Fluoride Delivery Methods

GDC Learning Outcomes

• 1.1.8: Describes properties of medicines and therapeutics, and their application to patient management.
• 1.10.2: Highlights the importance of providing comprehensive, accurate preventative education to encourage self-care and motivation.
• 1.10.3: Focuses on preventative approach in all patient care, contributing to oral and general health.
• 1.10.4: Recommends applying preventative materials and treatments
• 2.3: Advocates for health promotion in terms of changing environmental, community, and individual behaviors for health gain.
• 2.4: Focuses on explaining and applying evidence-based preventative methods

Caries Development

• Caries development requires susceptible tooth surfaces, plaque bacteria, fermentable carbohydrates, and time

Fluoride Absorption and Action

• Fluoride is absorbed into the tooth surface, increasing resistance to demineralization
• Fluoride absorption occurs in pre-eruptive and post-eruptive phases
• Post-eruptive fluoride absorption involves topical applications creating a fluoride reservoir in saliva
• Fluoride bonds to calcium in saliva, forming CaF2
• During acid attacks and pH drops, fluoride is released and enters the tooth during remineralization
• Maximum fluoride acquisition happens in the 2-3 years post-eruption due to higher enamel porosity
• Demineralized enamel absorbs fluoride more readily

Importance of Regular Fluoride Supply

• Regular, low-level fluoride is necessary to replace lost ions, serving as the basis for caries prevention

Cochrane Review (2015) Findings:

• Fluoride is observed to be effective in children
• Insufficient evidence to determine fluoride's effect in adults
• Fluoridated water reduces caries in children's permanent teeth by 26%
• Fluoridated water reduces caries in deciduous (baby) teeth by 35%
• Fluoridation increased the percentage of children with no decay in deciduous teeth by 15%
• Fluoridation increased the percentage of children with no decay in permanent teeth by 14%
• There is a 12% chance of fluorosis (mottling) from fluoridation at 0.7ppm
• 73% of studies focused on areas with natural fluoridation
• Research was done with older research methods, no modern research available

Fluoride Sources:

• Without prescription: Toothpaste, Mouth rinse, Fluoridated Water, Fluoridated Salt, Fluoridated Milk
• With prescription: 2800ppm Toothpaste, Mouth rinse, 5000ppm Toothpaste, Fluoride Tablets, and Fluoride Drops
• Professionally applied: Duraphat Fluoride Varnish, Profluorid Fluoride Varnish, Glass Ionomer Cement, Silver Diamine Fluoride

Systemic vs. Topical Fluoride

• Systemic fluorides incorporate into forming tooth structures through ingestion.
• Topical fluorides strengthen teeth already present in the mouth, increasing decay resistance.

Toothpaste

• <1450ppm fluoride toothpaste may be ineffective
• 1450ppm fluoride is contained in most toothpastes
• 2800ppm (0.619%) sodium fluoride toothpaste is available on prescription
• 5000ppm (1.1%) sodium fluoride toothpaste is available on prescription
• Under 3s should use a toothpaste with a minimum of 1000ppm fluoride
• Over 3s and adults should use a paste containing 1350-1500ppm fluoride
• High-risk children under 3 can use 1350-1500ppm fluoride toothpaste under supervision
• Children over 10 can be prescribed 2800ppm sodium fluoride toothpaste
• Children over 16 can be prescribed 5000ppm sodium fluoride toothpaste
• Higher doses aren't indicated if a child cannot be trusted not to swallow toothpaste
• Children's poor dexterity needs supervision until aged 7

Toothpaste - Pros & Cons

• Pros: Easy to use and in regular use, can tailor dose of fluoride to risk level, cheap and readily available, gives choice to those that do not wish to use fluoride
• Cons: Risk of ingestion for young children, hard to control dose given as varying amounts will be used, Patients may not be aware of fluoride levels in paste used and use lower levels than required

Fluoride Recommendations

• 0-3 years: No less than 1000ppm, no more than a smear
• 3-6 years: More than 1000ppm, no more than a pea size
• 0-6 years (giving concern): 1350-1500ppm, smear or pea size
• 7 years- Young Adult: 1350-1500ppm
• 7 years- Young Adult (giving concern): 10+ with active caries- 2800ppm, 16+ with active disease- 2800 or 5000ppm
• Adults: At least 1350ppm
• Adults (giving concern): For those with active coronal or root caries- 2800 or 5000 ppm

Spit, Don't Rinse

• People should spit out excess toothpaste, but not rinse with water or mouthwash
• Rinsing removes the fluoride reservoir in the saliva
• Rinsing with mouthwash dilutes the fluoride concentration in the saliva due to the mouthwash's lower concentration

Mouthwash

• Many over-the-counter mouthwashes contain fluoride
• Fluoride concentration in over-the-counter mouthwash is 0.05%
• Prescription fluoride rinses (.05% daily or .2% weekly) can be prescribed
• The lower concentration of fluoride means mouthwash needs to be used at another time of day to brushing
• Prescription rinses given only to 7 years or older giving concern

Mouthwash- Pros & Cons

• Pros: Easy to use and in regular use, can tailor dose of fluoride to risk level, cheap and readily available, gives choice to those that do not wish to use fluoride
• Cons: Risk of ingestion for young children, cannot be used in children who are unable to spit it out, weekly rinses may be forgotten

Recommendations when using mouthwash

• Use a daily fluoride rinse (0.05% NaF) at a different time for brushing for those older than 7 (or able to rinse without swallowing).
• Daily fluoride rinses are likely to be most useful in higher dental caries risk patients
• Higher caries risk patients include those with obvious active caries, orthodontic appliances, reduced salivary flow, and special needs

Fluoride Varnish

• Fluoride varnish has the highest concentration of fluoride at 22,600ppm
• Fluoride varnish is applied to the tooth surface every 3-6 months
• Can be applied by suitably trained nurses
• Recommended for all children except those with ulcerative colitis and those at risk of allergy requiring hospital administration
• Reduces decay in deciduous teeth by 37% and permanent teeth by 43%
• Has the potential to arrest existing lesions
• Caries prone adults who cannot or are unable to use a fluoride mouth rinse
• Patients with removable orthodontic appliances or removable dentures
• Twice yearly application for children >3
• Twice yearly application for high-risk children of any age
• Localized application to arrest caries progression
• Protection of exposed vulnerable root surfaces

Fluoride Varnish Application

• Apply fluoride varnish/ sticky substance on the teeth
• Ensure teeth are clean, dry, isolated, and there are no contraindications
• Apply fluoride varnish using a micro brush or floss to allow penetration interproximally
• Provide post-operative instructions to patient/guardian

Post Fluoride Varnish

• Advise patients that the teeth will feel sticky
• Patients should not eat, drink, or rinse for 30 minutes
• Brush the evening of the application
• Discontinue fluoride tablets for 2-3 days

Fluoride Varnish - Pros vs Cons

• Pros: Can target certain populations, can discontinue when needed, can have flavors to make more palatable, gives choice to those that do not wish to use fluoride
• Cons: Patients need to attend a dental appointment to receive this, May have compliance issues for some patients, Not able to eat or drink afterwards, can be difficult to control the dose

Silver Diamine Fluoride

• Clear, odorless liquid to arrest caries for at-risk individuals with progressing lesions
• Highest fluoride concentration at 44,800 ppm
• Can manage extensive lesions with no major symptoms
• For those with intolerance to restorative treatment, or with additional medical special needs

Silver Diamine Fluoride - Actions

• Blocks dentinal tubules, stops bacteria, remineralizes, and stops collagen from breaking down
• Side effect is permanent black staining
• Used 'off-label'
• Can buy time in child patients while waiting for treatment options

Glass Ionomer Cements

• Glass ionomer cement restorative materials can contain fluoride
• In theory these will leach fluoride into the underlying demineralized tooth surface
• Low levels of fluoride may be released for up to 8 years and that fluoride levels can be 'recharged' with further topical application
• The level released is so low it has limited significance

Prophylaxis Paste

• Prophylaxis paste can contain fluoride but using this purely for prevention is not indicated
• These pastes are abrasive, it makes more sense for a fluoride one to be use, not indicated for prevention
• Surface enamel loss caused by abrasive pastes may be greater than fluoride incorporation

Fluoride Tablets/Lozenges/Drops

• Concentrations are 0.25/0.5/1mg
• Supplements can be added to water or chewed or sucked
• Obtained via prescription only
• Dosage is dependent on fluoride availability in drinking water
• Should be carefully considered as they may increase patients' risk of fluorosis

Recommendations Using Fluoride Tablets/Lozenges/Drops

• Considered for specific patients but not first-line treatments
• Not recommend for all children
• May be okay for children at high risk of decay or medically compromised children
• Ensure sources are appropriate for their age, oral hygiene teaching should be first line
• Supplements should be taken different to brushing, not at the same time

Fluoride Tablet/Lozenges Dosage Recommendations

• Less than 0.3ppm (6 months- 2 years: 0.25mg, 3-5 years: 0.5mg, 6-17 years: 1mg, Adults: 1mg)
• 0.3-0.7ppm (6 months- 2 years: None, 3-5 years: 0.25mg, 6-17 years: 0.5mg, Adults: 0.5mg)
• Greater than 0.7ppm (All: None)
• Tablets should be sucked or dissolved in the mouth and taken preferably in the evening

Fluoride Tablets/ Lozenges Dosage - Pros vs. Cons

• Pros: Can target certain populations, can discontinue when needed, gives choice to those that do not wish to use fluoride
• Cons: Need a dental appointment to receive, compliance issues may form, risk of Fluorosis and/or toxicity, needs good motivation, potential expensive technique, Fluoride levels will peak once daily

Pre-natal fluoride administration

• There is no evidence that fluoride supplements taken by pregnant women are effective in preventing dental caries in their offspring

Fluoridated Salt

• Some countries have compulsory fluoridated salt (not the UK), for example Europe and South America
• Potassium or sodium fluoride is used
• Concentration of 250mg/F/Kg used
• Bypasses problems where people do not drink tap water

Fluoridated Salts - Pros vs. Cons

• Pros: Salt is a widely used commodity, used with freedom because it is listed, easy to discontinue its use
• Cons: No consistent dose as intake varies, cannot target a specific population, compulsion eliminates freedom of choice, Fluorosis possible if used with other sources, healthy diet discourages salt use

Fluoridated Milk

• Provided as a free program for school children
• No more fluoride should be taken with supplements
• Not UK wide, but technique is used in areas with high caries rates E.g. Blackpool
• A Cochrane systematic review on milk fluoridation is available but evidence base is limited
• 200ml cartons contain 1mg fluoride
• Under 5s should take every other day. Over 5's daily

Fluoridated Milk- Pros v Cons

• Pros: Targets specific populations, can be discontinued if needed, milk is palatable with children, gives the choice to those to not have fluoride
• Cons: Expensive, often too late when older than 5 years old, dose is not accurate, may become complicated if there is more than 1 child

Fluoride Toxicity

• Acute lethal dose approximately 15mg/kg body weight
• As little as 5mg/kg may be fatal for some children, emergency action needed
• 1mg/kg can produce sub lethal toxic effects, these include: increased salivation, nausea, vomiting
• A small quantity can be neutralised with a large volume of milk
• In any doubt, send to A&E
• Symptoms appear within 1 hour of injection, if side effects from topical application it may not be noticed
• Patients may experience death from respiratory or cardiac failure within 24 hours of a lethal dose

Sub Lethal vs. Potentially Lethal Poisoning Doses in a Five-Year-Old Weighing 20 kg:

• APF gel (1.23%F): Sub-lethal - 1.7ml (1/3 teaspoon), Potentially lethal - 8ml (1.5 teaspoons)
• Sodium Fluoride Varnish (2.26%F): Sub-lethal - 0.9ml (1/5 teaspoon), Potentially lethal - 4ml = 4/5 teaspoon
• Stannous Fluoride Gel (0.4%SnF2): Sub-lethal - 20ml (4 teaspoons), Potentially lethal - 100ml = 1 cup
• Rinse (0.2% NaF): Sub-lethal - 22ml (1/5th cup), Potentially lethal - 105ml = 1 cup
• Rinse (0.05% NaF): Sub-lethal - 88ml (4/5th cup), Potentially lethal - 420ml = 4 cups
• Tablets (0.5mg F): Sub-lethal - 40 tablets, Potentially lethal - 200 tablets
• Tablets (1.0mg F): Sub-lethal - 20 tablets, Potentially lethal - 100 tablets
• Toothpaste (1000ppm): Sub-lethal - 33ml, Potentially lethal - 100ml
• Toothpaste (1500ppm): Sub-lethal - 22ml, Potentially lethal - 66ml

Summary of Fluoride Delivery Methods

• Fluoride varnish is the topical agent of choice for high-risk patients lacking compliance with home regimes like fluoride rinses
• Dental products for home use, especially toothpaste, should be kept out of young children's reach
• Topical fluoride preparations should be used with caution due to their potential toxicity
• Supervise young children’s use of toothpaste
• The use of fluorides in dental practice should be combined with dietary advice and oral hygiene, which needs to be tailored to the individual patient