Topical Fluorides PDF

Topical Fluorides Associate Prof. Dr. Nurul Asyikin Yahya BDS, MSc, DDPHRCS, PhD Dept. of Family Oral Health, Faculty of Dentistry, UKM January 2024 Lecture Outline Pre- and post-eruptive mechanism of F F Toothpaste High F Toothpaste F Mouth rinse Professionally applied F gel and varnish Pos...

Topical Fluorides Associate Prof. Dr. Nurul Asyikin Yahya BDS, MSc, DDPHRCS, PhD Dept. of Family Oral Health, Faculty of Dentistry, UKM January 2024 Lecture Outline Pre- and post-eruptive mechanism of F F Toothpaste High F Toothpaste F Mouth rinse Professionally applied F gel and varnish Post-eruptive Mode of action of fluoride for caries control: Under a cariogenic challenge (left), the layer of phosphate covering calcium fluoride deposits dissolves, allowing the release of calcium and fluoride. The fluoride released from calcium fluoride adds to the pool of fluoride present in the enamel fluid, which adsorbs to the hydroxyapatite crystals. When these crystals are completely covered by adsorbed fluoride, their surfaces become similar to fluorapatite and are not dissolved by bacterial- derived acids; demineralisation is inhibited. However, the uncoated surfaces are dissolved when the hydroxyapatite crystals are only partially covered by adsorbed fluoride. After the acidic challenge (right), the salivary buffers gradually increase the pH. At pH >5.5, remineralisation will naturally occur, since saliva is supersaturated concerning the dental mineral. In the presence of low fluoride levels, the fluids become supersaturated for fluorhydroxyapatite, which allows the precipitation of fluoridated apatite over the partially dissolved crystals. This newly formed mineral is more resistant to future acidic challenges. Fluoride Ion Reactivity With Apatite By Chemical Equation Occurs when Form Iso-ionic exchange Ca10 (PO4)6OH2 + 2 Long-term exposure Firmly-bound of F– for OH– in F–  Ca10(PO4)6F2 + to low fluoride fluoride apatite 2 OH– levels in the solution (0.01 -10 Crystal growth of 10 Ca2+ + 6 PO43– + 2 ppm F) from either fluorapatite from F–  Ca10(PO4)6F2 systemic or latent super-saturated topical sources solutions (waterF) Pre- & Post- eruptive Apatite dissolution Ca10 (PO4)6 OH2 + 20 High fluoride Loosely-bound with CaF2 formation F–  10 CaF2 +6 concentration fluoride (calcium- PO43– + 2 OH– (100–10,000 ppm fluoride formation) F), eg. professional gels , varnishes or OTC toothpastes & mouthrinses Post-eruptive F Toothpaste Fluoride toothpaste: overview Fluoride toothpaste (dentifrice) is purchased over the counter. The standard toothpaste contains 1,000-1,500 ppm F. Low fluoride options are available for young children. Dental professionals may recommend using high-fluoride toothpaste (over 1,500 ppm F). Fluoride toothpaste helps to prevent dental caries by interacting with tooth structures and the oral biofilm. Fluoride toothpaste: use & application Twice daily, apply approximately 1cm of the paste to the head of a toothbrush and brush the teeth for 2 minutes. Spit out and do not rinse, or rinse with a minimal amount of water. Children under the age of 6 should use an amount equal to the size of their little fingernail, and children under two years are recommended a smear layer (or grain of rice). Fluoride toothpaste: Effectiveness, Efficacy & Safety Strong evidence suggests that daily fluoride toothpaste is fundamental for effective caries prevention in all age groups and in all populations. The prevented fraction in permanent teeth is 24% compared with placebo. Toothpaste formulas containing less than 1,000 ppm F are less effective across the life course. Fluoride toothpaste is safe when used according to recommendations. Ingestion of fluoride during the first three years of life may increase the risk of dental fluorosis. The amount of toothpaste used by toddlers and preschool children should be carefully monitored. Personalized fluoride regimens should be based on a risk analysis and a review of the patient’s current exposure. Fluoride toothpaste: Cost-effectiveness & Recommendation Being a self-applied preventive measure, the cost-effectiveness of fluoride toothpaste is outstanding. It is important that fluoride toothpastes are made available and affordable for customers worldwide. Twice a day brushing with fluoride toothpaste has been shown to reduce caries in all age groups. Its use should be strongly advocated and encouraged with individual instructions. Prescription Home Care High F Toothpaste High fluoride toothpaste (HFT) High fluoride toothpaste (HFT) refers to toothpaste containing fluoride concentrations above 1,500 ppm F, typically containing 2,800 up to 5,000 ppm F. The availability of ‘over the counter’ HFT products, such as Duraphat 5,000 ppm toothpaste, varies from country to country. HFT is used in the same manner as regular toothpaste. Apply 1 cm of paste onto the head of a toothbrush and brush the teeth for 1-2 minutes, ideally twice daily. Spit out and do not rinse, or rinse with a minimal amount of water. HFT: Effectiveness, Efficacy & Safety The anticaries effect of HFT has been estimated in clinical trials and summarised in systematic reviews [1,2,3]. A positive dose-response benefit has been observed, and HFT is superior to low-fluoride toothpaste in reducing caries. The anticaries effect of HFT (5,000 ppm F) to arrest root caries lesions is very positive, with 51% more lesions becoming inactive than conventional toothpaste. HFT toothpaste should be kept out of reach by children and is usually not recommended for use by children under the age of 16 years. Otherwise, HFT is safe when used according to instructions. HFT: Cost-effectiveness & Recommendation HFT costs more than standard ‘over the counter’ toothpaste. As a self-applied preventive measure, the cost is favourable compared with professional fluoride alternatives. Further health-economic evaluations are required to establish the costs for high-risk groups. HFT is particularly recommended for preventing and controlling caries in high-risk individuals and patients with active disease. Typical cases are patients with impaired saliva functions, frail elderly with exposed root surfaces and cancer patients who have been treated with head and neck radiation.  Toothpaste Active Components Sodium fluoride Sodium Monofluoro-phosphate Stannous Fluoride Amine Fluoride Formula NaF Na2FPO3 SnF2 C27H60F2N2O3 Concentration 1000, 1100 or 1000 ppm total F , mostly as 1000 - 1500 ppm F, 1000 - 1450 ppm F, 1450 ppm free FPO32- ion that does not enhance mostly mostly fluoride ion F- reminera-lizatio, but hydrolyzes free fluoride ion F- free fluoride ion F- rapidly in dental plaque to form free F- ion which then acts Stannous ion antibacterial. Anti- gingivitis activity Must have a compatible abrasive P P P that does not bind the fluoride e.g. hydrated silica All other components must not P P P interfere with fluoride topical actions Must be stable with time and P P P P temperature F Mouth rinse Fluoride Mouth Rinse (FMR) Fluoride mouth rinses (FMR) are neutral water solutions containing between 0.05% (230 ppm) and 0.2% (900 ppm) sodium fluoride, with or without flavour. They are traditionally applied in school-based programmes but are currently recommended by dental professionals for home use. The fluoride ions interact with the tooth structures and the oral biofilm to prevent caries. FMR: Use & Application 10 mL of the solution is “swished” around the teeth for 1 minute 1-2 times daily. The solution should be spat out and not swallowed. Avoid eating and brushing your teeth for 60 minutes. The lower concentration (0.05%) is intended for children between 6 and 12 years, the higher (0.2%) for caries-active subjects above 12 years. Children under age 6 should not use fluoride mouth rinses as they cannot spit out effectively. FMR: Effectiveness, Efficacy & Safety In supervised fluoride mouth rinsing programs among children and adolescents, the caries preventive effect is 27% compared to placebo. Some clinical trials have shown that the caries preventive effect of FMR equals that of professional fluoride applications. Fluoride mouth rinses seem better than placebo in arresting root caries in dry mouth elderly. Fluoride mouth rinses are safe to use. FMR: Cost-effectiveness & Recommendation The cost-effectiveness of FMR, particularly in supervised school settings, is specifically favourable in communities with low fluoride exposure and low socio-economic status. The cost-effectiveness compared with other preventive strategies for children is sparsely investigated. FMR is a home-use option for high-risk and caries-active subjects over six years of age. In particular, daily rinses are suitable for patients undergoing orthodontic treatment, compliant dry mouth patients and those with irregular, non-daily tooth brushing with fluoride toothpaste. Various F concentration of Mouth rinses Plax PreviDent/ Phos-Flur Duraphat Content NaF 0.05% w/w NaF 0.2% w/v APF 0.044% w/v Ppm F ion 225 900 200 School-based Fluoride Rinse Programme In the non-fluoridated area, 10ml fluoride mouth rinses containing 0.2% sodium fluoride are prescribed for weekly school fluoride rinsing programs. Professionally-Applied Topical Fluoride Professionally-Applied Topical Fluoride Concentrated forms of topical fluorides such as fluoride varnishes, gels or foams should only be applied by dental professionals or the appropriate allied operating personnel. Fluoride varnishes, gels or foams should be limited to individuals professionally assessed as being at risk for dental caries.  Fluoride Gel Sodium fluoride , NaF Stannous Fluoride, APF SnF2 Percent 2% 8% 1.23% ppm 9,200 19,500 12,300 Stability Stable Unstable Stable in plastic container pH 7.0 2.4-2.8 3.5 Limitations: Bitter, metallic taste, Increased uptake. C/I Gagging reversible gingival for patients with fixed Ingestion irritation, staining of prosthesis Not suitable for teeth young children Fluoride Varnish Fluoride varnish (FV) is a resin-based product that contains 2.26% fluoride (22,600 ppm F) from 5% sodium fluoride (NaF) in an alcoholic solution of natural tree resin. The FV adheres strongly to teeth, allowing prolonged fluoride contact and interaction with the hard tissues of teeth over time. Fluoride is slowly released, helps prevent mineral loss from teeth, and enhances remineralization to reverse or slow the progression of early carious lesions. Fluoride Varnish: Use & Application FV treatments are carried out by a dental professional after thorough cleaning and drying. The varnish is topically applied with a small brush, probe or applicator in a thin layer on high-risk tooth surfaces, such as occlusal fissures, between teeth (proximal surfaces) or exposed root surfaces. FV can also be applied directly on early caries lesions to arrest or re-mineralize the surface. The varnish should dry and set for one minute. Patients should be instructed to avoid eating, drinking, and cleaning their teeth for a few hours after application. Moderate-risk patients should receive FV at 6-month intervals, whereas high-risk groups should get FV applied at 3-month intervals. FV: Effectiveness, efficacy & safety A Cochrane systematic review has shown that FV provides caries protection at 43% in young permanent teeth and 37% in primary teeth. There is evidence showing that FV is effective for arresting or reversing non-cavitated lesions and may reverse root caries in the elderly. FV is the only high-fluoride product suitable for children under six years old. The average amount of FV used in one application for a child is around 0.3-0.5 mL, which will deliver around 6.8-11.3 mg F in the oral cavity. This dose is far below the probably toxic dose. FV: Cost-effectiveness & Recommendation The cost of FV varies widely between providers and suppliers. The costs for FV programs have been reported to be lower than fissure sealant programs. FV applied in the clinical setting is unlikely to be cost-effective in low-risk populations but more favourable in medium and high-risk patients. The WHO and many professional organisations worldwide endorse FV for prevention and non-restorative management of caries lesions. Target populations are communities with low socio-economy and low health literacy, high- risk individuals and patients with active caries disease. The current recommendations suggest that FV should be topically applied by dental professionals 2-4 times per year. The use of FV is safe and suitable for all age groups. References 1. Walsh T, Worthington HV, Glenny AM, Marinho VCC, Jeroncic A. Fluoride toothpaste of different concentrations for preventing dental caries. Cochrane Database of Systematic Reviews 2019, Issue 3. Art. No.: CD007868. 2. Marinho, V.C., Cochrane reviews of randomised trials of fluoride therapies for preventing dental caries. Eur Arch Paediatr Dent 2009; 10(3):183-191. 3. Pretty IA. High Fluoride Concentration Toothpastes for Children and Adolescents. Caries Res. 2016;50 Suppl 1:9-14. 4. Singh A, Purohit BM. Caries Preventive Effects of High-fluoride vs Standard-fluoride Toothpastes – A Systematic Review and Meta-analysis. Oral Health Prev Dent. 2018;16(4):307-314. 5. Wierichs RJ, Meyer-Lueckel H. Systematic review on non-invasive treatment of root caries lesions. J Dent Res. 2015 Feb;94(2):261-71. 6. Marinho VC, Worthington HV, Walsh T, Clarkson JE. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2013 Jul 11;(7):CD002279. 7. O’Mullane DM, Baez RJ, Jones S, Lennon MA, Petersen PE, Rugg-Gunn AJ, Whelton H, Whitford GM. Fluoride and Oral Health. Community Dent Health. 2016;33:69-99. Thank you