Fluoride Delivery Methods PDF

Fluoride Delivery Methods Oral and Dental Science Josh Hudson GDC Learning Outcomes: 1.1.8 Describe the proper0es of relevant medicines and therapeu0c agents and discuss their applica0on to pa0ent management 1.10.2 Provide pa0ents with comprehensive and accurate preventa0ve educa0on and...

Fluoride Delivery Methods Oral and Dental Science Josh Hudson GDC Learning Outcomes: 1.1.8 Describe the proper0es of relevant medicines and therapeu0c agents and discuss their applica0on to pa0ent management 1.10.2 Provide pa0ents with comprehensive and accurate preventa0ve educa0on and instruc0on in a manner which encourages self care and mo0va0on 1.10.3 Underpin all pa0ent care with a preventa0ve approach that contributes to the pa0ent's long-term oral health and general health 1.10.4 Advise on and apply a range of preventa0ve materials and treatment as appropriate 2.3 Describe and evaluate the role of health promo0on in terms of the changing environment, community and individual behaviours to deliver health gain 2.4 Explain evidence-based preven0on and apply appropriately Pre-reading ‘Ae0ology of Dental Caries’ SuscepAble tooth surface Caries Lecture Plaque Bacteria Time Fermentable Carbohydrate Pre-reading ‘Histology of enamel and den0ne’ Lectures Pre-reading ‘Fluoride and the Tooth Surface’ Lecture Learning ObjecAves Objec0ves, by the end of this session you will be able to.. List the over-the-counter op0ons available for Ruoride supplementa0on List the prescrip0on only op0ons available for Ruoride supplementa0on Describe professionally applied Ruoride interven0ons Discuss the Ruoride levels that would be considered dangerous for various age groups Recap – What do we know so far? How is it absorbed? - Post-ErupAve Stage Drop in PH due Loss of calcium and Healthy tooth to bacterial acid Demineralised phosphate from surface tooth surface hydroxyapa0te Addi0on of calcium Increase in and phosphate and Remineralisa0on PH Ouoride from saliva to form OuoroapeAte How does it work? - Uptake into the tooth Pre-erup0ve Post-erup0ve stage (systemic stage (topical Ul0mately, Ruoride is Ruoride) Ruoride) absorbed into the tooth surface making it more resistant to Matrix demineralisa0on from Secre0on the caries process. This occurs at mul0ple Matura0on stages; Stage How is it absorbed? - Post-ErupAve Stage Topical applica0ons of Ruoride create a reservoir of Ruoride Key Points: in saliva This Ruoride bonds to calcium The most Ruoride is acquired during in saliva forming CaF2 the 2-3 years post-erup0on This is because it is more When an acid a^ack occurs porous which facilitates and PH drops, the Ruoride is di\usion and uptake released Demineralised enamel also This can then enter the tooth absorbs Ruoride more easily during remineralisa0on for this reason  It is therefore essen0al that there is a regular supply of low level Ruoride to replace the ions lost. This forms the basis of caries preven0on with Ruoride. Recap Insuccient Based on older Fluorida0on increased the evidence on research (no percentage of children with e\ect 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 8uorida9on by 26% Fluorida0on of 0.7ppm Fluoridated water Fluorida0on increased the gives a 12% chance of reduces caries in percentage of children with Fluorosis (mo^ling) that deciduous (baby) no decay in permanent may cause aesthe0c teeth by 35% teeth by 14% concerns How can this Ouoride be supplied? Delivering beQer oral health 4th Edi0on Nov 2021 Sources without prescripAon Toothpaste Mouth rinse Fluoridated Water Fluoridated Salt Fluoridated Milk Sources with prescripAon 2800ppm Toothpaste Mouth rinse 5000ppm Toothpaste Fluoride Tablets Fluoride Drops Professionally applied sources Duraphat Fluoride ProRuorid Fluoride Glass Ionomer Silver Diamine Varnish Varnish Cement Fluoride Systemic vs Topical Systemic Topical ‘Systemic Ruorides are those that ‘Topical Ruorides 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 Ouoride concentraAon of topically applied Ouoride and pros and cons of these? Toothpaste Fluoride toothpaste lower than 1450ppm (lower than 1000ppm proves ine\ec0ve at controlling caries) Most common Fluoride toothpastes contain 1450ppm Toothpaste 2800ppm (0.619%) sodium Ruoride toothpaste (e.g duraphat) is available on prescrip0on 5000ppm (1.1%) sodium Ruoride toothpaste (e.g. duraphat) is also available on prescrip0on 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 Ruoride 1000ppm Ruoride Ruoride provided they are supervised and can spit out Children over 10 can be prescribed duraphat 2800ppm sodium Ruoride toothpaste Children over 16 can be prescribed duraphat 5000ppm Smear Pea sized sodium Ruoride 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 un0l aged 7 doses not indicated. RecommendaAons 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 ac0ve caries- 2800ppm 16+ with ac0ve disease- 2800 or 5000ppm Adults At least 1350ppm Adults (giving concern) (same as above) For those with ac0ve coronal or root caries- 2800 or 5000 ppm Pros and Cons Easy to use and in regular use Risk of inges0on for young children Can tailor dose of Ruoride to risk level Hard to control dose given as varying amounts will be used Cheap and readily available Pa0ents may not be aware of Ruoride levels in paste Gives choice to those that used and use lower levels do not wish to use Ruoride than required Fluoride Levels Non fluoride containing toothpastes. Full list in the Delivering Be^er Oral Health Document What does the term ‘Spit don’t rinse’ mean? Spit don’t rinse When pa0ents have mnished using toothpaste they should SPIT out the excess paste and then NOT RINSE, even with mouthwash. Why not? Removes fluoride Spit don’t rinse If pa0ents rinse, the Ruoride reservoir in the saliva from the toothpaste will be washed away and the benemcial e\ects lost Why can’t we rinse with mouthwash? Spit don’t rinse As you will see, mouthwash has a much lower Ruoride concentra0on than toothpaste and hence you will dilute the concentra0on of the Ruoride in saliva Mouth wash Many over the counter This is much lower mouth washes contain A D concentra0on Ruoride than toothpaste Fluoride concentra0on Due to this, need to be in over the counter will B E used at another 0me be 0.05% of day to brushing Prescrip0on 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 inges0on for young children Can tailor dose of Ruoride 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 Ruoride be forgo^en RecommendaAon ‘Use a daily Ruoride rinse (0.05% NaF) at a di\erent 0me 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 pa0ents’ Who might be ‘a higher caries risk’ pa0ent? RecommendaAon Pa0ents who may give concern include; Obvious ac0ve caries Pa0ents with orthodon0c appliances Pa0ents with reduced salivary Row Those with special needs Delivering be^er oral health Examples of fluoride varnishes Fluoride Varnish Fluoride vanish has the highest concentra0on of Ruoride (usually 22,600ppm Ruoride) Applied to the tooth surface every 3-6 months Can be applied by suitably trained nurses Recommended for all children except those with ulcera0ve coli0s and those at risk of allergy requiring hospital administra0on (e.g asthma) Has been shown to reduce decay in deciduous teeth by 37% and permanent by 43% Evidence suggests can also arrest exis0ng lesions Fluoride Varnish Indica0ons; 1) Caries prone adults who cannot or are unable to use a Ruoride mouth rinse 2) Pa0ents with removable orthodon0c appliances or removable dentures 3) Twice yearly applica0on for children >3 4) Twice yearly applica0on for high risk children of any age 5) Localised applica0on to arrest caries progression 6) Protec0on of exposed vulnerable root surfaces Fluoride Varnish ‘S0cky’ substance that is applied to the teeth 1) Ensure no contraindica0ons 2) Clean, dry and isolate the teeth which are to have varnish applied 3) Apply Ruoride varnish using a microbrush or Ross to allow penetra0on interproximally 4) Give post-opera0ve instruc0ons to pa0ent/guardian Fluoride Varnish The teeth will feel s0cky Do not eat, drink or rinse for 30 minutes Brushing can commence the evening of the applica0on If pa0ent taking addi0onal Ruoride supplements (e.g. tablets) these should be discon0nued for 2-3 days Pros and Cons Can target certain Pa0ents need to a^end a popula0ons (e.g. those at dental appointment to high risk) receive this Can discon0nue when May have compliance needed issues for some pa0ents Can have Ravours to make Not able to eat or drink more palatable aqerwards Gives choice to those that Can be diccult to control do not wish to use Ruoride the dose Silver Diamine Fluoride This is a clear, odourless liquid that 0 can be used to arrest caries in This has the highest concentra0on of Ruoride at 0 adults and children of high caries 1 risk and have diccult 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 addi0onal care needs infec0on Silver Diamine Fluoride A C When applied, a series of chemical reac0ons occur leading to den0nal tubule blockage, bacterial death, This is used ’o\ label’ remineralisa0on and inhibi0on of collagen breakdown B Side e\ect of this is permanent D Useful in child pa0ent to ‘buy 0me’ to allow acclima0sa0on or black staining wait for other treatment op0ons (e.g GA) The use of silver diamine Ruoride in dental prac0ce – N Seifo et al The use of silver diamine Ruoride in dental prac0ce – N Seifo et al The use of silver diamine Ruoride in dental prac0ce – N Seifo et al The use of silver diamine Ruoride in dental prac0ce – N Seifo et al Glass Ionomer Cements A Glass ionomer cement restora0ve materials can contain Ruoride In theory these will leach Ruoride B into the underlying demineralised tooth surface D Studies suggest low levels of Ruoride may be released for up to 8 years and C that Ruoride levels can be ’recharged’ with further topical applica0on Some suggest however that the level that is released is so low it has limited signimcance Prophylaxis Paste Prophylaxis paste can be Ruoride containing however using this purely for preven0on is not indicated These pastes are abrasive and the loss of surface enamel due to this may be greater than the amount of Ruoride incorporated However, if being used it makes sense for a Ruoride one to be u0lised So what is the Ouoride concentraAon of systemically applied Ouoride methods and the pros and cons of these?  Fluoride tablets/lozenges/drops 1 0.25/0.5/1mg concentra0ons Supplements can be added to water 2 or chewed or sucked 3 These are prescrip0on only 4 Dose needs to be dependant on Ruoride availability in drinking water Need to be carefully considered as 5 may increase pa0ents risk of Ruorosis RecommendaAons Can be considered for pa0ents below but not considered mrst line. Systema0c review concluded ‘..evidence unclear on deciduous teeth’ Children at high risk of decay Medically compromised children Delivering be^er oral health/Cochrane RecommendaAons Ensure other sources are appropriate for age (toothpaste etc) and ensure there is no intake from these other sources Diet advice and oral hygiene instruc0on should always be mrst line Supplements should be taken at a di\erent 0me to brushing RecommendaAons < 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 Administra0on: Tablets should be sucked or dissolved in the mouth and taken preferably in the evening Pros and Cons Pa0ents need to a^end a dental Can target certain appointment to receive this popula0ons (e.g. those at high risk) May have compliance issues for some pa0ents/parents Greater risk of overdose and hence Ruorosis or toxicity Can discon0nue when needed Needs good mo0va0on Expensive technique Gives choice to those that do not wish to use Ruoride Fluoride levels will peak once daily Pre-natal administraAon of Ouoride It has been considered that Ruoride supplementa0on (tablets, lozenges, chewing gum, drops etc) in pregnant women may aid in caries preven0on for their child ‘There is no evidence that Ruoride supplements taken by women during pregnancy are e\ec0ve in preven0ng dental caries in their o\spring’ Cochrane Systema0c Review Fluoridated Salt A Some countries have undertaken compulsory salt Ruorida0on (not the UK) such Potassium or sodium Ruoride B as some of Europe and South used America D This bypasses issues of some people not Concentra0on 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 par0cular popula0on If listed as being If compulsory, eliminates used, can give freedom of choice freedom of choice Risk of Ruorosis if used in conjunc0on with other sources Can easily discon0nue its use Salt use discouraged as part of a healthy diet Fluoridated Milk Free Ruoridated milk A Cochrane systema0c review on programmes for school children milk Ruorida0on is available but evidence base is limited Children should not take part if 200ml cartons contain already having Ruoride 1mg Ruoride supplements Not UK wide but areas with Under 5’s should drink a carton high caries rate u0lise this every other day, over 5’s daily technique (e.g Blackpool) Pros and Cons Can target certain popula0ons (e.g school Expensive children in one area) Can discon0nue when Oqen 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 Ruoride family Fluoride Toxicity Toxicity The acute lethal dose is approximately 15mg/kg body weight. As li^le as 5mg/kg may be fatal for some children, and should trigger immediate emergency ac0on. 1mg/kg can produce sub lethal toxic e\ects. Symptoms include: Saliva0on Nausea Vomi0ng  A small quan0ty (less than 5mg/kg body weight) is neutralised by drinking a large volume of milk If in any doubt about the quan0ty the child has ingested, the child should be taken to A&E Symptoms usually appear within an hour of inges0on and, if overdose occurs as a result of topical applica0on, the signs might not be obvious un0l the pa0ent has leq the surgery Death from respiratory or cardiac failure occurs within 24 hours of a lethal dose Toxicity of Ouoride preparaAons calculated for a 5 year old child weighing 20kg Sub lethal acute PotenAally 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 Ruoride 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 pa0ents whose compliance home use, including with home regimes, such as toothpaste, should be Ruoride rinses, may be a kept out of the reach problem of young children The use of Ruorides in dental Topical Ruoride Parents should always prac0ce should always be prepara0ons should be supervise young combined with dietary advice applied carefully children’s use of and oral hygiene. Instruc0on and because of their toothpaste advice should be tailored to the poten0al toxic e\ects needs of the individual pa0ent References Public Health England (2017) Delivering be^er oral health: an evidence-based toolkit for preven0on. Available at: h^ps://assets.publishing.service.gov.uk/government/uploads/system/uploads/a^a chment_data/mle/605266/Delivering_be^er_oral_health.pdf [Accessed; 10/6/21] World Health Organisa0on (2009) Milk Ruorida0on for the preven0on of caries. Available at: h^ps://www.who.int/oral_health/publica0ons/milk_Ruorida0on_2009_en.pdf [Accessed; 10/6/21] Marthaler, TM et al (2005) Salt Ruorida0on – an alterna0ve in automa0c preven0on of dental caries Interna9onal Dental Journal 55; 351-358 Cochrane Group (2015) Fluoridated milk for preven0ng tooth decay The Cochrane database of systema9c reviews (9) References Forsten, L (1998) Fluoride release from glass ionomers and related materials and its clinical e\ect Biomaterials 19(6); 503-508 Tubert-Jeannin, S et al (2011) Fluoride supplements (tablets, drops, lozenges or chewing gums) for preven0ng tooth decay in children. The Cochrane database of systema9c reviews (12) Takahashi, R et al (2017) Fluoride supplementa0on (with tablets, drops, lozenges or chewing gum) in pregnant women for preven0ng dental caries in the primary teeth of their children The Cochrane database of systema9c reviews (10) N Seifo et al (2020) The use of silver diamine Ruoride in dental prac0ce. Bri9sh Dental Journal 228; 75-81 Thank You!