hands seen in advanced stages. Called knock knee syndrome also damage fetus if mother 4/23/12 consumes excess fluoride during

Severe

Outward

Can

you ank Th

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