Topical and Systemic Fluorides PDF

Topical and Systemic Fluorides Abdulhamid Al Ghwainem, BDS, MSc, DClinDent Pediatric Dentistry Assistant Professor of Pediatric Dentistry [email protected] Sunday, 3 March 2024 Copyright © 2023 by PSAU, Abdulhamid Al Ghwainem Preventive Dentistry DSV 1010 Learning outcomes: By the end of this...

Topical and Systemic Fluorides Abdulhamid Al Ghwainem, BDS, MSc, DClinDent Pediatric Dentistry Assistant Professor of Pediatric Dentistry [email protected] Sunday, 3 March 2024 Copyright © 2023 by PSAU, Abdulhamid Al Ghwainem Preventive Dentistry DSV 1010 Learning outcomes: By the end of this lecture, you should be able to: § Highlight the importance of fluoride in preventive dentistry. § Classify and differentiate between systemic and topical fluoride applications. § Describe systemic fluoride, its history, mechanism, and applications, and assess its suitability and evidence in preventive dentistry. § Describe topical fluoride, its mechanism, and applications, and assess its suitability and evidence in preventive dentistry. § Recognize and define fluorosis as a side effect of excess fluoride intake and highlight the ways to prevent it. § Recognize fluoride toxicity and apply a protocol to deal with such cases. Outline: § Introduction § Classification of systemic and topical fluorides § Definition of systemic fluoride, history, mechanism, applications, and effectiveness. § Definition of topical fluoride, mechanism, applications, and effectiveness. § Fluorosis § Fluoride toxicity. § Concluding remarks Fluorides § Fluoride is a mineral that is found in all natural water sources. Fluorite CaF It is the ionic form of the trace element fluorine, which is commonly found in the environment (e.g.: water, soil, plants, rocks, air and in foods such as tea and fish, etc.). § Fluorine reaches water sources by leaching from soil and rocks into groundwater. This Photo by Unknown Author is licensed under CC BY Fluorides § Fluoride is a safe and effective agent that can be used to prevent and control dental caries when consumed in appropriate amounts. This Photo by Unknown Author is licensed under CC BY Classification of Systemic and Topical Fluorides Fluorides Systemic Fluorides Topical Fluorides Community Water Fluoridation Self-Applied Fluorides Salt Fluoridation Dentifrices Milk Fluoridation Mouth rinses Fluoride Supplements Gels This classification is intended to classify dental fluorides as clearly as possible Professionally-Applied Fluorides Sodium Fluoride (NaF) Acidulated Phosphate Fluoride (APF) Stannous Fluoride (SnF) Silver Diamine Fluoride (SDF) Systemic Fluorides Systemic Fluorides Systemic ingestion of fluoride, which is incorporated into the developing tooth structure and converting hydroxyapatite into fluorapatite, thus reducing the solubility of tooth enamel in acid and making it more resistant to caries Systemic Fluorides Systemic Fluorides - Blood plasma fluoride levels begin to rise about 10 min. after ingestion. - It reaches maximum levels within 60 min. - It returns to pre-ingestion levels after 11-15 hours. - ↑ 99% of the fluoride in the body is found in calcified tissues. - Provides low concentration of fluoride over a long period of time. Systemic Fluorides Systemic Fluorides The Story of Fluoridation I. Clinical Discovery Phase (1901-1933) II. Epidemiologic Phase (1933-1945) III. Demonstration Phase (1945) IV. Technology Transfer Phase (began 1950) Systemic Fluorides The Story of Fluoridation I. Clinical Discovery Phase (1901-1933): - It was characterized by the pursuit of knowledge to determine the cause of developmental enamel defects. - In 1901, Dr. Fredrick McKay, noticed that some patients presented with discolored enamel, which locals called “Colorado brown stains” - He called it “mottled enamel” and began a study to find its causes in the Rocky Mountain area. - He sought the consultation of Dr. G V Black, and they alerted the profession about this condition. Systemic Fluorides The Story of Fluoridation Systemic Fluorides The Story of Fluoridation I. Clinical Discovery Phase (1901-1933): - In 1927, McKay published an important finding: people who have fluorosis, have less decay - In 1930, McKay contacted Churchill, a chemist, and sent him samples of the water. - He identified high levels of fluoride in the water (2-12 ppm F). - McKay has identified his etiologic factor. Systemic Fluorides The Story of Fluoridation II. Epidemiologic Phase (1933-1945): - It was concerned with the search for additional information about the role of fluoride in the cause of enamel fluorosis and the prevention of dental caries. - Trendly Dean conducted some impressive epidemiologic studies, including the “4 City Study” and “Dean’s 21-Cities Study” - In 1938, he found that: 1 - The number of carious teeth and the severity of fluorosis were inversely related. 2 - The amount of fluoride in the water and the severity of fluorosis were directly related. Systemic Fluorides II. Epidemiologic Phase (1933-1945): Systemic Fluorides The Story of Fluoridation III. Demonstration Phase (1945): - It was characterized by a series of community trials in which fluoride levels were adjusted in the public drinking water supply. - In January 1945, the fluoride content of the water supply of Grand Rapids, Michigan, was adjusted to 1 ppm. - The results were impressive, and the eventual reduction in the dental caries for children was 50-70%. Systemic Fluorides The Story of Fluoridation IV. Technology Transfer Phase (began 1950): - It started around 1950 when planning for the implementation of fluoridation in many large US cities began, and the establishment of set of national health goals. Systemic Fluorides Community Water Fluoridation § In 2005, the WHO issued the following statement: “Fluoridation of water supplies, where possible, is the most effective public health measure for the prevention of dental caries” This Photo by Unknown Author is licensed under CC BY-NC-ND Systemic Fluorides Community Water Fluoridation § The controlled addition of fluoride compounds to the water supply in order to bring its concentration to an optimal level to prevent caries. § Water fluoridation of 0.7-1.2 milligrams (mg) of fluoride ion per liter is considered to be optimal for dental health. § 1 ppm fluoride = 1mg/Liter § In 2015, the US set a level of 0.7 ppm. § 1 ppm is the optimal level to reduce 50% of caries. § Depends on climate: § Hot climate 0.7 ppm § Cold climate: 1.2 ppm Systemic Fluorides Community Water Fluoridation § It is a population-based method of primary prevention designed to serve as the cornerstone for the prevention of dental caries. § It has been cited by the CDC as one of the 10 great public health achievements of the 20th century. § Institute of Medicine & WHO identify fluoride as a nutrient important for health. § Fluoridation contributed to a dramatic decline in dental caries from 1950s to 1980s. § It continues to reduce and prevent caries today when multiple sources of fluoride, such as toothpaste, are readily available. Systemic Fluorides Community Water Fluoridation § There have been 113 studies in 23 countries over the last 60 years showing that water fluoridation reduces dental caries by 50%. § Water fluoridation has been reviewed comprehensively (Parnell et al., 2009; McDonagh et al., 2000). Systemic Fluorides Community Water Fluoridation 35% caries reduction in primary teeth. 26% caries reduction in permanent teeth. 15% percent increase in caries-free children in primary dentition 14% percent increase in caries-free children in permanent dentition. Systemic Fluorides Community Water Fluoridation Advantages: § Benefits people of all ages. § Socially equitable. § Continuous protection with no need for compliance. § No need to access health care. § Cost-effective. Disadvantages: § Legalization and approval. § Consents. § No evidence for side effects: neurotoxicity, decreased cognitive ability, endocrine disruption, thyroid diseases, cancer, or bone diseases. § Fluorosis. Systemic Fluorides School Water Fluoridation § It is a suitable alternative for community water fluoridation as children would consume water during school days. § The concentration of fluoride is higher due to a lower intake of water during school times (about 4.5x more). Advantages: § Target school children. § No need for compliance. § No need to access health care. § Cost-effective. Disadvantages: § Legalization and approval. § Need continuous adjustments. § Interruption by holidays. § Limited pre-eruptive benefits to primary teeth. § Fluorosis. Systemic Fluorides Bottled Water Fluoridation § § § § The fluoride content of bottled water is usually very low. Some water filters may remove fluoride. Can vary with water sources, seasons and labelling requirements. 46% caries reduction in Bulgaria. This Photo by Unknown Author is licensed under CC BY-SA-NC Systemic Fluorides Salt Fluoridation § A controlled addition of fluoride, usually sodium or potassium fluoride, during the manufacture of salt for human consumption. § Introduced by Wepsi in 1948 in Switzerland. § The amount of fluoride added is 250 mg F/kg salt (250 ppm). § 50% caries reduction in Switzerland and Hungary Advantages: Disadvantages: § Cheap and can be made available to the population. § Prevents dental caries by both systemic and topical action. § It does not require a community water supply. § It permits individuals to accept it or reject it. § No precise control over indicated consumption since salt intake varies greatly among people. § International efforts to reduce sodium uptake. § Not appropriate for countries having water fluoridation. § Less sodium (Na) intake to help control hypertension Systemic Fluorides Milk Fluoridation § Milk fluoridation has not been implemented on a wide scale. § Insufficient evidence about its effectiveness (Yeung et al., 2015). § 15–65% caries reduction. Systemic Fluorides Fluoride Supplements § Fluoride supplements are available in different forms such as fluoride tablets, drops, lozenges. § Caries reductions vary from 20% to 80%. § It can be prescribed for children ages 6 months to 16 years who are at high risk for caries and whose primary drinking water has a low fluoride concentration. § Tablets and lozenges are manufactured with 1.0, 0.5, or 0.25 mg F. § Most supplements contain NaF as the active ingredient. § To maximize the topical effect of fluoride, tablets, and lozenges are intended to be chewed or sucked for 1–2 minutes before being swallowed. § Dosing is based on the natural fluoride concentration of the child's drinking water and the age of the child. Systemic Fluorides Fluoride Supplements American Academy of Pediatric Dentistry. Fluoride therapy. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2023:352-8. These Photos by Unknown Author is licensed under CC BY-SA Systemic Fluorides Fluoride Supplements 24% caries reduction in permanent teeth. Topical Fluorides Topical Fluorides The use of systems containing relatively large concentrations of fluoride that are applied locally, or topically, to erupted tooth surfaces to prevent the formation of dental caries. Topical Fluorides Topical Fluorides - Inhibits demineralization and Promotes remineralization. - Has Antibacterial effects as it Concentrates in plaque Disrupts enzyme systems Topical Fluorides Self-Applied Fluorides § Dispensed at home by individuals but at recommendation. § Lower fluoride concentration. Topical Fluorides Self-Applied Fluorides: Dentifrices § Standard concentration (OTC) contains 1000-1500 ppm fluoride. § Best topical application for compliance. § Fluoride is added in one of the following forms: - Sodium fluoride (NaF with a highly compatible abrasive system is the most effective dentifrice). - Sodium monofluorophosphate (MFP). - Stannous or amine fluoride. § Ingestion is a concern. Topical Fluorides Self-Applied Fluorides: Dentifrices Topical Fluorides Self-Applied Fluorides: Dentifrices Topical Fluorides Self-Applied Fluorides: Mouth rinses and Gels § Daily use: - 0.05% NaF (220 ppm). - Partly acidulated solution of sodium fluoride, phosphoric acid, and sodium monobasic (200 ppm) § Weekly use: - 0.2% NaF (900 ppm), has little evidence of effectiveness at this concentration. § OTC Gel: 0.04% SnF § Prescription Gel: 1% NaF Topical Fluorides Self-Applied Fluorides: Mouth rinses and Gels Indications: § Caries. § High-risk patients. § High sugar diet. § Reduced salivation. § Orthodontic appliances or prostheses. § Extensive dental restorations. § Gingival recession. § Patients who cannot tolerate professionally applied fluorides. Topical Fluorides Self-Applied Fluorides: Mouth rinses and Gels 27% caries reduction in permanent teeth. 20% caries reduction in primary teeth. 28-38% caries reduction in permanent teeth. Topical Fluorides Professionally Applied Fluorides § Dispensed in dental office by professionals. § High fluoride concentration. Topical Fluorides Professionally Applied Fluorides: Sodium Fluoride (NaF) § It comes in powder, gel, foam, liquid, and varnish. § Knutson and Feldman recommended a technique of four applications of 2% NaF at weekly intervals in a year at 3, 7, 11, and 13 years. § NaF has a neutral pH, 9,200 ppm of F § Caries reduction in first year was 45% and in 2nd year was 36%. Topical Fluorides Professionally Applied Fluorides: Sodium Fluoride (NaF) § The most commonly used agent for professionally applied fluoride treatments is 5% sodium fluoride varnish (2.26 percent fluoride, 22,600 ppm). § Recommended for very young children and disabled individuals at 3-6 months intervals. Topical Fluorides Professionally Applied Fluorides: Sodium Fluoride (NaF) 37% caries reduction in primary teeth. 43% caries reduction in permanent teeth. Topical Fluorides Professionally Applied Fluorides: Acidulated Phosphate Fluoride (APF) § Acidulated Phosphate Fluoride 1.23% (1.23 percent F, 12,300 ppm). § It comes in solution, foam, and gel. § All are stable and ready to use. § The pH is about 3.5. § Thixotropic gels are also available (set in a gel-like state but are not true gels). On application of pressure, they behave like solutions. § Disadvantage: may etch ceramic or porcelain surfaces. Topical Fluorides Professionally Applied Fluorides: Stannous Fluoride (SnF) § In powder form. § Dudding and Muhler tried a single annual application of 8% SnF and reported a 32% caries reduction. § Acidic. § Aqueous solutions are not stable. § Ready-to-use solutions are not available. § A stable, flavored solution can be prepared with glycerin and sorbitol. § Disadvantage: pigmentation of carious teeth and it has a strong, unpleasant, bitter metallic taste. Topical Fluorides Professionally Applied Fluorides: Sliver Diamine Fluoride (SDF) § 38% Silver Diamine Fluoride liquid. § Approximately 45,000 ppm of Fluoride in addition to silver. § Approved for use in the US by the FDA in August 2014 as a cavity liner and/or dentinal desensitizer. § It can be used off-label for caries prevention and caries arrest. § Commercial product(s) became available in 2015. Topical Fluorides Professionally Applied Fluorides: Sliver Diamine Fluoride (SDF) § The specific mechanism of action is unclear, but it postulated that : -Inhibits biofilm formation. -Has antibacterial action. -Penetrates deep into tooth enamel and reduces its solubility. § Indicated for arrest of cavitated lesions when conventional treatment is not feasible. Topical Fluorides Professionally Applied Fluorides: Sliver Diamine Fluoride (SDF) § The application schedule is uncertain annually, biannually, but the recommendation is to monitor caries lesion arrest after 2-4 weeks period and consider reapplication (AAPD, 2023). § The effectiveness of one-time SDF application in arresting dental caries lesions ranges from 47 percent to 90 percent. § Increasing the frequency of application can increase the caries arrest rate. § Side effect: black staining of carious lesions and soft tissue. Fluorosis § A potential risk of fluoride use is the development of fluorosis, which may occur when excess levels of fluoride are ingested during tooth development. § Fluorosis varies in appearance from white striations to stained pitting of enamel. This Photo by Unknown Author is licensed under CC BY Fluorosis § The degree of fluorosis depends on the total dose of fluoride from all sources, timing, and duration of fluoride exposure. § It cannot occur once enamel formation is complete and the teeth have erupted, regardless of intake. Fluorosis How to reduce the risk of fluorosis? § Knowledge of fluoride concentration in drinking water. § Parents of children younger than 6 years should supervise the toothbrushing. § Fluoride supplements and mouth rinses should be limited to children. § Living in non- or low-fluoridated areas. § Fluoride ingestion should be reduced during the development of teeth, particularly under the age of 6 years, when teeth are still calcifying. Fluoride Toxicity § Excessive ingestion of fluoride may cause toxic and harmful effects. § It is important to note that the major source of fluoride toxicity remains oral hygiene products. (Martínez-Mier, 2012) Fluoride Toxicity (Ullah et al., 2012) Fluoride Toxicity § Certainly Lethal Dose (CLD) =16-32 mg F/kg (Hodge and Smith) body weight. =15 mg F/kg (Whitford) body weight. § Death is likely in a child who ingests more than 16 mg F/kg body weight. § Probably Toxic Dose (PTD) is defined as the minimum dose that could cause toxic signs and symptoms, including death, and the ingestion of which should trigger immediate intervention and hospitalization is 5mg F/kg body weight. § Example: For a child about 7 years, who weighs approximately 20 kg, the PTD would be approx. 100 mg F. Fluoride Toxicity § Certainly Lethal Dose (CLD) =16-32 mg F/kg § Probably Toxic Dose (PTD) = 5mg F/kg. (Ullah et al., 2012) Fluoride Toxicity Summary § Fluoride can be delivered topically and systemically. § Systemic fluorides are ingested and become incorporated into forming tooth structures. § Systemic fluorides also provide topical protection because fluoride is present in saliva, which continually bathes the teeth. § Community water fluoridation 35% caries reduction in primary teeth. 26% caries reduction in permanent teeth. Summary § Topical fluorides strengthen teeth already present in the mouth, making them more caries-resistant. § Self-applied topical fluorides include toothpastes, gels and Mouth rinses: 27% caries reduction in permanent teeth. § Professionally applied topical fluorides include higher-strength rinses, gels, and foams; fluoride varnishes; and silver diamine fluoride. Gels: 20% caries reduction in primary teeth. 28-38% caries reduction in permanent teeth. Fluoride varnishes: 37% caries reduction in primary teeth. 43% caries reduction in permanent teeth. Summary § Excessive use and intake of fluoride can lead to fluorosis. § Fluoride Toxicity: Optimal Dose = 0.05 – 0.07 mg F/kg Certainly Lethal Dose (CLD) =16-32 mg F/kg Probably Toxic Dose (PTD) = 5 mg F/kg. § Treatment of fluoride toxicity Suspected ingestion amount known: < 5 mg F/kg: slow the absorption, observe for some hours, and refer if symptoms develop. > 5 mg F/kg: hospital admission, administer products that slow the absorption. > 15 mg F/kg: immediate transport to the emergency department, induce vomiting, and IV of calcium. Suspected ingestion amount unknown: Asymptomatic: treat as < 5 mg F/kg Symptomatic: treat as > 5 mg F/kg References: Required: § Harris NO, Garcia-Godoy F, Nathe CN (2014. Primary Preventive Dentistry, 8th Edition. Chapter 14 and Chapter 15 § Burt, B. A., & Eklund, S. A. (2005). Dentistry, dental practice, and the community. Elsevier Health Sciences. § Casamassimo, P. S., Fields, H., McTigue, D. J., & Nowak, A. J. (2012). Pediatric dentistry: infancy through adolescence, 5th Edition. Chapter 14, pages 200-212 § American Academy of Pediatric Dentistry. (2023). Fluoride therapy. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2023:352-8. § American Academy of Pediatric Dentistry. (2023).. Policy on use of fluoride. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2023:100-2. § Crystal YO, Marghalani AA, Ureles SD, et al. Use of silver diamine fluoride for dental caries management in children and adolescents, including those with special health care needs. Pediatr Dent 2017; 39(5):E135-E145. Additional: Parnell, C., Whelton, H., and O’Mullane, D. (2009). Water fluoridation.European Archives of Paediatric Dentistry, 10, 141–8. McDonagh, M.S., Whiting, P.F., Wilson, P.M., et al. (2000). A systematic review of public water fluoridation. NHS Centre for Reviews andDissemination, York. Iheozor-Ejiofor, Z., Worthington, H. V., Walsh, T., O'Malley, L., Clarkson, J. E., Macey, R.,... & Glenny, A. M. (2015). Water fluoridation for the prevention of dental caries. Cochrane database of systematic reviews, (6). Yeung, C. A., Chong, L. Y., & Glenny, A. M. (2015). Fluoridated milk for preventing dental caries. Cochrane Database of Systematic Reviews, (8). Tubert-Jeannin, S., Auclair, C., Amsallem, E., Tramini, P., Gerbaud, L., Ruffieux, C.,... & Ismail, A. (2011). Fluoride supplements (tablets, drops, lozenges or chewing gums) for preventing dental caries in children. Cochrane Database of Systematic Reviews, (12). Marinho, V. C., Higgins, J., Logan, S., Sheiham, A., & Cochrane Oral Health Group. (1996). Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane database of systematic reviews, 2016(11). Walsh, T., Worthington, H. V., Glenny, A. M., Marinho, V. C., & Jeroncic, A. (2019). Fluoride toothpastes of different concentrations for preventing dental caries. Cochrane database of systematic reviews, (3). Marinho, V. C., Worthington, H. V., Walsh, T., & Chong, L. Y. (2015). Fluoride gels for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews, (6). Marinho, V. C., Worthington, H. V., Walsh, T., & Clarkson, J. E. (2013). Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews, (7). Marinho, V. C., Chong, L. Y., Worthington, H. V., & Walsh, T. (2016). Fluoride mouth rinses for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews, (7). Acknowledgment: Thanks to Dr. Maram Alagla and other colleagues in the Pediatric Dentistry Division for sharing some of the slides. Thank you! Any questions [email protected]