Fluoride Delivery Methods

• Oral and Dental Science: Fluoride Delivery Methods

GDC Learning Outcomes:

• Relevant medicines and therapeutic agents' properties and applications in patient management should be described and discussed.
• Provide preventative education and instruction to patients to encourage self-care and motivation.
• All patient care should be underpinned by a preventative approach for long-term oral and general health.
• Give advice and apply relevant preventative materials and treatments.
• Describe and evaluate the role of health promotion, while understanding the changing environment and the importance of community and individual behaviors.
• Explain and appropriately apply evidence-based prevention.

Pre-reading:

• Important to review the topics like Aetiology of Dental Caries, Histology of enamel and dentine, and Fluoride and the Tooth Surface

Learning Objectives:

• Identify over-the-counter fluoride supplementation options.
• Identify prescription-only fluoride supplementation options.
• Outline professionally applied fluoride interventions.
• Discuss dangerous fluoride levels for different age groups.

Fluoride Absorption: Post-Eruptive Stage

• A healthy tooth surface undergoes demineralization when bacterial acids lower the pH, resulting in calcium and phosphate loss from hydroxyapatite.
• Remineralization occurs when calcium, phosphate, and fluoride from saliva are added back, forming fluoroapatite due to the increase in pH.

Fluoride Uptake in Teeth

• Fluoride absorbed into the tooth surface increases its resistance to demineralization.
• This absorption happens at multiple stages: pre-eruptive (systemic fluoride) and post-eruptive (topical fluoride) stages.

Fluoride Absorption: Post-Eruptive Stage Key Points

• Topical fluoride applications create a fluoride reservoir in saliva.
• Fluoride bonds to calcium in saliva, forming CaF2.
• During an acid attack, when the pH drops, fluoride is released.
• Fluoride can then enter the tooth during remineralization.
• The most fluoride is acquired during the 2-3 years post-eruption because the tooth is more porous, facilitating diffusion and uptake.
• Demineralized enamel can absorb fluoride more easily.
• Regular, low-level fluoride is essential to replace lost ions, which is the basis of caries prevention with fluoride.

Fluoride Review:

• Cochrane Review 2015 showed:
• Insufficient evidence on the effect offlouride in adults
• Based on older research with no modern research available
• An increase in the percentage of children with no decay in deciduous teeth by 15%
• 73% of studies focused on areas with natural fluoridation
• Fluoridated water reduces caries in children's permanent teeth by 26%
• A 12% chance of fluorosis (mottling) due to fluoridation of 0.7ppm which may cause aesthetic concerns.
• An increase in the percentage of children with no decay in permanent teeth by 14%
• Fluoridated water reduces caries in deciduous (baby) teeth by 35%

Fluoride Supply:

• Fluoride can be delivered through various sources, broken into 3 categories
• Sources without prescription; Toothpaste, Mouthwash, Fluoridated Water, Fluoridated Salt, Fluoridated Milk
• Sources with prescription; 2800ppm Toothpaste, Mouthwash, 5000ppm Toothpaste, Fluoride Tablets, Fluoride Drops
• Professionally Applied Sources; Duraphat Flouride Varnish, Profluorid Flouride Varnish, Glass Ionomer Cement, Silver Diamine Fluoride,

Systemic vs Topical Fluoride:

• Systemic fluorides are ingested and incorporated into forming tooth structures.
• Topical fluorides strengthen teeth already present in the mouth, making them more decay-resistant.

Topical Fluoride Concentration: Toothpaste

• Fluoride toothpaste with concentrations lower than 1450ppm, especially below 1000ppm, is ineffective at controlling caries.
• Most common fluoride toothpastes contain 1450ppm.
• 2800ppm (0.619%) and 5000ppm (1.1%) of sodium fluoride toothpaste are available by prescription.
• Children under 3 should use toothpaste with at least a minimum of 1000ppm fluoride.
• Children over 3 and adults should use a fluoride paste containing 1350-1500ppm.
• High-risk children under 3 can use 1350-1500ppm fluoride paste under supervision to avoid swallowing.
• Children over 10 can be prescribed Duraphat 2800ppm sodium fluoride toothpaste.
• Children over 16 can be prescribed Duraphat 5000ppm sodium fluoride toothpaste.
• If a child cannot be trusted not to swallow toothpaste, higher doses are not indicated.
• Children have poor manual dexterity and need supervision until age 7 when brushing.

Toothpaste Recommendations by Age:

• 0-3 years: No less than 1000ppm fluoride, using no more than a smear.
• 3-6 years: More than 1000ppm, using no more than a pea-sized amount.
• 0-6 years (giving concern): 1350-1500ppm with a smear or pea-sized amount.
• 7 years-Young Adult: 1350-1500ppm
• 7 years-Young Adult (giving concern):
• Same as above and those 10+ with active caries-use 2800ppm
• Use 2800 or 5000ppm sodium fluoride toothpaste if 16+ with active disease
• Adults: At least 1350ppm
• Adults (giving concern):
• Same as above.
• For active coronal or root caries- use 2800 or 5000 ppm

Toothpaste: Pros and Cons

• Pros:
• Easy and regular use
• The dose of fluoride can be tailored to risk level
• Cheap and available
• Gives a choice to those that do not wish to use fluoride.
• Cons:
• Risk of ingestion, particularly in young children
• Hard to manage the prescribed dose
• Patients are not aware of fluoride levels and use lower levels when a higher ppm is required

Spit, Don't Rinse:

• After brushing, patients should spit out excess toothpaste without rinsing, even with mouthwash.
• Rinsing washes away the reservoir of fluoride in saliva, reducing its beneficial effects.
• Mouthwash has a lower fluoride concentration than toothpaste, diluting the fluoride concentration in saliva.

Mouthwash:

• Many over-the-counter mouthwashes contain fluoride, but this is a much lower concentration than in toothpaste.
• OTC Fluoride concentration will be 0.05%
• Fluoride rinses can be prescribed either daily (0.05%) or weekly (0.2%).
• Mouthwash needs to be used at another time of day to brushing.
• Prescription rinses should only be given to those over 7 years old with concern.

Mouthwash: Pros and Cons

• Pros:
• Easy and regular use
• The dose of fluoride can be tailored to risk level
• Cheap and available -Gives a choice to those that do not wish to use fluoride.
• Cons:
• Risk of ingestion for younger children
• Cannot be used in children who are unable to spit it out.
• Weekly rinses may be forgotten

Mouthwash Recommendation

• Use a daily fluoride rinse (0.05% NaF) at a different time for brushing for those older than 7 or who can rinse without swallowing.
• Considered in patients with a higher risk to dental caries

Patients that are high risk and would benefit from mouthwash:

• Active caries
• Orthodontic appliances
• Reduced salivary flow
• Special needs

Flouride Varnish

• Fluoride varnish has the highest fluoride concentration, usually 22,600ppm.
• It is applied to the tooth surface every 3-6 months and can be applied by suitably trained nurses.
• Recommended for all children, except for those with ulcerative colitis and those at risk of allergy requiring hospital administration (e.g., asthma).
• Can reduce decay in deciduous teeth by 37% and in permanent teeth by 43%, and may arrest existing lesions.
• Caries-prone adults who cannot use fluoride mouth rinse.
• Patients with removable orthodontic appliances or dentures.
• Twice yearly for children over 3.
• Twice yearly for high caries risk children of any age.
• Localized treatment to stop decay.
• Protection of exposed vulnerable root surfaces.
• Steps when applying is to ensure no contraindications, clean, dry, and isolate the teeth receiving varnish, apply using a microbrush or floss interproximally, and provide post-operative instructions.
• Post Op, let patients know that teeth will feel sticky, to not eat, drink or rinse for 30 minutes, tooth brushing can begin again in the evening, discontinue any further fluoride treatment

Fluoride Varnish: Pros and Cons

• Pros:
• It can target certain populations (e.g., those at high risk).
• Can discontinue when needed.
• Flavors can be palatable
• It can give the patient the choice to opt in to having flouride added.
• Cons:
• The patients need to attend a dental appointment to receive this
• There are compliance issues
• Cannot eat or drink afterwards
• The required dose can be difficult.

Silver Diamine Fluoride

• Is a clear, odorless liquid that can arrest caries in adults and children at high risk, especially if controlling advancing cavities is challenging.
• It can manage lesions that are extensive and unsuitable for restoration without pain or infection, particularly if the patient is intolerant to treatment, elderly, or medically compromised.
• Contains the highest concentration of fluoride at 44,800ppm.
• The series of chemical reactions that lead to the blockage of the tubules, the death of bacteria, the remineralization, and the inhibition of the breakdown of collagen will occur while applying it.
• Its side effect is permanent black staining

Silver Diamine Fluoride: Indications

• For asymptomatic cavitated dentine carious lesions in primary teeth
• Lesions that are, or can be made, cleansable
• Non-restorable dentinal lesions
• Several carious lesions that may not all be treated in one visit
• Root surface carious lesions (primary and permanent teeth)
• Non-carious cervical lesions giving sensitivity
• Molar incisor hypomineralisation to reduce sensitivity
• Pre-cooperative children, children and adults whose behaviour/ medical conditions limit invasive restorative treatment and where there is a need to 'buy time' to avoid or delay treatment with sedation or general anaesthesia
• Patients with high caries risk with medical or psychological conditions that limit other treatment approaches eg patient with dental phobia, medical conditions or disabilities
• Patients who already have a high standard of brushing or are likely to be responsive to measures to change behaviour to carry out frequent, high quality toothbrushing or other methods to clean carious lesions

Silver Diamine Fluoride: Contraindications

• Clinical signs or symptoms of irreversible pulpitis, or dental abscess/fistula
• Radiographic signs of pulpal involvement, or peri-radicular pathology
• Infection or pain from pulp or food packing (unless shape of tooth can be changed to become cleansable)
• Ongoing active lesions that are not arresting (only detectable over time)
• Not able or willing to brush and unlikely to. Patients (or parents) unable or unwilling to take responsibility
• Potassium iodide is contra-indicated in pregnant or breastfeeding women, patients undergoing thyroid gland therapy or on thyroid medication or patients with known allergy to potassium or iodine
• Patients with ulceration, mucositis, stomatitis
• Patients with allergy to silver, fluoride or ammonia

Silver Diamine Fluoride: Advantages and Disadvantages

• Tooth

• Can help to maintain space in the primary/mixed dentition if avoids the extraction of a tooth/root

• Attributes May avoid restorations or dental extractions in patients who would find this difficult to cope with (medically or psychologically)

• Person

• Useful for improving cooperation in anxious or pre-cooperative individuals by allowing a minimally invasive treatment then building on successful treatment and coping strategies

• Attributes

  • Not always successful. Relies to some extent on cleansability and cleansing by the patient/ carer or biofilm profile and these may not be possible to predict

• Attributes

  • Difficult to monitor success

• Attributes

  • Might not work rapidly enough or with enough success to avoid the pulp becoming irreversibly damaged or infected

• Attributes

  • Aesthetics

• Attributes

  • Feeling of delaying/avoiding a traditional restorative solution

Silver Diamine Flouride Side Effect

• Permanent black staining

Glass Ionomer Cements:

• Glass ionomer cement restorative materials contain fluoride
• In theory, fluoride will leach into the underlying demineralized tooth surface.
• Studies suggest low levels of fluoride released for up to 8 years which can be "recharged" with further topical application.
• Some suggest however that the level that is released is so low it has limited significance

Prophylaxis Paste:

• Prophylaxis paste does contain fluoride; however, using it purely for prevention is not recommended.
• The loss of enamel because these pastes are so abrasive may be greater than the amount of fluoride

Systemically Applied Fluoride:

• Fluoride Tablet/Lozenges/Drops
• 0.25/0.5/1 mg concentrations
• Can be added to water, chewed or sucked
• These are prescription only
• The dose prescribed needs to be based on the amount of fluoride the patient has availability in their drinking water
• There are risks for developing Fluorosis

Recommendation for children

• It's not considered the first line
• Use if the review evidence is unclear on deciduous teeth
• For those at high risk of decay, compromised children

Recommendation for all

• Ensure the other sources that are being taken along side such as toothpaste is appropriated for their age
• Ensure there is no intake with any extra products
• Always provide dietary and oral hygiene as the first line of treatment
• Tablets should be taken at least once a day for 6-17 yr olds and adults, to maximize its benefits, by dissolving or sucking them in the evenings

Recommendations for 6-17 years

• Use a low 0.3 ppm solution of 0.25mg
• Use a medium high 0.3-0.7 ppm solution of 0.5mg
• Do not use if it is a high +0.7 ppm solution

Recommendations for adults

• Use a low 0.3 ppm solution of 1mg
• Use a medium high 0.3-0.7 ppm solution of 0.5mg
• Do not use if it is a high +0.7 ppm solution

Pros and Cons of Tablets

• • (+) can target certain populations (e.g those high risk)

• (+) can disontinue dose

• (+) pt does not require for it

• (-) pt need to go and get for it

• (-) compliance issues

• (-) risk of fluorosis

• (-) good motivation

Pre-Natal Administration of Fluoride:

• Should be considered that supplements, lozenges or gum may help prevent
• However, there is not enough evidence that supplementing during pregnancy has proven to be beneficial in helping prevent dental issues in their child

Fluoridated Salt:

• Some countries, not including the UK have undertaken compulsory fluoridated salt such as some countries in Europe and South America
• The concentration must be 250mg/F/Kg

Pros and Cons of fluoridated salts

• (+) common commodity used
• (+) freedom of speech is kept when used
• (+) easy to discontinue
• (-) varies because the consistent amounts are not the same intake as most
• (-) target population
• (-) eliminates freedom of choice
• (-) fluorosis in the wrong source
• (-) pt not encouraged

Flouridated Milk

• Free products provided at schools
• To use this patients should not have supplements with
• There have been very high limited numbers on flouride products but it can be helpful

Summary:

• The fluoride varnish is the topical agent of choice, especially for high-risk patients.
• Always keep products for dental home-care usage, especially toothpaste, out of the reach of children.
• Make sure the topical fluoride preparation is applied, keeping toxic effects in mind.
• Lastly, the use of fluorides in a dental practice always is to do with diet and oral hygiene issues/
• Tailor instruction to the patients' individual needs.

Fluoride Toxicity:

• Acute lethal dose is approximately 15mg/kg body weight but as little as 5mg/kg may be fatal for some children and can trigger immediate emergency action
• Symptoms include salivation, neausea, and vomiting
• A small quantity (under 5 mg/kg) is neutralised if there is a large volume of milk
• If unsure about the quantity ingestion, be taken to A &E
• Symptoms appears after an hour but if the overdose is the result of topical application The signs might be obvious until it leaves
• Death is apparent within 24 hours with respiratory failure