systemic and topical fluoride

2012/11/23 jah Yang shu-han report

mechanism of actions of fluoride

increases enamel resistance/reducing enamel solubility remineralization of incipient lesion increases the rate of post-erupitve maturation improves tooth morphology interferes the function of dental plaque microorganisms
Textbook of Public Health Dentistry Pb

systemic delivery
water, salt, tablets, drops which are swallowed tablets or drops rarely used where public water supplies are fluoridated

topical

gels, varnishes, toothpaste/dentifiecs, mouth wash...

most effetive when a low concentration of fluoride is maintained consistently in the oral environment community fluoridated water and fluoride toothpaste rank first

acts topically
promoting remineralization and reducing demineralization as a posteruptive phenomenon Calcium and phosphate need to be present in solution to effect remineralization

remineralization
when remineralization takes place in the presence of fluoride the remineralized enamel is more caries resistant than the original enamel mineral due to increased fluoroapatite and decreased carbonated apatite this effect is evident with even very low fluoride concentrations(less than 0.1 ppm)

effect on the glycolytic pathway of oral-microorganisms reducing acid production interefering with the enzymatic regulation of carbohydrate metabolism This reduces the accumulation of plaque

halo effect
increase in availability of fluoride from foods, beverages, toothpastes and topical agents halo effect in low fluoridated communities benefit from the widespread distribution of these products from fluoridated communities where they have been manufactured

bottled and filtered waters

fluoridated water: 0.8~1 ppm F( 1.0mg F-/L) bottled water: very low filtered water some filters may remove fluoride: reverse osmosis, bone or charcoal filters, distillation or ion exchange ceramic and carbon filters retain fluoride in the filtered water

Home Fluoridation/Fluoride tablets as water supplements (1ppm)

1* 2.2mg NaF containing 1.0 mg F- dissolved in 1 L water 2*1.1mg NaF in 1 L 4*0.55mg NaF in 1 L

tablets dissolve readily in water at room temperature The fluoride water should be refrigerated and used for drinking and food preparation for the entire family

Dental fluorosis
defect of enamel(hypomineralization) threshold: unknown, but suggested to be around 0.1 mg/kg body weight primary affects primarily permanent teeth and is a dose related condition Dx requires a detailed history of fluoride exposure

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enemel mineralization sensitive to fluoride high dose of fluoride can

breakdown and withdraw of enamel matrix protein (e.g. enamelins, amelogenins), resulting in permanent hypomineralization of enamel (subsurface and surface porosity) affect the activity of the ameloblasts

dental fluorosis

the first 36 months the crowns of the maxilalry permanent incisors are undergoing mineralization or enamel maturation

excess fluoride
toothpaste ingestion as a significant source of excess fluoride in young children another source is infant formula (marked variations 0.9~2.8ppm)

management of dental fluorosis

remineralization microabrasion restorative replacement of the disoloured enamel

pretreatment with hypochlorites as deproteinizing agent (using commercially kits, or dilute hydrochloric acid, or 35% phosphoric acid and pumic paste) remineralization with topical fluoride, CPP-ACP or CPP-ACPF

CPP-ACP (casein phosphopeptideamorphous calcium phosphate) CPP-ACPF (casein phosphopeptideamorphous calcium phosphate fluoride)

mild fluorosis

reduces the whiteness(opacity) and promotes remineralization

extensive lesions

restored with labial veneers of composite resin or porcelain once the tooth is fully erupted and the height of the marginal gingiva is established

Topical fluorides
lifetime caries prevention enhence the remineralization of white spot lesion control initial carious lesion limit lesions occurring around existing restorations effective for both adults and children

optimal concentration of fluoride is required each day

caries risk: high, medium, low

consider before commiting

cariogenicity of the diet/oral clearance rate patient age and compliance use of systemic and topical fluoridation modalities community water fluoridation levels existing medical conditions

Fluoridated toothpaste-25%
maintaing elevated fluoride concentration at the plaque-enamel interface added as sodium fluoride(NaF), sodiumm monofluorophosphate(MFP), stannous or amine fluoride(SnF) greatest benefit observed on interproximal and smooth surfaces as well as newly erupted teeth

childrens toothpaste
low concentration: 250,400,500 ppm F- are available for children 250 ppm is less effective than standard 1000 ppm toothpaste 30% on a childs toothbrush can be swallowed

good oral hygiene habits

brushing twice day in children younger than 2 y/o significant reduced caries tooth cleaning before one year of age was associated with reduced caries prevalence

from the time teeth first erupt(about 6 month) to the age of 17 months, childrens teeth should be cleaned by a responsible adult, but toothpaste should not be used 18 months-5y/o, clean twice a day with 0.4-0.5mg F-/g(400~500ppmF-) toothpaste;pea-sized amount; smear across a child-sized soft tooth brush; should spit out, not swallow, not rinse >6 y/o, twice a day or more, 1mg F-/g(1000ppmF-); should spit out, not swallow, not rinse

standard fluoridatted toothpaste

caries protection : less than a lifetime exposure to community water fluoridation, but effects are addictive 1000-1100ppm F-(1.0-1.1 mg F-/g)

HIGH-CONCENTRATION FLUORIDTED TOOTHPASTES

treatment toothpaste 1500-5000ppmF-(1.5-5.0 mgF-/g) teenagers, adults, older adults who are at high risk of developing caries

mouth rinse-20-50%
0.2% w/v (900-910 ppmF-)NaF/week 0.05% w/v (220-227 ppmF-)NaF/day Indication:(children)
ortho Tx post-irrafiation hyposalivation unable adequate brushing during high risk

should not be used under 6 y/o(before the eruption of the permanent incisors) should not substitute for tooth brushing

varnishes-30%
prolong contact times between fluoride and enamel effective in primary and permanent dentitions no fluorosis over twice yearly applications

slow release from the resin vehicle results in lower pea plasma fluoride levels than from swallowed

varnish indications
Indications hypersensive areas newly erupted teeth local remineralized of white lesions individuals at high caries risk individuals in high caries groups

Duraphat (Colgate Oral Care): alcoholic solution, 50mg NaF(5%NaF), 2.26% F-, 226000ppm F-,22.6mg F-/ml varnish resin remains on the teeth for 12-48 hr after application, slow releasing fluoride Duraphat
primary dentition:0.25ml(6mg F-) mixed dentition0.40ml(9mg F-) permanent dentition:0.75ml(17mg F-)

gels, foams, solutions, creams

gels more effective to permanent dentition than the primary dentition, especially first permanent molars high concentration gels(9000123000ppm) professional use lower concentration gels(1000ppm) use at home

acidulated pohosphate fluoride gels

professional application 1.23%APF(12300ppm) mixture with NaF, hydrofluoric, and orthophosphoric acid 5000ppm with NaF, phosphoric acid, sodium phosphate monobasic APF used for prevention of caries development

neutral NaF
9000ppm F-(2%NaF) for enamel erosion, exposed dentin, carious dentine, porous enamel stable, acceptable taste, not irritating, not discolored teeth neutral PH is prefered when restoration exist(GI, composite resin, porcelain)

SnF2 Stannous fluoride white spot and gel for remineralization of

hypomineralization lesions of enamel(incisor and molar) localized remineralization is desired before placement of a definitive restoration 0.4%SnF2(1000ppmF- 3000ppm Sn2+) proved effective in arresting root caries incorporated into a synthetic saliva solution to reduce caries in postirradiation cancer patirent

stannous fluoride solution

10%SnF2 use to target at-risk surface of teeth pit-fissue, white spot lesion, accessible proximal surfaces cause discoloration of teeth and staining on margin of restorations,especially hypocalcified areas

CPP-ACP/CPP-ACPF
creams for topical application at home Tooth Mousse,Tooth MoussePlus apply to surface at risk or white spot lesion releases fluoride, calcium, phosphate ions for local remineralization of enamel 900ppm F-; use by age > 6 y/o apply with a clean finger or cotton-tipped applicator after brushing and flossing, not rinse out should not used by people with a milk protein allergy

Fluoride therapy for infants and children fluorosis will occur with ingestion of 2mg or
more fluoride per day parents should perform tooth brushing and flossing for children up to 8 years of age, and should supervise these children in play brushing should use low-fluoride toothpaste 400500ppm reduce use of fluoridated gels for children aged under 10 years upper limit: 0.07mg F-/kg for child between 2 and 7 years of age

sCHEDULES
low risk increas risk 0.02%NaF,APF daily mouthrinse spot application fo topical fluoride to newly erupting permanent posterior teeth
no new caries for 1 yr twice daily brush spot topica; F for new erupting permanent posterior teeth

adolescent without F water patient temporary high risk: ortho, under chemo radiotherapy

moderate

1-2 lesions per year cervical white spot lesions

0.05%NaF daily,or 0.2%NaF weekly mouthrinse spot topical F professional 1.23% APF (10%SnF2) every 3 month

>2 lesion per year

high caries rate initial 0.2%NaF mouthrinse daily + 1.23% APF(10%SnF) every 3 month spot application of F varnish to susceptible areas