Fluoride Delivery Methods for Dental Care

Fluoride Delivery Methods

• Fluoride is important for preventing tooth decay.
• Various methods exist for fluoride delivery.
• Different sources of fluoride exist, both over-the-counter and prescription.
• Professionals apply fluoride in various ways, including varnish, and cement among others.
• Systemic fluoride: ingested and incorporated into tooth structures.
• Topical fluoride: strengthens existing teeth, making them more resistant to decay.
• Important to understand the different concentrations of fluoride in various products (e.g., toothpaste, mouth rinses, fluoride varnishes, fluoride tablets/lozenges/drops).
• Different dosages of fluoride are recommended for different age groups.
• Fluoride concentration levels can be harmful if taken in high amount.

GDC Learning Outcomes

• Describe the properties of medicines and therapeutic agents, and how they're used in patient management.
• Provide patients with comprehensive and accurate preventative education, emphasizing self-care and motivation.
• Underpin all patient care with a preventative approach, promoting long-term oral and general health.
• Advise on and apply various preventative materials and treatments appropriately.
• Describe and evaluate health promotion's role in changing environments, communities, and individual behaviors.
• Explain evidence-based prevention and apply it effectively.

Pre-reading: Aetiology of Dental Caries

• Caries development is influenced by susceptible tooth surfaces, time, and fermentable carbohydrates, and plaque bacteria.

Pre-reading: Histology of Enamel and Dentine

• The histology of enamel and dentine is a key topic in pre-reading.

Pre-reading: Fluoride and Tooth Surface

• Fluoride's impact on the tooth surface is a key lecture topic.

Learning Objectives

• List over-the-counter and prescription options for fluoride supplementation.
• Describe professional fluoride applications.
• Discuss dangerous fluoride levels for different age groups.

Recap - What do We Know So Far?

• Summarize important details about fluoride and its role in preventing tooth decay.

How is it Absorbed? - Post-Eruptive Stage

• Explains the process of fluoride absorption in the tooth after it erupts.
• Discusses how a drop in pH due to bacterial acid leads to demineralization and how addition of calcium, phosphates, and fluoride from saliva form fluoroapatite.
• This explains the remineralization process.

How does it Work? - Uptake into the Tooth

• Describes how fluoride is absorbed into the tooth surface to make it resistant to demineralization (during multiple developmental stages).
• Discusses pre-eruptive and post-eruptive fluoride stages.

How is it Absorbed? - Post-Eruptive Stage (Key Points)

• Most fluoride is acquired during the first 2-3 years after tooth eruption.
• Tooth enamel is porous, facilitating fluoride diffusion and uptake.
• Demineralized enamel readily absorbs fluoride, helping in remineralization.

Fluoride Sources Without Prescription

• Include items such as toothpaste, mouth rinse, fluoridated water, and fluoridated salt, fluoridated milk.

Fluoride Sources with Prescription

• Includes stronger concentrations of fluoride in toothpaste, mouth rinses, etc.

Professionally Applied Sources

• Discusses professional applications of fluoride in varying forms like varnishes, and cements.

Systemic vs Topical Fluoride

• Systemic fluoride is ingested and becomes incorporated into tooth structures.
• Topical fluoride strengthens existing teeth by increasing their resistance to decay.

Fluoride Concentration of Topically Applied Fluoride

• Covers the concentration of fluorides in various topical applications.
• The pros and cons of using these types of fluoride are discussed too.

Toothpaste

• Toothpastes vary in fluoride concentration (e.g., 1000ppm).
• Children under 3 should use toothpaste with a minimum of 1000ppm.
• Fluoride toothpaste less than 1450 ppm (often less than 1000ppm) proves ineffective for controlling cavities.
• Toothpaste containing 2800ppm and 5000ppm fluoride is available but usually requires a prescription.
• Important to use the correct amount of fluoride for specific age groups to prevent fluorosis.
• Children under 3 should use a smear amount of toothpaste.
• Children over 3 use a pea-sized amount.

Recommendations

• Age-appropriate fluoride recommendations (0-3, 3-6, 6-17 years, Adults).
• Fluoride ppm and corresponding amounts for different age groups.
• The factors to consider using higher fluoride concentrations.

Pros and Cons of Different Fluoride Methods

• Pros and cons of fluoride in various forms.
• Discuss the ease of use and regular use factors.
• Mention aspects regarding dosage control like risk levels.
• The impact of using fluoride may be seen to be cheap and readily available.
• Fluoride intake may be controlled based on individual risk levels.

Fluoride Levels

• A full list of fluoride levels in different products is in the Delivering Better Oral Health Document.

What does the term "Spit Don't Rinse" mean?

• Spitting after brushing is crucial to help keep fluoride in the saliva for remineralization.

Mouthwash

• Many over-the-counter mouthwashes contain fluoride.
• Fluoride concentration in over-the-counter mouthwash is 0.05%.
• Note that fluoride rinses can also be prescribed on a daily and weekly basis.
• Rinses are often advised when brushing is not done at the same time.

Recommendation for Mouthwash Use

• Recommend using a fluoride rinse (0.05%) at a different time for brushing, or when not able to rinse without swallowing.
• Especially for high caries risk patients

Recommendations Regarding Patients with Concerns

• Potential issues in patients with active cavities, or those with orthodontic appliances, or reduced salivary flow, or special needs.

Fluoride Varnish

• This is a topical fluoride application.
• It is used to treat and prevent cavities.
• It contains a 'sticky' substance that is professionally applied to the teeth and is used to help prevent decay.

Fluoride Varnish Indications

• Caries-prone adults who cannot use fluoride mouth rinse.
• Patients with removable orthodontic appliances.
• Twice yearly application for children over 3.
• High risk children of any age.
• Localizing application for caries progression arrests.
• Protection for exposed vulnerable root surfaces.

Fluoride Varnish Application Procedure

• Ensure no contraindications exist, and isolate/clean and dry teeth.
• Use a microbrush or floss to apply varnish interproximally.
• Provide post-operative instructions.

Fluoride Varnish Application Instructions

• Patients should avoid eating, drinking, or rinsing for 30 minutes after application.
• Brushing can be resumed after that period

Pros and Cons of Using Fluoride Varnish

• Allows targeting specific populations at high risk.
• Ease of discontinuation when not needed.
• Available in many flavors, thus making it more palatable.

Silver Diamine Fluoride

• This is a liquid that can be used to arrest dental caries in high-risk adults/children with difficult to control lesions or problems, and intolerance of treatments.
• This has the highest fluoride concentration (44,800 ppm).
• It's used to manage severe to extensive to restore lesions that aren't associated with pain, or infections.
• May be due to an intolerance, the elderly, medically compromised, or additional care needs.

Silver Diamine Fluoride - Chemical Reactions on Application

• When applied, silver diamine fluoride causes chemical reactions, leading to dentinal tubule blockage, bacterial death, remineralization and collagen breakdown inhibition.

Silver Diamine Fluoride Side Effects

• A permanent black staining can occur as a side effect.

Silver Diamine Fluoride Usefulness

• Useful in children, but may need to be used as a 'time-buying' measure due to lack or delay of treatment options such as general anaesthesia (GA) being used in patients with anxiety or other issues.

Toxicity of Silver Diamine Fluoride

• Includes important safety precautions, especially regarding potential harmful levels.

Glass Ionomer Cements

• Glass ionomer cement materials may contain fluoride.
• These materials are able to leach fluoride into the underlying demineralized tooth surface.
• Studies suggest the slow release of fluoride for up to 8 years and are often topped up with further fluoride applications.
• The fluoride is leached at a low rate, impacting how great the effects will be.

Prophylaxis Paste

• Fluoride content may be present in some formulations, but not necessarily the key focus.
• Some prophylaxis pastes are abrasive, and loss of enamel due to these types of pastes can impact the extent of fluoride benefit.
• Their role for prevention may be limited.

Fluoride Tablets/Lozenges/Drops

• Different concentrations and dosage forms (0.25/0.5/1mg).
• They are usually prescription-only.
• Important to consider that dosage is dependent on the availability of fluoride in drinking water or other sources.
• They may increase the risk of fluorosis (check with professional).

Systemic Fluoride Recommendations

• Can be considered for high-risk (decay or special needs) patients, but not a first line treatment.
• Systematic reviews show unclear evidence on deciduous teeth.

Recommendations and Considerations for all the Fluoride Types

• Ensure that the type of fluoride used is appropriate for the patient's age.
• Ensure ingestion of fluoride is not possible from other fluoride sources (e.g., toothpaste).
• Ensure that all diet and oral hygiene instructions are strictly followed.
• Fluoride supplements should be taken at a different time of day compared with brushing to ensure maximized benefit.

Fluoride Toxicity

• The acute lethal dose of fluoride is approximately 15mg/kg body weight.
• As little as 5 mg/kg body weight may be fatal to some children, triggering immediate emergency action.
• Symptoms of sub-lethal toxicity may include salivation, nausea, and vomiting.

Pre-natal fluoride administration

• Fluoride supplementation during pregnancy may aid in preventing dental caries in offspring.
• Yet, the evidence for this is still under debate (lacks conclusive proof), hence clinical applications are still inconclusive.

Fluoridated Salt

• Some countries mandate fluoride in salt.
• Bypassing concerns about some people not having access to fluoridated tap water.
• 250mg fluoride per kg of salt.
• Pros (e.g widely used commodity, available/ easy to consume) and cons (e.g may not target certain population, may not be used as part of a diet, if compulsory, may eliminate freedom of choice).

Fluoridated Milk

• A free fluoridated milk program may exist in some regions such as school programmes.
• Children should not take part if already on fluoride supplements.
• 200ml cartons usually contain 1mg of fluoride.
• May be more useful or beneficial to areas with high decay rates e.g., Blackpool area.

Summary of fluoride use in practice

• Dental professionals must provide clear instructions and monitoring regarding fluoride use for all patients, especially for children.
• This applies to topical and systemic fluoride, considering factors like patient compliance, and risk levels.

References

• Relevant texts regarding the topic above are referenced in the document.