Fluoride Presentation PDF

Fluoride History Dr. Frederick S. McKay Dentist Early 20th century Brown stain Colorado Springs: Mottled enamel/fewer cavities H.V. Churchill: Chemist 1931 Identified Fluorine as the problem Dr. H. Trendley Dean 1930’s Directed US Public Health Service...

Fluoride History Dr. Frederick S. McKay Dentist Early 20th century Brown stain Colorado Springs: Mottled enamel/fewer cavities H.V. Churchill: Chemist 1931 Identified Fluorine as the problem Dr. H. Trendley Dean 1930’s Directed US Public Health Service Optimal levels for prevention 1 ppm First communities were fluoridated in 1945 Fluoride & Tooth Development  Pre-Eruptive: Mineralization Stage  Primary teeth formation begins in utero  First permanent molars begin mineralization at birth  Fluoride is available to developing teeth by way of the circulatory system.  Hydroxyapatite (crystalline structure) becomes fluorapatite  Contributes to shallow occlusal grooves  Fluorosis: too much fluoride during tooth development Fluoride & Tooth Development  Pre-Eruptive: Maturation Stage  After mineralization is complete and before eruption  Fluoride deposition continues in the surface of enamel Fluoride & Tooth Development  Post- eruptive  Uptake is rapid on the enamel surface during the first years after the eruption of teeth  Uptake continues throughout life through surface exposure  Repeated uptake of drinking water provides a topical source throughout life. Fluorosis  Disturbance of enamel formation (Ameloblasts) by fluoride during tooth development.  Associated with levels over 2ppm  Hypomineralization  Fluorosis Facts  Fluoridation  Adjustment of fluoride content in a water supply to the optimal concentration  Cost per person per year is low, with lower cost per person for communities of > 20,000 people. Partial Defluoridation  Chemical systems to remove excess fluoride.  Implemented in communities with levels above optimal concentration. Absorption  GI tract  less absorption when taken with milk or food  Fluoride not absorbed by the stomach will be absorbed in the small intestines.  Blood stream: Max. levels reached within 30 minutes of intake  Concentration in saliva 0.01-0.04 ppm Distribution and Retention  Fluoride has a strong affinity for calcified tissues  99% of fluoride in the body is stored in mineralized tissues  When teeth are fully matured, fluoride content can be altered by caries, erosion, or mechanical abrasion. Excretion  Most fluoride is excreted through the kidneys in the urine.  Limited transfer from plasma to breast milk for excretion through this route. Topical Effects of Fluoride  Inhibition of demineralization  Enhancement of remineralization  Inhibition of bacterial activity  Inhibits enolase an enzyme needed for bacteria to metabolize carbohydrates  Fl is a natural constituent of enamel  Fl level may be greater in dentin  Fl level in cementum is high and increases with exposure Demineralization  Loss of mineral content of the tooth primarily calcium and phosphorus  A result of acids produced by metabolism of fermentable carbohydrates by bacteria Remineralization  Saliva buffers and neutralizes the acid  Calcium and phosphorous are returned to the enamel  Fluoride enhances remineralization  Continuous exchange of minerals between biofilm and enamel crystals  The Hydroxyapatite crystalline structure becomes Fluorapatite  Less soluble Water Fluoridation  Estimates have shown that the reduction in caries due to water fluoridation alone (factoring out other sources of topical fluoride) among adults of all ages is 27%.  With fluoridation from birth, the caries incidence is reduced up to 40% in the primary teeth.  Maximum benefit with continuous use from birth through life. Fluoride a salt of hydrofluoric acid  Fluoride compounds occur naturally and are mined in areas around the world.  Dry Compounds include Sodium fluoride (NaF) and Sodium silicofluoride  Liquid Solution: hydrofluorosilicic Acid  Delivered to the teeth in two methods  Topical application: Diffuses into the surface of the enamel of an erupted tooth.  Post- eruption  Systemic: Delivered systemically through circulation incorporation into enamel during tooth development  Pre-eruption Systemic Delivery  1962: Optimum fluoride levels 0.7 ppm. in warmer climates to 1.2 ppm in colder climates  2015: The U.S. Department of Health and Human Services recommended the lower level of 0.7 ppm due to many sources available to the general population.  Water, foods, supplements, mouth rinses & dentifrice  CDC.gov  Teeth exposed to an optimum or slightly higher level of fluoride appear white, shining, opaque, and without blemishes. Food Sources  Meat, eggs, vegetables, cereals, & fruits in small amounts  Tea and fish have higher levels  Fluoridated salt available in Europe  Bottled water, and processed beverages ( may not contain optimal amounts)  Foods cooked in fluoridated water retain the fluoride Halo/Diffusion Effect  The halo or diffusion effect can result in increased fluoride intake by individuals living in non-fluoridated communities, providing them with some protection against dental caries. Foods and beverages commercially processed in optimally fluoridated cities are distributed and consumed in non- fluoridated communities. Other sources of Water  Well Water  Bottled Water: depending on the source it may not have Fl  Filtered Water  Reverse Osmosis and distillation removes fluoride  Carbon filters vary in the amount of fluoride removed  Water Softeners do not remove fluoride Infant Formula  Ready-to-feed formulas do not need to be reconstituted ( mixed with water)  Water is added to powdered and liquid concentrate formulas.  Breast milk may contain 0.02 ppm fluoride, and all types of infant formula contain a low amount of fluoride (0.11–0.57 ppm) Dietary Fluoride Supplements  To compensate for the fluoride-deficient drinking water.  Determine if the fluoride level of all sources of drinking water is below 0.6 ppm.  Recommended for ages 6-16 and those at high risk for caries  Prescribed NaF agents: drops, lozenges, tablets  Prescribed individually for use at home Fluoride Supplements Dose Schedule Fluoride Supplements  NaF supplements are available as tablets, lozenges, and drops in 0.25, 0.50, and 1.0 mg dosages.  Tablets are chewed thoroughly, swished/rinsed around in the oral cavity, and forced between the teeth before swallowing.  Lozenges are dissolved for 1 to 2 minutes in the mouth to provide both pre-eruptive and post-eruptive benefits.  Drops: A liquid concentrate for children 6 months to 3 years or those unable to use tablets or Lozenges. Prescription Guidelines  No more than 264 mg Na F (120 mg fluoride ion) to be dispensed per household at one time.  Take supplements with food to decrease stomach upset  Avoid taking with dairy products because fluoride can combine with calcium and be poorly absorbed.  Prenatal supplements not recommended: evidence is weak to support the use of fluoride to prevent caries in primary teeth. Professionally Applied Topical Fluorides  Professional Topical Applications  2.0% NaF: Neutral Sodium Fluoride  Contains 9,050 ppm fluoride ion.  Recommended for esthetic restorations  Neutral Ph 7.0  4-minute application  Foam or gel  Limited evidence of foam Professional Applications  1.23 APF (Acidulated Phosphate Fluoride)  Ortho-phosphoric acid 3.5 pH (low pH enhances Fl uptake)  12,300 ppm fluoride ion  Thixotropic agent  Dissolves macro inorganic filler particles in composite materials  Newer micro filled composites/resins are not as sensitive.  May etch porcelain and composite restorations and sealants  4-minute tray application is recommended  1-minute foam or gel were marketed but evidence supports a 4- minute application. Table 34-3 Procedure for Professional Tray Application Table 34-4 Fluoride Varnish  5% NaF Fluoride  High concentration of Fluoride 22,600 ppm  Lesser amount of Fl used is required  Remains on the teeth for several hours releasing Fl to pits and fissures and proximal surfaces.  Reduces demineralization of white spot lesions Contraindications  Rosin/colophony (sticky secretion form plants or trees) used in varnish may rarely cause allergic reactions ( tree nut allergies)  Formulations are now available that contain a synthetic rosin for those suspected to have allergy  Fluoride Varnish  1994 Approved in the United States for Desensitizer & Cavity Liner/Base for restorations  Used “off label” for caries prevention and has become the standard of care in practice  The only professional topical Fl. to be used for children under the age of 6 yrs.  Can be applied at age 1  Application  Now offered with mineral enhancements: page 630 2018 ADA Recommendations  To arrest or reverse non-cavitated carious lesions on the occlusal surfaces of primary and permanent teeth. -Sealants and 5% NaF varnish (3-6 months) -1.23% APF Gel ( 3- 6 months) -.02% NaF mouthrinse one time a week - Proximal surfaces 5% NaF varnish every 3-6 months Application of Fl Varnish  Dry teeth apply varnish  Paint on Buccal Surfaces  Avoid eating or drinking for 30 minutes  Avoid rough foods and brushing for 4 hours 38 % Silver Diamine Fluoride Indications  24.4%-28.8% Silver (antimicrobial effect)  5- 5.9% Fluoride  8% Ammonia (stabilizing agent/solvent)  FDA-approved as a desensitizing agent for dentinal hypersensitivity  Used “off label” for caries arrest and prevention in high- risk patients  2x a year application  State practice acts determine who can apply SDF Indications & Advantages  Extreme caries risk (xerostomia, severe early childhood caries, or cancer treatments—radiation/chemotherapy)  Treatment challenged by behavioral/medical management  Patients with carious lesions that may not all be treated in one visit (stabilize patient) and difficult to treat dental carious lesions  Patients with no access to dental care (underserved populations)  Noninvasive (no needle or drill required)  Cariostatic agent inhibits the progression of dental caries  Reduces dentinal hypersensitivity  Application Contraindications  Allergy to silver  Pregnancy/breastfeeding  Relative—Painful sores or raw areas on the gingiva or in the mouth (ulcerative gingivitis or stomatitis)  Do not use in teeth with pupal involvement. Limitations and Risks  Communicate effectively with the patient/parent/legal guardian/advocate and consider written informed consent form for SDF placement prior to application.  Sole placement of SDF does not eliminate the need for future restorations.  SDF needs to be applied one to two times at separate visits for maximum benefit (approximately once every 6–12 months).  The affected area of decay will likely stain black/gray permanently upon SDF placement; however, healthy enamel will not stain.  If accidentally applied to the skin or gingiva, a brownish stain may appear, which will not wash away immediately (should dissipate within 1–3 weeks).  Metallic/bitter taste. Application  Table 34-5 Self Applied Fluoride Mouth Rinses  Self-applied fluoride rinses.  Available in RX ( high potency) and OTC (low potency)  Not recommended for children under 6 years of age  High-risk preteens and adolescents  Patient with demineralization, root exposure, orthodontics, Xerostomia, hypersensitivity  Alcohol-based rinses are not recommended for children or for recovering alcoholics.  Table 34-6 Self Applied Fluorides  RX (prescription) and OTC products( 1500 ppm or less of Fl)  Toothbrushing or Rinsing  Mouth trays: custom or disposable Xerostomia, radiation therapy, root surface hypersensitivity Fluoride Gels RX and OTC Table 34-7  Fluoride Dentifrice  Sodium Fluoride (NaF)  Stannous Fluoride (SnF2)  Sodium Monofluorophosphate (Na2 PO3 F)  1,000-1,100 ppm  ADA Seal of Acceptance  < 3 years of age: a smear (grain of rice) 2 x daily  3-6 years of age = Pea size 2X daily  Adults: ½ inch 2 x daily Lethal & Safe Doses of Fl Box 34-4 Adults CLD =Certainly lethal Dose 5-10 g of sodium fluoride 32-64 mg F/kg of body weight. STD=Safely tolerated Dose = ¼ CLD 1.25-2.5 g of sodium fluoride. 8-16 mg F/kg body weight Signs & Symptoms of Acute Toxic Dose  Symptoms begin within 30 minutes of ingestion  GI Tract: Nausea, vomiting, diarrhea, abdominal pain, increased salivation & increased thirst  Systemic: Blood calcium is bound by circulating Fl resulting in Hypocalcemia,  CNS: Convulsions, Cardiovascular & respiratory depression resulting in death in a few hours  Chronic Toxicity  Skeletal fluorosis  Long term ingestion > 10 years of high levels of fluoride (8-10 ppm)  Dental fluorosis: Severe /over 2PPM  Mild fluorosis: White spots, mild esthetic problems Emergency Treatment  Induce Vomiting: Digital stimulation  Call EMS  If no vomiting: Administer Fluoride binding liquid: milk, milk of magnesium, lime water (calcium hydroxide)  Support respiration and circulation Documentation  Always seek permission for fluoride  Document type, concentration, and mode of delivery