TOPICAL FLUORIDE

By:- RICHA SINGH

CONTENTS
1.Introduction
2.Definition of topical fluoride <mouth rinses
3.Fluoride delivery method <gel
a. Topical fluoride
10.Comparison
b. Systemic fluoride
4.Indication for topical fluoride 11..Recommendation for topical
5.Categories of topical fluoride fluoride application
a. Professionally applied 12.Conclusion
<Stannous fluoride 13.REFERENCES
< Addulated phosphate fluoride
<sodium fluoride
<neutral sodium fluoride
<varnish
b. Self applied
< dentrifices
6.Sodium fluoride
7.Stannous fluoride
8.Amine fluoride
9.Monofluoro phophate
 INTRODUCTION

• Topical fluoride are those fluoride containing agents

which are applied to the tooth surface in regular interval
in order to prevent the development of caries.

• These exert an anti -caries effect by increasing the

concentration of fluoride in the outermost surface of
enamel.
 FLUORIDE DELIVERY METHOD…
Flurides

Topical fluoride Systemic fluoride

Milk Water
Professional Self applied Salt Fluoridation
Fluoridation fluoridation

1.Neutral sodium Community water School water

1. Dentrifices
fluoride Fluoridation Fluoridation

2.Stannous fluoride 2.Mouthwashes

3.Apf sol/gel 3. Gels

4. Varnish
 INDICATION FOR TOPICAL FLUORIDE..
1. Caries active individuals I .e with past caries experienceor those who
develop new carious lesion on smooth tooth Surfaces.
2. Children shortly after tooth eruption , especially those who are not caries
free.
3. Medication to reduce salivary flow or had undergone head and neck
radiation.
4. After periodontal surgery when root of the tooth have been exposed.
5. Patient with fixed or removable prosthesis and after placement and
replacement of restoration.
6. Patient with eating disorder or who are undergoing a change in lifestyle
which may affect eating or oral hygiene habits conductive to good oral
health.
7. Mentally or physically challenged individual.
TOPICAL FLUORIDE ARE DIVIDED INTO
TWO CATEGORIES……….

• PROFESSIONALLY APPLIED TOPICAL FLUORIDE..

1.SODIUM FLUORIDE
2.STANNOUS FLUORIDE
3.ACCIDULATED PHOSPHATE FLUORIDE
4.VARNISH
SODIUM FLUORIDE

Caries reduction was insignificant because of

incompatibility of components of
abrasive system.
Na –bicarbonate , Na metaphosphate, Na phosphate are
used.
1973 FDA approved-
NAF + PYROPHOSPHATE-650 ppf
 Neutral Sodium Fluoride (NaF)
Neutral Sodium Fluoride(NaF) was the first fluoride compound to be
used for topical fluoride application. A minimum of four applications of with
2% Sodium Fluoride solution gives a caries reduction of about 30%.

Methods of preparation of 2% NaF

It is prepared by dissolving 20gm of Sodium Fluoride powder in one
liter(1000ml) of distilled water in plastic bottle. It is essential to use plastic
bottles because if stored in glass bottles it may react with silica and form
Silicon Fluoride thus by reducing the availability of free active fluoride of anti-
caries action.

9
 Procedure for application of Sodium Fluoride
[ Knutsons Technique ]:
oral prophylaxis done

teeth isolated either by quadrant or by half mouth

2% NaF solution is painted on the air dried teeth so that all surfaces are visibly
wet

allowed to dry for 3-4 minutes

repeated for each of the isolated segments until all teeth are treated

2nd, 3rd and 4th NaF application, each not preceded by a prophylaxis, is
scheduled at intervals of approximately one week.

The fourth visit procedure is recommended for ages 3,7,11 and 13 years,
coinciding with the eruption of different age groups of primary and permanent
teeth. Thus, most of the teeth will be treated soon after their eruption, maximizing
the protection afforded by topical application.
10
Advantages :

• Relatively stable when kept on a plastic bottles

• Taste well accepted by patients.

• Non- irritant to Gingiva

• Doesn't results in discoloration of teeth

• Once applied allowed to dry for 3-4 minutes so can pursue a multiple-chair
procedure in public health programme.

• The series of treatment must be repeated only four times in general age range
of 3-13 years rather than annual or semiannual intervals, therefore in public
health program, other group of children can be treated in intervening years.

Disadvantages:
• The only disadvantage is that the patient has to make four consecutive visits
within a short period of time.

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 Mechanism of Action
NaF Hydroxyapatite crystals Calcium Fluoride
reacts forms

“Chocking Off Effect”

[as thick layer of formation of Calcium fluoride forms , it interferes diffusion ofFfrom
NaF solution to react with hydroxyapatite and blocks further entry of Fions]
And acts as resorvior for Frelease [it is the reason allowed to dry for 3-4minutes]

Calcium Fluoride Hydroxyapatite crystals Fluoridated Hydroxyapatite

increase of fluoride content on enamelsurface resistance against caries attack

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 Stannous Fluoride
(SnF2)
Stannous Fluoride has been used at 8% and 10% concentrations in
solutions equivalent to 2 and 2.5% fluoride. Although 10% solutions used
for adults and 8% for children there is no any clinical difference between
the two. However 8% Stannous Fluoride is preferred.

18
Methods of Preparation of Stannous Fluoride
Solutions of Stannous Fluoride are not stable so soon after
mixing they become cloudy due to formation of Tin Hydroxide reducing the agents
effectiveness. Since, Stannous is believed to contribute to anticarries benefits, aged
solutions are considered to be clinically less effective so Muhler et al recommended
to use fresh solutions of Stannous Fluoride for each patients.

To prepare 8%Stannous Fluoride solution the content of one capsule which is 0.8
gm(‘0’ no.gelation capsule) is dissolved in 10ml of distilled water in the plastic
bottles and shaken briefly.

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 Mechanism ofAction

SnF2 Low concn tin Hydroxyphosphate oral fluids dissolveit

forms gets

”metallic taste application”

SnF2 highconcentration

Calcium tri-fluoro-stannate Tin tri-fluoro-phosphate

“Tin tri-fluoro-phosphate makes tooth surface more stable & less suspectibility to decay”

Calcium fluoride is also formed both at high and low conc which reacts withhydroxyapatite and
results in formation of fluorohydroxyapatite.

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• Advantages:
– Using 8% Stannous Fluoride solution at 6-12 months intervals
conforms to the practicing dentist’s usual patient – recall system.

– Administrative difficulties, particularly in public health programs.

• Disadvantages:
– In aqueous solution the Stannous Fluoride is not stable.

– Since 8% solution is quite astringent and disagreeable in taste, its

application is unpleasant
– The solution usually causes reversible tissue irritation manifested by
gingival blanching usually on individuals with poor oral hygiene.

– It usually causes pigmentation on teeth which has characteristic light

brown color. Staining usually appears in association with carious
lesions, hypo calcified regions and around margins of restorations. 22
RECOMMENDATION FOR
TOPICALFLUORIDE APPLICATION..

• Not more than 2gm of gel per tray or approximately

 Topical fluorides are divided into two categories

Professionally applied topical fluorides:

It was introduced by Bibby in 1942.

Bibby in 1942 was the first to demonstrate that the, repeated application of
sodium or potassium fluorides to teeth of children significantly reduced their
carries prevalence. This achievements became the fore runner of many studies to
test the effectiveness of various topical fluorides and the effective methods of its
application.
Involve the use of high fluoride concentration products ranging from 5000-
19,000ppm, which is equivalent to 5-19 mgF/ml.

8
Self applied products:

Include fluoride dentifrices, mouth rinses & gels

Are low fluoride concentration products ranging

from 200-1000ppm or 0.2-1 mgF/ml.

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 Professionally Applied Fluorides

1. SODIUM FLUORIDE
2. STANNOUS FLUORIDE
3. ACIDULATED PHOSPHATE FLUORIDE
4. VARNISH

-
 Paint on Technique

Hodgson (2005) has suggested an alternative technique utilizing a 5 ml plastic

syringe. This method allows a more efficient application of the varnish which
can be particularly useful in cases where speed is important, such as with a
difficult pediatric patient. 12
Tray Technique

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 Acidulated Phosphate Fluoride (APF)

Acidulated Phosphate fluoride was introduced

in1960’s by Brudevold and his co-workers at
the Forsyth Dental Center, Boston,
Massachusetts.

Methods of preparation of Acidulated Phosphate Fluoride

An aqueous solution of Acidulated Phosphate Fluoride is prepared by
dissolving 20gms of Sodium Fluoride in 1 lit of 0.1 M phosphoric acid and
then 50% hydrofluoric acid added to adjust the pH at 3.0 and fluoride ion
concentration at 1.23%. It is also called as Brudevold’s Solution.
For the preparation of Acidulated Phosphate Fluoride gel, a gelling agent
methylcellulose or hydroxyethyl cellulose is added to the solution and the pH is
adjusted between 4-5.
Procedure for application of Acidulated
Phosphate Fluoride

The patient seated upright position in chair & Oral prophylaxis is done& teeth are treated
completely.

Clinical application of APF gel by tray technique [disposable foam line tray is preferred] To

reduce ingestion a minimal amount of fluoride gel kept [coverage of tooth surfaces ,<5ml ]

The patient is told not to swallow the gel but to exert slight pressure using the cheeks and the
tongue as well as light biting forces in order to cause the gel to flow inter-proximally. The gel
thins out under the biting force because of thixotropic nature.

The fluoride gel should be in mouth for 4 minutes and remaining oral fluids should be
expectorated.

saliva ejector is used to wipe out saliva and excess fluoride

The patient is instructed not to eat drink or rinse his mouth for at least 30 minutes.
 Mechanism of Action
APF applied

Initially leads to dehydration & shrinkage of hydroxyapatite crystals

hydrolysis
Dicalcium phosphate dihydrate (DCPD)
highly reactive with fluoride ion
Fluoride penetrates into crystals deeply through openings produced by shrinkage and
leads to formation of Fluoroapatite

The amount of Fluoroapatite deposited dependent on DCPD formation. For conversion

of DCPD into fluoroapatite deeper penetration and continuous supply of Fluoride
required. Hence APF solution was applied at 30 sec intervals and teeth kept wet for 4
minutes.
High fluoride concentration and low pH, favors fluoride deposition, acidification of
fluoride solution with phosphoric acid found to suppress dissolution of enamel, as well
as formation of calcium fluoride

The intermediate product DiCalcium phosphate & principal reaction product Calcium
fluoride
Advantages:
• Requires only 2 application in a year and is thus suited for most dental
office routines.
• The gel preparation can be self applied and the cost of application also gets
reduced.
• It has the ability to deposit fluoride in enamel to a deeper depth than a
neutral Sodium Fluoride or Stannous Fluoride.
• Acidulated Phosphate Fluoride is stable and need not be freshly prepared
for each individual.

Disadvantages:
• Practical difficulties like the teeth should be kept wet for four minutes so
repeated application necessitates the use of suction thereby minimizing its
use in the field. This also increase the chair side time making this methods
more expensive.
• It is acidic, sour and bitter in taste.
1.FLUORIDE VEHICLES:

Aqueous solutions & gels

The gel adheres to teeth & eliminates the continuous wetting of enamel
surfaces required when solutions are used.

Thixotropic solutions are not gels, but have a high viscosity under
storage conditions & become fluid under conditions of high stress
FLUORIDATED PROPHYLACTIC PASTES:

 If prophylaxis pastes containing fluoride are used, the lost

fluoride is replenished & there is a significant gain in the
concentration of fluoride.
FOAM:

Developed to minimize the risk of fluoride over dosage as well as to

maintain the efficacy of topical fluoride treatment.

Advantages :

Its lighter than a conventional gel & therefore only a small amount of
agent is needed for topical application

The surfactant has cleansing action by lowering surface tension, this

facilitates the penetration of material into interproximal surfaces.
It doesn’t require suctioning so it offers advantages for home use
FLUORIDE VARNISH:
Increasing the time of contact between enamel surface & topical fluoride
agents favours the deposition of fluorapatite & fluorhydroxyapatite.

DURAPHAT:

It s a viscous yellow material, containing 22,600 ppm fluoride as sodium

fluoride in a neutral colophonium base.

FLUORPROTECTOR:

Its a clear polyurethane based product containing 7000 ppm fluoride from
difluorosilane.
 Its dispensed in 1ml ampules each ampule containing 6.21mg of fluoride.

CAREX:
It has low fluoride concentration than duraphat & has equal efficacy to that
of duraphat as caries preventive agent.
Recommendation For Topical Fluoride Application

According to Lecompte (1987), the recommendation for Topical Application of high

potency fluorides are:-

1. Not more than 2gm of gel per tray or approximately 40% of tray capacity should be
dispended. Even more conservative amount should be considered for small children.

2. To prevent the swallowing of saliva during 4 min topical application , use of Saliva
Ejector is recommended.

3. Following the 4 min of application procedure, the patient should be instructed to

expectorate thoroughly for from 30 sec-1 min, regardless the use of suction cause
the Expectoration is the only single most effective way of reducing orally retained
fluoride.

4. When utilizing custom individually fitted trays for patients requiring daily or
weekly application of a high fluoride concentration product utilize only 5-10 drops

of products per tray.

 Self Applied TopicalFluorides

Self applied fluorides products are usually bought and dispended by the individual patient
but at the recommendation of a dental professional. These fluoride products are of low
concentration ranging from 200-1000 ppm or 0.2-1.0 mgF/ml. The self applied
fluorideusually are:-

1. Fluoride Dentifrices
2. Fluoride gels
3. Fluoride rinse

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dentifrices

It’s a mixture of abrasive or polishing agents, detergent,

Binders, flavoring agent, and substances necessary to
facilitate their preparation

Therapeutic paste/dentifrices contains addition one or more

Compounds intended for reduction of oral dental diseases.

Exact formulation depends on Manufacturer but basic components

remains same

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Fluoride Compounds in Dentifrice

1. Sodium Fluoride Dentifrice

2. Stannous Fluoride Dentifrice
3. Monofluorophosphate
4. Amine Fluoride Dentifrice

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 Composition of dentifrices
 NaF or Na – monofluoroPhosphate Cariostatic effect
 Sorbitol, Glycerin Humectants
 Silica, DCP Abrasive
 Na- Lauryl sulfate Surfactant
 Water Vehicle
 Hydrated Na Phosphate or Na- citrate Buffer
 saccharin Sweetener
 Spearmint oil, menthol, coriander Flavor
eucalyptol, lemon
 Titanium di oxide Opacifier
 Xantham gum, Ca- carrageenan Binder
cardomer
 Aqueous solution Na-benzoate pH Stabilizer
adjusted to approximately neutral
 STANNOUS FLUORIDE:

Mulher associates at Indiana university

1955 ---1ST To recognized by FDA

Undergoes quick dissociation by hydrolysis and oxidation so needs to be

stabilized , 1% stannous pyrophosphate is used
Not compatible with CaHPo4 so replaced with Ca – pyrophosphate
or insoluble Meta phosphate

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DISADVANTAGES:

•Staining of teeth, particularly in mouth with poor oral hygiene

•Pigmentation of hypo plastic areas and margins of restoration
•Metallic taste, due to low pH & high conc. of Sn2F
•Astringent taste and difficult to mask with flavoring agents
•Poorly accepted by children So now not available in market

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MONO FLUOROPHOSPHATE:
1981, most widely used, with good results
Doesn’t occur in nature so prepared synthetically in
laboratory, OKALAHOMA

CONTAINS:
1 Atom of phosphate Exist as divalent ion

2 atom of 02

1 Atom of fluoride

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ADVANTAGES:
No staining of teeth.

Abrasive system includes

* CHALK ( calcium carbonate) &
* DICAL ( Di calcium phosphate)

MECH OF ACTION : not absolutely established , thought that

Monofluorophosphate anion has anticaries property of its own and
exchange phosphate groups in apatite crystals

Other Mech.. is by slow hydrolysis, releases Fions

PO3F2 + H2O▬> H2PO4 +F-

Also thought that their might be release catalyst present in the
saliva or dentifrices

Other mech..
Is due to Fluoride ion released by degradation of the complex
PO3F2- ion in the oral environment by bacterial enzymes,
Contains 800ppmF
AMINE FLUORIDE:
1st tested in Zurich, Switzerland

Components:
Amine fluoride 297 (OLAFLUR) contains 1000ppmF
Amine fluoride 242(HETAFLUR) contains 250ppmF
Both are stable and have long life
FEATURES:
Insoluble meta phosphate
* Is the abrasive & polishing agent
* Less foaming action
* Developed to improve the affinity of fluoride to enamel by the
Organic Cationic molecule thus making more resistant to
dental caries

* Marketed in Europe and not in northAmerica

* Have shown Higher reductions in dental caries

Other superior properties includes:

Reduced enamel solubility
Increased F uptake by enamel
Antiglycolytic property
DISADVANTAGES/LIMITATIONS:
Concern has been raised for
* Taste characteristics and
* Long range toxic effects

RETENTION OF FLUORIDE DENTIFRICES:

Continuous use at low conc. is beneficial as Fluoride conc.
in oral fluid is elevated to bring its effect
 Fluoride Mouth Rinses

• The use of fluoride mouth rinses was first described by Bibby et al in1946.
• In1979 the Council of Dental Therapeutics of American Dental Association acepted
Neutral Sodium fluoride and Acidulated Phosphate Fluoride mouth rinses as
effective caries preventive agents.

Sodium Fluoride Mouth rinses

• They are usually formulated at concentrations of either0.2%(900ppm F)
for weekly use or 0.05%(225 ppm F) for daily use.

• These rinses are intended to be used forcefully swishing 10ml of the liquid
around mouth for 60 sec before expectoring it.
Advantages of DailyRinsing
• If the patient misses several sessions it is probably less critical than if he
was on a weekly schedule.

• Advantage of 0.05% Sodium Fluoride concentration is that it can be used

to produce topical as well as systemic benefit when indicated for
individual patient.

Ref: Marinho VCC, Higgins JP,Logan S, Sheiham A. Fluoride mouthrinses for preventing
dental caries in children and adolescents.Cochrane Database Syst Rev
2003;(3):CD00284.
 Fluoride Gels
Fluoride gels products includes neutral sodium fluoride and acidulated phosphate fluoride
with a fluoride concentration of 5000 ppm and stannous fluoride with1000 ppm. The
stannous fluorides products usually called gels, but actually are glycerin based solutions.

• The gels are applied either by brushing or in trays.

• Professionally, applied fluoride given twice a year while self applied fluoride can be once
a day or more.

• Patients brush their teeth for 1 min with a gel or if trays used several drops are placed in
each tray and applied for 5 min. Patient should be informed to expectorate the gel and
not to swallow. And should rinse mouth after the application so as to minimize the risk
of swallowing gels by children and usually not recommended for children 6 years or
younger.
 Limitation of FluorideGels
• They violate the principle of delivering low concentration of fluoride at
regular intervals. High concentrations of fluorides deposit calcium fluoride
on teeth rather than forming hydroxyapatite.

• They present a toxicity hazard as relatively large amounts of fluorides are

given in uncontrolled manner to people ofvarying intelligence.

• They are tedious to use on daily basis over a long period of time. However
they may be a value when prescribed professionally for use at home
especially for high risk subjects.

Ref: Marinho VCC, Higgins JP, Logan S, Sheiham A. Systematic review of controlled trials
on the effectiveness of fluoride gels for the prevention of dental caries in children. J Dent
Educ.2003;67(4)
 Conclusion

The role of fluoride in preventive dentistry is very

important as it has a long history of effective decline in
caries occurrence when used wisely either systemically or
topically
REFERENCES
• 1.Shobha Tandon,textbook of pediatric dentistry
Age Recommendation
Below 4 years Not recommended
4-6 years Once daily with fluoride paste and
twice without paste
6-10 years Twice daily with fluoride paste and
once without paste
Above 10 years Thrice daily with fluoride paste