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Fluoride presentation

  2. Fluorides in Dental Tissues: Caries Prevention and Fluorosis AUTHOR : Michel Goldberg Goldberg M (2020) Fluorides in Dental Tissues: Caries Prevention and Fluorosis. JSM Dent 8(1): 1123
  3. CONTENTS  Introduction  The element Fluoride chemistry and occurrence  Total intake of fluoride  From Air  From Water  From Food  Historical evolution of fluorides  Fluoride metabolism and bioavailability  Physiologic distribution of fluoride  In blood and soft tissue  In hard tissue
  4.  Excretion of fluoride  Water fluoridation  School water fluoridation  Fluoride tablets  Fluoridated salt  Fluoridated milk  Fluoridated flour and sugar  Professionally aaplied fluorides  Self appied fluorides  Toxicity of fluoride  Defluoridation  conclusion
  5. INTRODUCTION ⦁ Dental caries is a major dental disease affecting a large proportion of the inhabitants of the world. ⦁ It impairs the quality of life for many people causing pain and discomfort. ⦁ Its very high morbidity potential has brought this disease into the main focus of dental health professionals.
  6. THE ELEMENT FLUORIDE CHEMISTRY & OCCURRENCE  -The Federal Register of United States Food and Drug Administration describes fluoride as an essential nutrient.  -The WHO expert committee on trace elements included fluorine as one of the 14 physiologically essential elements.  -These essential elements are required for the normal growth and development of Human Beings.
  7.  Greek “floris”- destruction  Latin “fluor”- flow or flux  Symbol- “F”  Atomic no.- 9  Atomic weight- 18.99  It is a pale yellow, corrosive gas, which reacts with practically all organic and inorganic substances  Most electronegative of all elements
  8.  Most electronegative of all elements  Small size of atom  High electron affinity
  9.  17th in order of abundance of all elements  Constitutes about 0.032% in earth’s crust  Fluoride containing minerals-  Fluorspar (CaF2) - 48.8%  Cryolite (Na3AlF6) – rare  Fluorapetite Ca10(PO4)6F2- 3.8% WHO Expert Committee on Oral Health Status & Fluoride Use Geneva, 22-28 November,1993
  10.  Fluoride in Air-  HF or Gaseous F2  Dust of f2 containing soils, gaseous industrial, coal smoke, and volcanic emulsion.  Fluoride in plants-  Roots form soil and Leaves form air  Indian Tea leaves – 70 to 375 ppm  Vegetables- factories- 10ppm  Fruits and vegetables- 0.2 to 0.5gm
  11.  Fluoride in animal products-  Beef, pork and mutton-0.3ppm  Higher in Chicken- contamination bone and cartilage fragments  Fish products- up to 20ppm  Dried sea foods also fluoride rich 84.5ppm (South East Asia)  Fluoride in beverages-  Ranges from 0.05 to 1.05 ppm  Fluoride content in alcoholic beverages generally reflects that of water used.
  12. Fluoride from Air  Minimal Fluoride from Water  Most important single source of fluoride  Dependent on fluoride concentration and amount  Fluctuation –climatic and geographical areas Fluoride from food  0.3 to 0.6 mg/day  Breast fed infant receives 0.003 to 0.004mg/day- formula fed infants (1.2ppm) fluoride intake increased 50 times
  13.  Excessive consumption of tea and sea foods- increased fluoride  National Research Council 1980 – safe and adequate 1.5 to 4.0 mg/day in adults 0.05 to 0.07 mg/day in children for optimal dental health Threshold level drinking water 2.0ppm- dental fluorosis
  14. ⦁ The history of fluoride is more than 100 years old. The first hint of possible connection of fluoride and dental health was given by: SIR JAMES CRICHTON BROWNE in 1802. He emphasized the importance of fluoride
  15. ⦁ 1901- DR. FREDRICK McKAY Permanent stains present on the teeth of local inhibitants of Colarado Spring, U.S.A. known as COLARADO STAINS noticed. He called the stain Mottled Enamel ⦁ 1902- DR. J.M. EAGER described similar stains present on teeth of certain italian emigrants embarking at Naples as “ denti di chiaie. ⦁ 1916, Dr Green Vardmin Black supported MCKay work with histologic evidence reporting it as “an endemic imperfection of the enamel of the teeth
  16. ⦁ 1925,Dr F McKay change of water supply from spring water of the Great Salt Lake of Oakely, Idaho City, showed no brown stains in children. ⦁ 1928,Dr McKay and Gromer Kempt Similar observation found in Bauxite where changed water supply from a shallow well to foot well resulted in children with badly stained teeth. ⦁ 1931,Mr HV Churchill -A spectrographic analysis of Bauxite city water showed the presence of fluoride at the level of 13.7ppm.
  17. ⦁ 1933,Dr H Trendley Dean Shoe Leather Survey ⦁ 1939,Dean and McKay - Came out with the most conclusive and direct proof that fluoride in domestic water is primary cause of human mottled enamel. - ⦁ 1939,Dr H Trendley Dean - Hypothesis showing the inverse relationship between endemic dental fluorosis and dental caries emerged with survey of four illinois cities. In the same year- hypothesis showing ‘inverse relationship between endemic fluorosis and dental caries’
  18. Fluoride metabolism ⦁ Major route of the fluoride absorption is ingestion via the GIT. ⦁ The fluoride source may be organic and inorganic. ⦁ Fluoride is generally ingested in a beverage, in food or as a pharmaceutical preparation such as NaF tablets. ⦁ The principal source of Fluoride ingestion is WATER.
  19. After ingestion of fluoride , such as drinking a glass of optimally fluoridated water Majority is absorbed from stomach and small intestines Into the blood stream causing short term increase in level of blood within 20-30 minutes This conc. declines rapidly within 3-6 hours.
  20. EXCRETION OF FLUORIDE ⦁ Fluoride is excreted in urine and feces and lost through occurs in traces in milk, saliva, hair and tears. ⦁ Principal route of fluoride excretion is via the URINE . ⦁ Kidney is the main pathway of fluoride excretion with an average fluoride intake of 3.9mg/day
  21. ⦁ Fejerskov et al 1981 only children benefit from Fluoride incorporate into forming Tooth enamel before eruption helps to prevent later decay, Presence of Fluoride at the surfaces of teeth after eruption has been shown to be equal importance. ⦁ Hopcraft et al 2006- Fluoride prevent dental caries on both smooth surfaces and occlusal surfaces of teeth. Water fluoridation reduces caries by approximately 38% on approximal surfaces and 26% on occlusal surfaces.
  22. ⦁ Singh et al 2007- timing of exposure of Fluoride is also important, with exposure during crown completion being effective irrespective of exposure at maturation and post eruption. ⦁ Spencer et al 2008 Children living in non fluoridated areas take fluoride supplements in the form of tablets, drops, chewable lozenges. However evidence suggests that supplements increase the risk factor for dental fluorosis. ⦁ Rolla et al 1990- post eruptively, Fluoride affects plaque and saliva.Acid produced by acidogenic bacteria releases fluoride from the dental plaque, which is then taken up by demineralised enamel to form a more stable enamel structure.
  23. Physiologic Distribution of fluoride Fluoride in Blood:-  Blood plasma is most reliable indicator  ¾ in plasma and ¼ in RBC  Fluoride exists in both forms -bounded from -ionic form- varies concentration F in drinking water  Increase in plasma F with age and in presence of renal failure Drinking water 0.25 or 1.25 ppm –plasma level 0.01 or 0.025ppm Increased reactive sites and voids in old bone is more saturated and filled with F than young bone
  24. Fluoride in soft tissue:-  Tissue/ plasma ratio = 0.4 to 1  Ectopic calcification loci- F accumulation in Aorta, tendon, cartilage and placenta
  25. Effects on kidney  Fluoride is normally cleared from the blood by deposition in bone, excretion in urine- unable to find toxic effect on kidney endemic fluorosis.  Patients with chronic renal failure- dialysed with fluoridated have additional load of fluoride So fluoride free water is used for kidney dialysis
  26. Fluoride in hard tissue Bone:-  Total amount-2.6mg  Most of F in the body retained in the skeleton-vary according to the renal clearance  F enter in mineralized tissue-replacing 0H-, C03 2-  Remodeling bones deposit more fluoride than older people  Fluoride deposition is a reversible process
  27. Teeth:-  Deposition occurs in successive stages. Initial deposition – organic and mineral phases are laid down Pre-eruptive maturation phase-before eruption Post eruptive maturation and aging period  Dentine contains 4 times more than enamel  Fluoride concentration not uniform  Fluoride concentration –initial stages is higher than on completion (mineralization process- release of F to the bathing fluid)  Primary teeth less fluoride concentration than permanent teeth
  28.  Fluoride concentration in the outer enamel (2micrometer)- 1700ppm-non fluoridated areas (0.1ppm) 2200 to 3200ppm- optimally fluoridated areas (1ppm) 4800ppm- 5 to 7ppm  Depth 5 micrometer- Permanent teeth Primaryteeth Non-fluoridated areas Fluoridated areas 1100ppm 2200ppm 670ppm 950ppm
  29.  F concentration in newly erupted teeth- higher in in incisal than cervical margin  Diffusion of F in enamel NaF and monoflurophosphate(100pmm)- 10-9cm2/sec  Speed at which F penetrates in enamel- 38 micrometer/ hour (186micrometer/ day)
  30. Concentration in dentin:- more than enamel-apatite crystals are smaller -surface area and capacity to take is much larger In permanent teeth: Highest near the pulpal surface low in secondary dentin In primary teeth complicated –physiologic resorption occurs towards pulpal side greatest rise and fall – Pulpal surface of multirooted teeth
  31. Fluoride concentration in Cementum:-  Higher than any skeleton or dental tissue  Tissue is very thin  Near the tissue surface- accessible to fluoride present in blood  Increases with age
  32. Placental transfer of fluoride  Fluoride in primary teeth and bones: placental transfer  Placenta does not selectively inhibit fluoride transfer  Higher the fluoride ingestion: partial barrier may exist
  33. MECHANISM OF ACTION •Increase enamel resistance/ Reduction enamel solubility •Increased rate of post eruptive maturation •Remineralisation of incipient lesions •Interference with plaque microorganisms •Modification in tooth morphology
  38. • Carbonate substitute for phosphate CARBONATES • Magnesium substitute for calcium MAGNESIUM • Fluoride substitute for hydroxyl ion FLUORIDES 42
  41. Newly erupted tooth Matured tooth Matured tooth With fluoride Enamel structure (carbonated apatite- more soluble in acid) Hydroxyapatite (less soluble in acid) Fluorapatite (least soluble in acid) Fluoride uptake FIRMLY BOUND 45 DIFFERENT LEVELS OF ENAMEL SOLUBILITY IN ACIDS
  42. Ca10 (PO4)6 (OH)2 + 2F - (HYDROXYAPATITE) Ca10 (PO4)6 F2 + 2OH – (FLUOROAPATITE) LOW CONCENTRATION OF FLUORIDE Hydroxyapatite + Low concentration of Fluoride [Systemic fluorides] Fluorhydroxyapatite + Fluoride Fluorapatite 46
  43. Hydroxyapatite + high conc. of fluoride [Topical fluorides] CaF2 + Po4 + Hydroxyapatite HIGH CONCENTRATION OF FLUORIDE Hydroxyapatite + CaF2 Fluoridated hydroxyapatite ( FHA) Fluorapatite Repeated exposure to fluoride over long period of time CaF2 Ca++ and F F- + LOOSELY BOUND FLUORIDE 20
  44. Ca10 (PO4)6 (OH)2 + 20F - (Hydroxyapatite) 10CaF2 + 4PO4 3- + 2OH – (calcium fluoride) 48
  45. CRITICAL PH 49 The critical pH is the pH at which saliva and plaque fluid cease to be saturated with calcium and phosphate, thereby permitting the hydroxyapatite in dental enamel to dissolve Critical pH for Hydroxyapatite is around 5.5 Fluorhydroxyapatite is around 4.5
  46. • Enamel exposed to a pH • Ca10(PO4)2(OH)2 + 8H+ 5.5 or lower, it will dissolve 10 Ca++ + 6HPO- + 2H2O The Stephan Curve 50
  47. • concentration of calcium, phosphate and other ions in the solution • Plaque stops producing acid pH rises and precipitation of mineral • cyclic phenomenon 51
  49. • Hypo mineralized areas ( very common in newly erupted teeth: prone to dental caries) • Fluoride RATE OF MINERALIZATION • Post-eruptive maturation and similar process but maturation occurs in remineralisation are hypo mineralized areas while remineralisation occurs in demineralised areas ( incipient caries)
  50. 54
  54. Fluoride supplementation Systemic Topical Dietary fluorides Salt fluoride Fluoride in sugar Water fluoridation School water fluoridation Milk fluoridation Professional application Self application
  55. Water fluoridation Definitions:-  ‘Water fluoridation is defined as controlled adjustment of the concentration of fluoride in a communal water supply so as to maximum caries reduction and a clinically insignificant level of fluorosis.’  Defined as’ upward adjustment of the concentration of fluoride ion in a public water supply in such way that the concentration of fluoride in the water may be consistently maintained at 1 ppm by weight to prevent dental caries with minimum possibility of causing dental fluorosis’
  56. Water fluoridation…  First began in Grand Rapids, U. S. A., in 1945 Studiesonwaterfluoridation(city) Control 1. GrandRapids(Michigan) 2. Newyork 3. Brantford(Ontario-Canada) 4. Evanston(Illinois) 5. Teil (Netherlands) Muskegon Kingston Sarnia Oak-Park Culemberg After 1o years -DMFT of fluoridated cities 60% lower than the control cities
  57.  Murray and Rugg-gunn  compiled the status of water fluoridation globally  using over 90 studies he compared cariostatic benefits in primary and permanent dentition.  Early 1960’s successful water fluoridation program –in Singapore and Hongkong  Backer Dricks conformed caries protection….  Buccal, lingual and gingival smooth surface- 85%  Interproximal surface- 75%  Pit & fissure and occlusal surfaces- 35%  First study on deciduous dentition in UK by Weaver in North and South Sheilds (41%)
  58.  Acc to Connet, Beck, Micklem (2010) the Fluoride used for water fluoridation of drinking water it is not considered as a nutrient but a drug instead.  Paul Connet (2012) points out the fact that fluoride acts topically and not by systematical accumulation, so the original reason for fluoride ingesting has disappeared.  Gray(2008) author of book DRINKING WATER QUALITY highlights children water consumption over the past 20 yrs from 1.4litres/day replaced by acidic sugar base drinks. So original purpose of fluoridating water has become redundant.
  59. ⦁ 1944-1959 FrancisArnold, Philip Jay and John Knutson -GRAND RAPIDS MUSKEGON STUDY. ⦁ 1945-1955 David et al NEWBURGH- KINGSTON STUDY 10 year study. - ⦁ 1967(1946-1960) Dr JR Blayney, TN Hill, Zimmerman EVANSTON OAK PARK STUDY .
  60. ⦁ 1951 Hutton et al and 1965 Brown and Poplove- CANADIAN STUDY ⦁ 1961, Backer Dirks et al -DUTCH STUDY (Tiel- Culemborg ⦁ 1965, Ludwig - NEW ZEALAND STUDY.
  61.  Fluoride compounds used in water fluoridation-  Fluorospar  Sodium fluoride- most expensive source  Silicofluoride  Sodium silicofluoride- cheapest form  Hydrofluorosilicic acid  Amonium silicofluoride  Types of equipments for water fluoridation-  Saturation system- 4% NaF (recommended for small towns)  Dry feeder system-NaF or silicofluoride (medium sized towns)  Solution feeder- Hydrofluosilicic acid (large towns)
  62. Optimal fluoride concentrations and climatic condition  In Temperate climates (formative stages) - 1ppm  Children living in this area- 1mg/daily  Galagan and Vermillion emperical formula: Based on daily fluid intake, body wt and temp ppm F =0.34/E E = -0.038+0.0062 t E -daily water intake t- max daily temp in degrees Fahrenheit WHO recommended (1994)- 0.5 to 1.0 ppm
  63.  Simple modified method to determine opt fluoride concentration and mean annual temp… Richard etall oC oF Recommended ppm <18.3 18.9-26.6 >26.7 <64.9 66.0-79.9 >80.1 1.1- 1.3 0.8- 1.0 0.5- 0.7 In addition to climatic condition total fluoride intake from sources otherthan water.. Reasonable goal 60 to 65% caries reduction without fluorosis
  64. Water fluoridation… Benefits:-  Both pre eruptive and post eruptive effects  Topical effect through release in saliva  Least expensive and most effective  “Halo effect” or “Diffusion” Feasibility in INDIA  Ground water btw 1 and 5mg/ml.. (21mg/ml)  Ministry of Health Govt of India prescribed 1.0mg/ml and 2mg/ml  1983 Nanoti & 1988 Nawlakhe given Indian standard specification desirable limit as 0.6 – 1.2 mg/ml  Short coming- only implemented only in areas have central pipe water supply system.  Only 30% of population have piped water supply
  65. School water fluoridation  Suitable alternative –b’cos f consumed during school days  4.5 to 6.3 ppm- no fluorosis  Caries reduction 45 to 50%  Venturi system is most suitable- almost no maintainance Advantages:-  Effective public health measure-water supply is not possible Disadvantages:-  5 to 6 years old upon starting school- will not provide preeruptive contact..  Intermittent fluoride exposure-less than 180 days in a year
  66. Fluoride tablets Provides systemic effect before mineralization and topical effect after.. In deciduous dentition:-  Caries reduction 50 -80%, started before2 years continued of 3-4 years  Hoskova 1968(4 years) - fluoride tab started prenatally-93% - since birth- 54% In permanent dentition:-  20 to 40% caries reduction  Longest clinical trial carried out by Aasenden and Peebles-0.5mg F tab below 3years and 1mg thereafter—followed by 8-11 years
  67. Fluoride tablets…  Fluoride level in surface enamel (1-2micrometer)  Increased to 3000ppm  Fluoridated water- 2300ppm  Non fluoridated water- 1800ppm  0.5mgF/day –upper limit desirable level first year of life  Concluding that fluoride supplements during developing dentitions results in caries reduction than water fluoridation Recommended dietary fluoride supplements (1999) Age in years Concentration offluoride in drinking water ppm < 0.3ppm 0.3 to0.6ppm >0.6ppm Birth to6 years None None None 6 months-3 year 0.25mg/day None None 3 to6 years 0.5 mg/day None None 6 to16 years 1.0mg/day None None
  68. Fluoride tablets… Commercially available NaF (fluoraday, tymaflour and luride)  2.2 mg NaF- 1mg of F  1.1 mg NaF -0.5mg of F  0.55 mg NaF – 0.25mg of F  Neuromuscular coordination not fully developed until 16- 18 weeks -up to 2 years drops are preferable  Daily recommended dose:-  Below 2 years – 0.5mg  2 to 3 years -0.5 to 0.7mg  Above 3 years- 1 to 1.5mg Fluoride tablets: topical caries preventive agent to be used as Dental Public Health Measure in Rural India
  69. Fluoride tablets… To enhance cariostatic effect-  Chew and suck the tab  Preferably at bed time..  Continued at least until 12 to 14 years  Should not given –water supply exceed 0.7ppm  Should not given with milk and milk products  Cannot replace water fluoridation –parents fail to comply with the regimen
  70. Salt fluoridation  Fluoridated salt in Switzerland for the first time in 1955 (90ppm)  90ppm -20 to 25% caries reduction  Optimum level of fluoride in salt –Toth suggested  Urinary fluoride excretion from salt should be similar to that obtained from fluoridated drinking water  200 to 350 ppm salt- 0.85 and 1.05 similar to populations ingested fluoridated water for 10 years.  250ppm did not achieve cariostatic effect – optimal fl content water
  71. Salt fluoridation… Advantages:-  Low cost  Negligible waste  Ease of implementation  Free choice for individual households Disadvantages:-  Fluoride dosages of different age in different regions  Lower salt consumption during tooth forming years
  72. Salt fluoridation… Feasibility in India:-  Viable and feasible method Easily monitored Effective control- supply Individual monitoring not required Freely available Readily acceptable- does not alter the colour
  73. Milk fluoridation  First mentioned by Ziegler in 1956  Stephen et al –daily ingestion of 200ml (7ppm) for 4 years, 38.8% reduction ( 1st permanent molar)  Hellestrom and Ericsson—fluoride uptake by enamel from salt is greater.. Advantages:-  Need to drink under 14 years of age Disadvantages:-  Incompletely ionized in milk  Lower absorption from milk than water  Variation in intake MILK FLUORIDATION
  74. Milk fluoridation…  Requires parental or school efforts  Technical difficulties  Problem in distribution  High cost Feasibility in India:-  Binding with calcium and protein in milk  Not seem to viable and feasible  Cannot afford milk daily  No central milk supply system  Variation in intake and quantity of milk
  75. Fluoridation of flour and sugar  Advantages requiring much less of chemical  Fluoridation of sugar has adv –combining the culprit and cure (difficulty to provide proper dosage)  The effects of fluoridating the water can extend to communities without a fluoridated water supply through a phenomenon known as the 'halo effect. ' This effect occurs when food and beverages prepared with fluoridated water are consumed in non-fluoridated communities, sharing the benefits of their fluoridated water.
  76. Exception to school water fluoridation, salt fluoridation most promising alternative to water fluoridation. Method Average % cariesreduction ofdentalcaries Community water fluoridation School water fluoridation Dietary fluoride supplementation 50 to 65% 40% 50 to 65%
  77. TOPICAL FLUORIDE PRODUCTS ARE DIVIDED INTO 2 CATEGORIES (A) Professionally applied  Introduced by Bibby in 1942  Dispensed by dental professionals in the dental office and usually involve the use of high fluoride concentration products ranging from 5000-19000 ppm which is equivalent to 5-9 mg F/ml (B) Self applied  Include fluoride dentifrices, mouth rinses & gels  Are low fluoride concentration products ranging from 200-1000ppm or 0.2-1 mgF/ml.
  78. SODIUM FLUORIDE(NaF) - Neutral ph, 9200 ppm -1941 Bibby, 1942 Knutson, -1948 Knutson & Fedelman • Method of Preparation:- 20 gm in 1 liter of distilled water • Technique of application (Knutson & Fedelman tech 1948). - four appointmets - quardrant/half mouth, isolated - applicator sticks, dried 3-4 mins - procedure repeated 20gms 1 L
  79.  Mechanism of action :- Ca10 (PO4)6 (OH)2 + 20 F-  10 CaF2 + 6PO4 -3 + 2(OH)- “CHOKING OFF EFFECT” CaF2 + 2Ca5 (PO4)3 OH  2Ca5 (PO4) 3F + Ca (OH)2 Advantages:- • Chemically stable • Taste accepted • Non irritating • No discoloration • Public health programs … multiple chair procedure Disadvantages:- • Four visits short time • John E. Butts 1966 in journal of public health dentistry • Sodium fluoride has been shown to be safe and effective as an agent for fluoridization; Virtually all researchers agree that approximately a 40 percent reduction in new carious lesions may be expected from the application of sodium fh- ride to the teeth of children who live in nonfluoride areas;
  80. STANNOUS FLUORIDE 1957 Muhler & Dudding Method of Preparation:- 0.8 gms powdered in 10 ml of distilled Water Technique of application (Muhler Tech)  Teeth cleaned,isolated Paint on technique Repeat every 6 months  Ref: MS Muthu, Pediatric dentistry principles and practice, 2nd edition,2011; pg:155-159, Elsevier publication.  Ref: J.J.Murray, Fluorides in caries prevention, 3rd edition, 1999; pg:179-207,Butterwort2h0- 0.8 gm 10L
  81. Mechanism of action :- •At low concentrations Ca5 (PO4)3 OH + 2SnF2  2CaF2 + Sn2 (OH)PO4 + Ca3(PO4)2 • At high concentration is: Ca5 (PO4)3 OH + 16 SnF2  CaF2 + 2Sn3F3PO4 + Sn2 (OH)PO4 + 4 Ca (SnF3)2 2Ca5(PO4) 3OH + CaF2  2 Ca5 (PO4) 3F + Ca (OH)2 • Advantages:- - conforms to the dentist’s recall system - administrative difficulties are avoided • Disadvantages:- - material not stable - unpleasant taste - tissue irritation - teeth pigmentation  ML Baker et al. 2013. Journal of clinical dentistry  When properly formulated into commercially available dentrifrices , stabilizes SnF2 provides greater level of enamel protection from citric acid ersion than either NaF or Sodium MFP.
  82. ACIDULATED PHOSPHATE FLUORIDE  Brudevold et al developed APF formula in 1960s Method of application Solution Gel Method of preparation Foam •20gms of sodium fluoride in 1l of 0.1M phosphoric acid +50% hydrofluoric acid- Brudevolds solution • for gel methylcellulose or hydroxyethyl Cellulose Acqueous – paint on Gel – tray technique Foam –tray technique •Sit upright •Oral prophylaxis,isolated •Foam trays , <5ml •Tray placed,saliva ejector •Pressure buccal and lingual, 4 mins •Not eat,drink 30 mins
  83. Mechanism of action :- dehydration of hydroxypatite crystals. Shrinkage of volume of hydroxyapatite crystals Formation of dicalcium phosphate dihydrate (DCPD) Formation of fluorapatite Ca5 (PO4)3 OH + 4 H+  5 Ca +2 + 3HPO4 -2 + H2O Ca +2 + HPO4 -2 Ca. HPO4. 2H2O 5Ca. HPO4. 2H2O + F  Ca5 (PO4)3 F + 2HPO4 - ADVANTAGES • 2 applications • Gel - self applied •Deposit in greater depth •Stable DISADVANTAGES •Long application time •Acidic, sour ,bitter •Cannot be stored in glass containers
  84. An in-vitro research by Song et al. found no significant differences between APF gel and foam regarding the amount of fluoride uptake into enamel. They stated that foam could provide an effect similar to that of gel in terms of dental caries prevention.
  85. Comparison Characterstics Sodium Flouride (NaF) Stannous Fluoride (SnF2) APF Percentage 2% 8% 1.23% Fluoride concn.(ppm) 9,200 19,500 12,300 pH Neutral (7) 2.4 - 2.8 3.0 Frequency of Application 4 at weelky intervals 3,7,11,13 yrs Biannually Biannually Adverse effect - Tooth pigmentation Gingival irritation - Caries reduction 30% 32% 28% Ref: MS Muthu, Pediatric dentistry principles and practice, 2nd edition,2011; pg:155-159, Elsevier publication. Ref: J.J.Murray, Fluorides in caries prevention, 3rd edition, 1999; pg:179-207,Butterwort2h8-
  86. Fluoride varnish  Discovered in Europe in 1960, Schmidt.  Commercially available.  Duraphat, fluorprotector, duraflor, carex Technique of application:- •Prophylaxis, teeth dried •No cotton •0.3-0.5ml…full dentition, tufted brush •First lower then upper •varnish …painted on the tooth surface •4 mins ..spit •Semisolid ,liquid diet…18 hours
  87. Duraphat(1968).  Heresel and Schmidt  Sodium fluoride in varnish form  2.26mg F/ml suspended in an alcoholic solution of natural organic varnishes,contains 22600ppm  Hardens into yellowish brown coating in the presence of saliva  Caries reduction – 30-40% in permanent, 7-44% in primary  10Ca5(PO4)3 OH + 10F- 6Ca5(PO4) 3F + 2CaF2 + 6Ca3(PO4)2 + 10 OH- CaF2 in low concentrations reacts with crystals of hydroxyapatite & forms fluorapatite. 2Ca5(PO4)3OH+ CaF2  2 Ca5(PO4)3F+ Ca(OH)2 Mechanism of action :-
  88. • 2% Difluorosilane in a polyurethane-based lacquer. • F content 7000ppm • 1ml ampules, 6.21mg fluoride • Efficacy 1-17% R-SiF2OH + H2O  R-Si(OH)3 +2 HF • Koritzer and Levy (1979) -fluorosilane enhance retention and penetration of fluoride in enamel. • Arends et al (1980)- fluorprotector penetrates the porosities of enamel. • A.G. Dijkman et al (1983)- CaF2 in Duraphat specimens was lost within 1 week but in fluorprotector was noticeable upto 1 month. Fluor protector: (1975)
  89. Duraflor  5% NaF,22.6F/ml  Xylitol, improves taste  Less viscous CAREX:-  contains a lower fluoride concentration [1.8% fluoride]. ADVANTAGES •Prolonged contact time •Slow-releasing reservoir •Simplicity of its application •Applied quickly and easily and sets rapidly on teeth •Gagging and swallowing are unusual DISADVANTAGE Temporary discoloration
  91. FLUORIDE DENTIFRICE 1)SODIUM FLUORIDE /STANNOUS FLUORIDE DENTRIFICES •First trial, Bibby 1942 sodium fluoride,approved in 1973 •Rules …0.188to 0.254% with 650ppm F •1954,clinical report stannous fluoride Muhler..1955 FDA recognized •Although not used due to staining and metallic taste
  92. Monoflourophosphate dentifrice • First commercial dentifrice to be . Insoluble metaphosphate as abrasive - - 25% caries reduction • MFP - compatible with other abrasives like calcium carbonate,etc • Mechanism of action Amine fluoride dentifrice  Contains two amine fluorides with total fluoride conc of 1125 ppm with an insoluble sodium metaphosphate as the abrasive.  Elmex …..Marketed in 1963 in Switzerland. PO3F + OH = PO4 + F + H
  93.  B. Aishwarya Reddy, et al in 2019: Prevalence of toothpaste swallowing habit in children between the age group of 3 and 5 years An online questionnaire was prepared using SurveyPlanet and was circulated among 75 parents of children between the age group of 3 and 5 years having toothpaste swallowing habit. Results: About 96% of the children had the habit of toothpaste swallowing. Intestinal problems were seen in more children and also few children’s complaint about stomach pain.
  94. Fluoridated toothpicks & dental floss  For proximal areas of the teeth.  Toothpicks are impregnated with sodium fluoride.  Toothpicks (0.1-0.2 mg /pick).  Flosses (0.3mg F/gm). Fluoridated chewing gums  Recommended to high caries risk (xerostomia) persons.  It stimulated saliva secretion.  Fluoride range 0.2-0.3mg F/gm.
  95. Fluoride Rinses  These are for school based health programmes or home.  It contains NaF, APF & SnF.  Reduce caries to 20-50%.
  96. RECOMMENDATIONS(AAPD,2014)  There is confirmation from evidence-based reviews that fluoride use for the prevention and control of caries is both safe and highly effective in reducing dental caries prevalence.  There is evidence from randomized clinical trials and evidence-based reviews that fluoride dietary supplements are effective in reducing dental caries and should be considered for children at caries risk who drink fluoride-deficient (less than 0.6 ppm) water.  There is evidence from randomized controlled trials and meta-analyses that professionally applied topical fluoride treatments as five percent NaF V or 1.23 per-cent F gel preparations are efficacious in reducing caries in children at caries risk.  There is evidence from meta-analyses that fluoridated toothpaste is effective in reducing dental caries in children with the effect increased in children with higher baseline level of caries, higher concentration of fluoride in the toothpaste, greater frequency in use, and supervision. Using no more than a smear or rice-size amount of fluoridated toothpaste for children less than three years of age may decrease risk of fluorosis. Using no more than a pea-size amount of fluoridated toothpaste is appropriate for children aged three to six.  There is evidence from randomized clinical trials that 0.2 percent NaF mouthrinse and 1.1 percent NaF brush-on gels/pastes also are effective in reducing dental caries in children.
  97. Fluoride toxicity Toxic effects of fluorides: Acute and chronic Acute toxicity:  Accidental contamination of food by NaF and NaSiF salts Certainly Lethal Dose (CLD) 5 to 10 gm NaF or 32 to 64 mgF/kg Safely Tolerated dose (STD) ¼ CLD 1.25 to 2.5mg NaF or 8 to 16 mgF/kg Toprevent accidentalpoisoningofaninfantweighing (10kg)Council onDentalTherapeuticsof ADA recommendedthat:nomorethan264mg ofNaF (120mg ofF) dispensedatone time
  98. Acute Fluoride toxicity… Acute poisoning:  Causes death by blocking normal cellular metabolism  Inhibits enzymes causing vital functions-Initiation and transmission of nerve impulses to cease  Interferences with essential body functions controlled by calcium. Common signs and symptoms of acute fluoride toxicity: Lowdosages High dosages Nausea Vomiting Hyper salivation Abdominalpain Diarrhea Parathesia Convulsions Cardiac Arrhythmias Painfulspasms Paresis
  99. Acute Fluoride toxicity…  Death usually results: cardiac failure or respiratory failure Serious symptoms : with in 1 to 2 hours after ingestion Death occurs from 2 to 4 hours after ingestion  Nausea and vomiting : dose 30 t0 80 mg of NaF  Vomiting diarrhea and severe abdominal pain: 100mg NaF  Gastrointestinal symptoms: corrosive effect on gastric mucosa by HF acid Treatment : administration of calcium or magnesium or aluminum salts
  100. Chronic toxicity Fluoride level Waterconsumption Effects 0.7 to 1.2 ppm 1.5 to 3.0ppm 3.0 to 8.0ppm 8.0ppm or more Depending ontemp of area Period of 5 to 10 years 15 to 20 years 5 to 10 years Prevents dental caries Mild dental fluorosis Severe dental fluorosis Mild skeletal fluorosis Severeform of dental skeletal fluorosis
  101. Dental Fluorosis  Dental Fluorosis also termed as mottled enamel is an extremely common disorder, characterized by hypomineralization of tooth enamel caused by ingestion of excessive fluoride during enamel formation.  It is a cosmetic condition that occurs during first eight years of life
  102. ⦿Excess fluoridation of drinking water ⦿Ingestion of fluoride toothpaste ⦿Overuse of Fluoride tablets ⦿Consumption of processed food made with fluoridated water
  103. • Structurally, an increase in fluoride intake results in an increase in degree and extent of porosity of enamel. • Enamel changes described may be a result of fluoride damage of secretory ameloblast. • There can either be due to fluoride induce change in compositon of enamel matrix or be a result of disturbance of the cellular processes during enamel maturation.
  104. Chalk like discoloration of teeth with white spot or lines on tooth enamel In more severe cases, the affected area have yellow or brown discoloration. In extreme forms, fluorosis may result in pitted tooth surface Symptoms : Discolored tooth
  105. 1. Dean’s Fluorosis Index- 1934 2. Community Fluorosis Index-1946 3. Thylstrup-Fejerskov Index-1978 4. The Developmental Defects of Enamel Index-1982 5. Tooth Surface Index of Fluorosis -1984 Horowitz et al 6. Fluorosis Risk Index-1990 given by Pendrys given by
  106. MOTTLED ENAMEL  It is a condition indicates the fluorosis characterized by minute white flecks or yellow or brown spots or area scattered irregularly streaked over the surface of tooth
  107. It is score according to method described by Al Alousi et al as follows ⦿Type A : White area less than 2 mm ⦿Type B : White area more than 2 mm ⦿Type C : Brown area less than 2 mm ⦿Type D : Brown area more than 2 mm ⦿Type E : Horizontal white lines ⦿Type F : Horizontal brown lines
  108. ⦁ Introduced by Trendley H Dean in 1934. ⦁ It is also known as Dean’s Classification System for Dental Fluorosis. ORIGINAL CRITERIA( 1934)- ⦁ It was based on a 7- point ordinal scale: normal, questionable, very mild, mild, moderate, moderately severe, severe.
  109. 🞂 NORMAL: Enamel is translucent, semi-vitriform type of structure. Smooth, glossy surface usually of a pale creamy white colour. 🞂 QUESTIONABLE: Slight aberrations, ranging from a few white flecks to occasional white spots. 1-2 mm in diameter. 🞂 VERY MILD:  Small, opaque, paper-white areas scattered irregularly or streaked on the labial and buccal surfaces  Involves <25% of the tooth surface.  Small pitted white areas are on the summits of the cusps.  No brown stains present. 🞂 MILD: White, opaque areas involve at least half of the tooth surface. Surfaces of molars, bicuspids and cuspids show thin white layers worn off . Bluish shades of underlying normal enamel.
  110. 🞂 MODERATE : No change in the form of tooth.All surfaces are involved. Minute pitting on labial and buccal surfaces. Brown stain is frequently a disfiguring complication. 🞂 MODERATELY SEVERE- Greater depth of enamel is involved. Asmoky white appearance is often noted. Pitting is observed on all the tooth surface. Brown stain if present is generally deeper in hue. 🞂 SEVERE- Hypoplasia is marked. Form of teeth is at times affected. Often manifests in older children as a mild pathologic incisal-occlusal abrasion. Deeper pits and often confluent stains are widespread . Range from chocolate brown to almost black in some cases.
  111. Classification Description Normal Smooth, Glossy, Pale, Creamy white translucent surface Questionable Ranging from few white flecks to occassional white spot Very mild Small opaque paper white area scattered over the tooth but not involving as much as 25 % of tooth surface Mild The white opaque areas in the enamel of the tooth are more extensive but do not involve as much as 50% of the tooth Moderate All enamel surface of teeth are affected and the surface subject to attrition show wear. Brown stain is frequently a disfiguring feature Severe All enamel surfaces are affected discrete or confluent pitting . Brown stains are widespread and teeth often present a corroded like appearance. CLASSIFICATION OF DENTAL FLUOROSIS ( Deans Index)
  112. Smooth, Glossy, Pale, Creamy white translucent surface
  113. Ranging from few white flecks to occassional white spot
  114. Small opaque paper white area scattered over the tooth but not involving as much as 25 % of tooth surface
  115. The white opaque areas in the enamel of the tooth are more extensive but do not involve as much as 50% of the tooth
  116. All enamel surface of teeth are affected and the surface subject to attrition show wear. Brown stain is frequently a disfiguring feature
  117. All enamel surfaces are affected discrete or confluent pitting . Brown stains are widespread and teeth often present a corroded like appearance.
  118. ⦁ The available data suggests that 15 states in INDIA are endemic for Fluorosis(fluoride level in drinking water >1.5mg/l), and 62 million people in INDIA suffer from dental, skeletal and non skeletal fluorosis. ⦁ Out of these 6 million are children below the age of 14 years ⦁ Groundwater is considered as the major source of drinking water in most places of earth. Fluorosis in India Int j RES Dev Health april2013;vol1(2)
  119. Microabrasion : ( Conservative removal of outer layer of enamel ) Followed by tooth whitening can make the brown discoloration less apparent
  120. ⦿It coats the teeth with hard resin that bonds to the enamel.
  121. ⦿These are the customized shells that cover the front of teeth to improve the appearance.
  122. ⦿ To prevent fluorosis , fluoridation of drinking water should not exceed normal range ⦿ Normal range : 0.7 to 1.2 ppm ⦿ Fluoride supplement should only be prescribed for children living in nonfluoridated ⦿ Use only acceptable amount of toothpaste for children under 6 year ( pea size ) ⦿ It is important to teach the child to spit out the toothpaste after brushing instead of swallowing
  123. FEATURES OF WHITE CARIOUS LESIONS ⦿ More defined shape ⦿ Well differentiated from surrounding enamel ⦿ Often located in the middle of the crown ⦿ Randomly distributed ⦿ If the growth stops brownish discoloration is seen which is known as arrested caries. FEATURES OF DENTAL FLUOROSIS ⦿ White/Yellowish lesion ⦿ Not well defined ⦿ They are visible without drying of teeth. ⦿ These usually have a smooth surface. ⦿ Symmetrically distributed
  124. ⦿A number of factors can lead to the development of white spot on tooth sometimes these spots are caused by nutrition, genetics, or an excessive intake of fluoride while other times they become evident after braces have been removed. ⦿Usually white spots that appear on teeth are actually areas of decalcified enamel and sometimes this problem leads to the deterioration of teeth
  125. ⦿ First evidence of tooth decay is a white spot lesion and by this the tooth enamel has taken on an opaque colour in the area where cavities begin to form ⦿ White spot on the tooth can appear after the changes have occurred in the mineral content of teeth ⦿ White spot can appear in connection with condition called fluorosis which results of having excess intake of fluoride. ⦿ White spot lesion are also commonly attributed to orthodontic braces
  126. ⦿TYPES OF WHITE CARIOUS LESIONS Smooth surface caries ⦿They are defined as the caries present on the proximal surfaces and along the gingival 1/3rd of the tooth surface.
  127. Pit and Fissure caries ⦿ Pits are defined as small depressions present along the terminal ends of the development clefts. ⦿Fissures are defined as long clefts present on the occlusal surface of molars and premolars.
  128.  ⦿ Patient with orthodontic braces have difficulty in brushing their teeth and results in build up of plaque  ⦿The acid in the plaque can severely harm to the enamel and eventually cause cavities.  ⦿The first evidence of this type of tooth decay is white decalcified enamel spot or lesion that becomes apparent when braces are removed.
  129. ⦿ Fluoride treatment  ⦿Bonding & Porcelain laminate placement depending on the severity of the problem
  130. DEFLUORIDATION  Defluoridation means to improve the quality of water with high fluoride concentration by adjusting the optimal level in drinking water Absorption and ion exchange method:- exchange negative ions such OH- group for fluoride ions depends up on PH, temperature, flow rate, grain size of the material common used materials: activated alumina, activated bauxite, Zeolite, Tricalcium phosphate, activated bone char, magnesite, magnesite etc
  131.  Precipitation method:- In a high PH condition, co-precipitation of several elements in water with fluoride ions forms fluoride salts- flocculation (Aluminum ions) Alum Alum and lime Lime softening Calcium chloride
  132. Membrane separation  Reverse osmosis process  Expensive developing countries  30% of raw water is lost in the process
  133. Indian technology for defluoridation  Nalgonda Technique: India in 1975 most simple least expensive Easiest to operate
  134. Fluoride water Supply Disinfection Filtration settling Flocculation Alum NALGONDA TECHNIQUE
  135. Advantages:  domestic and community levels  manually possible  cost effective  flexible design to use in different location
  136. Prashanthi technology  Activated Alumina- most popular cost effective Bio-Science, Department of Sathya Sai University of Higher Learning in Prasant Nilayam
  137. Other methods tried in India.  Fish bone charcoal- University of Roorkee  Drumstick Moringa cleifera- Reduce water turbidity -calcium and magnesium levels in plants  Askali- extract mycetial biomass-Osmania university Aspergillus riger  Clay materials-Montmosllonite KSF, Kaolin and a Silty Clay Sediment series  Tricalcium phosphate(TSP)
  138. CONCLUSION ⦁ Fluoride in recommended concentrations is definitely beneficial to health. ⦁ In excess amount it is harmful to the body. ⦁ Appropriate fluoride intake in different population groups in different areas has to be ascertained on the basis of fluoride concentration in food and water resources taken by the local population.
  139. THANK YOU