Fluoride Delivery Methods PDF

Fluoride Delivery Methods Oral and Dental Science Josh Hudson GDC Learning Outcomes: 1.1.8 Describe the properties of relevant medicines and therapeutic agents and discuss their application to patient management 1.10.2 Provide patients with comprehensive and accurate preventative educati...

Fluoride Delivery Methods Oral and Dental Science Josh Hudson GDC Learning Outcomes: 1.1.8 Describe the properties of relevant medicines and therapeutic agents and discuss their application to patient management 1.10.2 Provide patients with comprehensive and accurate preventative education and instruction in a manner which encourages self care and motivation 1.10.3 Underpin all patient care with a preventative approach that contributes to the patient's long-term oral health and general health 1.10.4 Advise on and apply a range of preventative materials and treatment as appropriate 2.3 Describe and evaluate the role of health promotion in terms of the changing environment, community and individual behaviours to deliver health gain 2.4 Explain evidence-based prevention and apply appropriately Pre-reading ‘Aetiology of Dental Caries’ Susceptible Lecture tooth surface Caries Plaque Bacteria Time Fermentable Carbohydrate Pre-reading ‘Histology of enamel and dentine’ Lectures Pre-reading ‘Fluoride and the Tooth Surface’ Lecture Learning Objectives Objectives, by the end of this session you will be able to.. List the over-the-counter options available for fluoride supplementation List the prescription only options available for fluoride supplementation Describe professionally applied fluoride interventions Discuss the fluoride levels that would be considered dangerous for various age groups Recap – What do we know so far? How is it absorbed? - Post-Eruptive Stage Drop in PH due Loss of calcium and Healthy tooth to bacterial acid Demineralised phosphate from surface tooth surface hydroxyapatite Addition of calcium Increase in and phosphate and Remineralisation PH fluoride from saliva to form fluoroapetite How does it work? - Uptake into the tooth Pre-eruptive Post-eruptive stage (systemic stage (topical Ultimately, fluoride is fluoride) fluoride) absorbed into the tooth surface making it more resistant to Matrix demineralisation from Secretion the caries process. This occurs at multiple Maturation stages; Stage How is it absorbed? - Post-Eruptive Stage Topical applications of fluoride create a reservoir of fluoride Key Points: in saliva This fluoride bonds to calcium The most fluoride is acquired during in saliva forming CaF2 the 2-3 years post-eruption This is because it is more When an acid attack occurs porous which facilitates and PH drops, the fluoride is diffusion and uptake released Demineralised enamel also This can then enter the tooth absorbs fluoride more easily during remineralisation for this reason  It is therefore essential that there is a regular supply of low level fluoride to replace the ions lost. This forms the basis of caries prevention with fluoride. Recap Insufficient Based on older Fluoridation increased the evidence on research (no percentage of children with effect in modern research no decay in deciduous teeth adults available) by 15% Fluoridated water 73% of studies reduces caries in focussed on areas children's Cochrane Review with natural permanent teeth 2015 fluoridation by 26% Fluoridation of 0.7ppm Fluoridated water Fluoridation increased the gives a 12% chance of reduces caries in percentage of children with Fluorosis (mottling) that deciduous (baby) no decay in permanent may cause aesthetic teeth by 35% teeth by 14% concerns How can this fluoride be supplied? Delivering better oral health 4th Edition Nov 2021 Sources without prescription Toothpaste Mouth rinse Fluoridated Water Fluoridated Salt Fluoridated Milk Sources with prescription 2800ppm Toothpaste Mouth rinse 5000ppm Toothpaste Fluoride Tablets Fluoride Drops Professionally applied sources Duraphat Fluoride Profluorid Fluoride Glass Ionomer Silver Diamine Varnish Varnish Cement Fluoride Systemic vs Topical Systemic Topical ‘Systemic fluorides are those that ‘Topical fluorides strengthen teeth are ingested and become that are already present in the incorporated into forming tooth mouth, making them more decay structures’ resistant’  Topical yste mic So what is the fluoride concentration of topically applied fluoride and pros and cons of these? Toothpaste Fluoride toothpaste lower than 1450ppm (lower than 1000ppm proves ineffective at controlling caries) Most common Fluoride toothpastes contain 1450ppm Toothpaste 2800ppm (0.619%) sodium fluoride toothpaste (e.g duraphat) is available on prescription 5000ppm (1.1%) sodium fluoride toothpaste (e.g. duraphat) is also available on prescription Toothpaste Children under 3 should be Children over 3 and adults High risk Children under 3 using a toothpaste should be using a paste can use a paste containing with a minimum of containing 1350-1500ppm 1350-1500ppm fluoride 1000ppm fluoride fluoride provided they are supervised and can spit out Children over 10 can be prescribed duraphat 2800ppm sodium fluoride toothpaste Children over 16 can be prescribed duraphat 5000ppm Smear Pea sized sodium fluoride toothpaste Toothpaste Need to remember Children also have poor however that if the child manual dexterity cannot be trusted not to therefore need swallow paste, higher supervision until aged 7 doses not indicated. Recommendations Age Fluoride ppm Amount 0-3 years No less than 1000ppm No more than a smear 3-6 years More than 1000ppm No more than pea size 0-6 years (giving concern) 1350-1500ppm Smear or pea size 7 years- Young Adult 1350-1500ppm 7 years- Young Adult (giving (same as above) concern) 10+ with active caries- 2800ppm 16+ with active disease- 2800 or 5000ppm Adults At least 1350ppm Adults (giving concern) (same as above) For those with active coronal or root caries- 2800 or 5000 ppm Pros and Cons Easy to use and in regular use Risk of ingestion for young children Can tailor dose of fluoride to risk level Hard to control dose given as varying amounts will be used Cheap and readily available Patients may not be aware of fluoride levels in paste Gives choice to those that used and use lower levels do not wish to use fluoride than required Fluoride Levels Full list in the Delivering Better Oral Health Document What does the term ‘Spit don’t rinse’ mean? Spit don’t rinse When patients have finished using toothpaste they should SPIT out the excess paste and then NOT RINSE, even with mouthwash. Why not? Spit don’t rinse If patients rinse, the fluoride reservoir in the saliva from the toothpaste will be washed away and the beneficial effects lost Why can’t we rinse with mouthwash? Spit don’t rinse As you will see, mouthwash has a much lower fluoride concentration than toothpaste and hence you will dilute the concentration of the fluoride in saliva Mouth wash Many over the counter This is much lower mouth washes contain A D concentration fluoride than toothpaste Fluoride concentration Due to this, need to be in over the counter will B E used at another time be 0.05% of day to brushing Prescription rinses should Fluoride rinses can also be prescribed C F only be given to those over which can be either daily (0.05% or 7 years old giving concern weekly (0.2%) Pros and Cons Easy to use and in regular use Risk of ingestion for young children Can tailor dose of fluoride to risk level Cannot be used in children who are unable to spit it out Cheap and readily available Weekly rinses may Gives choice to those that do not wish to use fluoride be forgotten Recommendation ‘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). They are likely to be most useful in higher dental caries risk patients’ Who might be ‘a higher caries risk’ patient? Recommendation Patients who may give concern include; Obvious active caries Patients with orthodontic appliances Patients with reduced salivary flow Those with special needs Delivering better oral health Fluoride Varnish Fluoride vanish has the highest concentration of fluoride (usually 22,600ppm fluoride) 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 (e.g asthma) Has been shown to reduce decay in deciduous teeth by 37% and permanent by 43% Evidence suggests can also arrest existing lesions Fluoride Varnish Indications; 1) Caries prone adults who cannot or are unable to use a fluoride mouth rinse 2) Patients with removable orthodontic appliances or removable dentures 3) Twice yearly application for children >3 4) Twice yearly application for high risk children of any age 5) Localised application to arrest caries progression 6) Protection of exposed vulnerable root surfaces Fluoride Varnish ‘Sticky’ substance that is applied to the teeth 1) Ensure no contraindications 2) Clean, dry and isolate the teeth which are to have varnish applied 3) Apply fluoride varnish using a microbrush or floss to allow penetration interproximally 4) Give post-operative instructions to patient/guardian Fluoride Varnish The teeth will feel sticky Do not eat, drink or rinse for 30 minutes Brushing can commence the evening of the application If patient taking additional fluoride supplements (e.g. tablets) these should be discontinued for 2-3 days Pros and Cons Can target certain Patients need to attend a populations (e.g. those at dental appointment to high risk) receive this Can discontinue when May have compliance needed issues for some patients Can have flavours to make Not able to eat or drink more palatable afterwards Gives choice to those that Can be difficult to control do not wish to use fluoride the dose Silver Diamine Fluoride This is a clear, odourless liquid that 0 can be used to arrest caries in This has the highest concentration of fluoride at 0 adults and children of high caries 1 risk and have difficult to control 44,800ppm 4 progressing lesions This can therefore be used to This may be due to an intolerance manage lesions that are too 02 to treatment, the elderly, medically compromised or those extensive to restore but not 03 associated with pain or with additional care needs infection Silver Diamine Fluoride A C When applied, a series of chemical reactions occur leading to dentinal tubule blockage, bacterial death, This is used ’off label’ remineralisation and inhibition of collagen breakdown B Side effect of this is permanent D Useful in child patient to ‘buy time’ to allow acclimatisation or black staining wait for other treatment options (e.g GA) The use of silver diamine fluoride in dental practice – N Seifo et al The use of silver diamine fluoride in dental practice – N Seifo et al The use of silver diamine fluoride in dental practice – N Seifo et al The use of silver diamine fluoride in dental practice – N Seifo et al Glass Ionomer Cements A Glass ionomer cement restorative materials can contain fluoride In theory these will leach fluoride B into the underlying demineralised tooth surface D Studies suggest low levels of fluoride may be released for up to 8 years and that fluoride levels can be ’recharged’ C with further topical application Some suggest however that the level that is released is so low it has limited significance Prophylaxis Paste Prophylaxis paste can be fluoride containing however using this purely for prevention is not indicated These pastes are abrasive and the loss of surface enamel due to this may be greater than the amount of fluoride incorporated However, if being used it makes sense for a fluoride one to be utilised So what is the fluoride concentration of systemically applied fluoride methods and the pros and cons of these?  Fluoride tablets/lozenges/drops 1 0.25/0.5/1mg concentrations Supplements can be added to water 2 or chewed or sucked 3 These are prescription only 4 Dose needs to be dependant on fluoride availability in drinking water Need to be carefully considered as 5 may increase patients risk of fluorosis Recommendations Can be considered for patients below but not considered first line. Systematic review concluded ‘..evidence unclear on deciduous teeth’ Children at high risk of decay Medically compromised children Delivering better oral health/Cochrane Recommendations Ensure other sources are appropriate for age (toothpaste etc) and ensure there is no intake from these other sources Diet advice and oral hygiene instruction should always be first line Supplements should be taken at a different time to brushing Recommendations < 0.3ppm 0.3-0.7ppm >0.7ppm 6 months- 2 years 0.25mg None None 3-5 years 0.5mg 0.25mg None 6-17 years 1mg 0.5mg None Adults 1mg 0.5mg None Administration: Tablets should be sucked or dissolved in the mouth and taken preferably in the evening Pros and Cons Patients need to attend a dental Can target certain appointment to receive this populations (e.g. those at high risk) May have compliance issues for some patients/parents Greater risk of overdose and hence fluorosis or toxicity Can discontinue when needed Needs good motivation Expensive technique Gives choice to those that do not wish to use fluoride Fluoride levels will peak once daily Pre-natal administration of fluoride It has been considered that fluoride supplementation (tablets, lozenges, chewing gum, drops etc) in pregnant women may aid in caries prevention for their child ‘There is no evidence that fluoride supplements taken by women during pregnancy are effective in preventing dental caries in their offspring’ Cochrane Systematic Review Fluoridated Salt A Some countries have undertaken compulsory salt fluoridation (not the UK) such Potassium or sodium fluoride B as some of Europe and South used America D This bypasses issues of some people not Concentration used is 250mg/F/Kg C drinking tap water Pros and Cons No consistent dose as intake Salt is a widely varies used commodity Cannot target one particular population If listed as being If compulsory, eliminates used, can give freedom of choice freedom of choice Risk of fluorosis if used in conjunction with other sources Can easily discontinue its use Salt use discouraged as part of a healthy diet Fluoridated Milk Free fluoridated milk A Cochrane systematic review on programmes for school children milk fluoridation is available but evidence base is limited Children should not take part if 200ml cartons contain already having fluoride 1mg fluoride supplements Not UK wide but areas with Under 5’s should drink a carton high caries rate utilise this every other day, over 5’s daily technique (e.g Blackpool) Pros and Cons Can target certain populations (e.g school Expensive children in one area) Can discontinue when Often given too late if >5 needed years old Milk is palatable by Dose is not accurate children May become complicated if Gives choice to those that more than one child in the do not wish to use fluoride family Fluoride Toxicity Toxicity The acute lethal dose is approximately 15mg/kg body weight. As little as 5mg/kg may be fatal for some children, and should trigger immediate emergency action. 1mg/kg can produce sub lethal toxic effects. Symptoms include: Salivation Nausea Vomiting  A small quantity (less than 5mg/kg body weight) is neutralised by drinking a large volume of milk If in any doubt about the quantity the child has ingested, the child should be taken to A&E Symptoms usually appear within an hour of ingestion and, if overdose occurs as a result of topical application, the signs might not be obvious until the patient has left the surgery Death from respiratory or cardiac failure occurs within 24 hours of a lethal dose Toxicity of fluoride preparations calculated for a 5 year old child weighing 20kg Sub lethal acute Potentially lethal poisoning dose poisoning dose APF gel (1.23%F) 1.7ml (1/3 teaspoon) 8ml = 1.5 teaspoons Sodium Fluoride Varnish (2.26%F) 0.9ml (1/5 teaspoon) 4ml = 4/5 teaspoon Stannous fluoride gel (0.4%SnF2) 20ml (4 teaspoons) 100ml = 1 cup Rinse (0.2% NaF) 22ml (1/5th cup) 105ml = 1 cup Rinse (0.05% NaF) 88ml (4/5th cup) 420ml = 4 cups Tablets 0.5mg F 40 tablets 200 tablets Tablets 1.0mg F 20 tablets 100 tablets Toothpaste 1000ppm 33ml 100ml Toothpaste 1500ppm 22ml 66ml Summary Fluoride varnish is the topical agent of choice especially for high-risk Dental products for patients whose compliance home use, including with home regimes, such as toothpaste, should be fluoride rinses, may be a kept out of the reach problem of young children The use of fluorides in dental Topical fluoride Parents should always practice should always be preparations should be supervise young combined with dietary advice applied carefully children’s use of and oral hygiene. Instruction and because of their toothpaste advice should be tailored to the potential toxic effects needs of the individual patient References Public Health England (2017) Delivering better oral health: an evidence-based toolkit for prevention. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/atta chment_data/file/605266/Delivering_better_oral_health.pdf [Accessed; 10/6/21] World Health Organisation (2009) Milk fluoridation for the prevention of caries. Available at: https://www.who.int/oral_health/publications/milk_fluoridation_2009_en.pdf [Accessed; 10/6/21] Marthaler, TM et al (2005) Salt fluoridation – an alternative in automatic prevention of dental caries International Dental Journal 55; 351-358 Cochrane Group (2015) Fluoridated milk for preventing tooth decay The Cochrane database of systematic reviews (9) References Forsten, L (1998) Fluoride release from glass ionomers and related materials and its clinical effect Biomaterials 19(6); 503-508 Tubert-Jeannin, S et al (2011) Fluoride supplements (tablets, drops, lozenges or chewing gums) for preventing tooth decay in children. The Cochrane database of systematic reviews (12) Takahashi, R et al (2017) Fluoride supplementation (with tablets, drops, lozenges or chewing gum) in pregnant women for preventing dental caries in the primary teeth of their children The Cochrane database of systematic reviews (10) N Seifo et al (2020) The use of silver diamine fluoride in dental practice. British Dental Journal 228; 75-81 Thank You!