Fluoride Flashcards
–% of adults aged 20-64
have had dental caries in
permanent teeth
92
—% of adults aged 20-64
have untreated decay
26
Fluoride is a — to caries prevention-not a
solution on its own
SUPPLEMENT
- — control is priority
Oral hygiene/plaque
- — habits must be addressed with patient
Dietary
Systemic application:
ingested agents that
become incorporated into forming tooth
structures
systemic application
ex (3)
- Water
- Supplements
- Food/beverages
Topical application:
strengthen teeth
already in the mouth making them more
resistant to caries
Topical application
ex (3)
- Water
- Homecare products (toothpaste,
mouth rinses, etc.) - In-office products
Systemic
- Ingested and incorporated into
enamel during development of
tooth structures
Topical
* Promotes
* Inhibits
remineralization and
prevents demineralization after
eruption
glycolysis in bacteria,
thereby inhibiting the ability of
bacteria to metabolize
carbohydrates and produce acid
Water
Fluoridation
- An increase of the natural fluoride level in a
community’s water supply to a level
optimal for dental health
Fluoridation has contributed to a major
decline in
dental caries from the 1950s to
the 1980s and continues to reduce and
prevent tooth decay
When cities discontinue water fluoridation,
evidence demonstrates
rapid increase in
caries rates
Water fluoridation is considered one of the
most — preventive dental
program by public health
cost-effective
Benefits of
Water
Fluoridation
—% decrease in caries in
primary dentition
30-39
—% decrease in
children/adolescent permanent
dentition
35
Approximately —% decrease in
coronal caries and —% decrease
in root caries in adult population
20-30
20-40
Levels of Water Fluoridation
Optimal =
minimal
caries with
minimal fluorosis
– ppm decreases
caries with <10%
of population with
fluorosis
.7
Optimal range:
— ppm
0.6-1.2
What is
Fluorosis?
Changes in the appearance
of enamel caused by too
much systemic fluoride
Demineralization of Tooth Structures
Upon exploring, tooth surfaces will feel —
rough
Fluorosis
Upon exploring, tooth surfaces will feel —
smooth
How does
Topical Fluoride
work?
(4)
- Fluoride deposited in enamel during enamel
maturation phase results in a concentration of
fluoride in the enamel - Highest concentration occurs on the outermost
portion (5-10 microns) and decreases as you move
toward the dentin - Fluoride ions are substituted into the hydroxyapatite
crystal and form a stable, more compact bond making
the tooth resistant to demineralization - It does NOT cause fluorosis
Fluoride/Enamel
Reaction to Fluoride
Influenced by concentration of (3)
fluoride, pH of
fluoride, and length of exposure
Acidic fluorides typically form
calcium
fluoride
- Higher concentrations form
calcium fluoride
In-office fluorides are >9000 ppm, so
they typically form
calcium fluoride
- Neutral fluorides <100 ppm form
fluorapatite
- Neutral fluorides <100 ppm form
fluorapatite
Benefits of Topical Fluoride- continued
(3)
Remineralization
Interferes with bacterial metabolism
Prevention
2% Neutral sodium
fluoride (9000 ppm)
Available as a
foam or gel
application
1.23% Acidulated
Phosphate Fluoride
(APF) (12,3000 ppm)
Available as a
foam or gel
application
5.0% NaF
(22,600 ppm)
Available as a
varnish
application
Commonly
used in dental
practices
- Initial deposits of fluoride is not permanent
(2)
- Relatively rapid loss after 24 hours
- Loss continues for several weeks
After every application of topical fluoride, there is an
increase in the amount of permanently bound fluoride in
the
outermost layer of enamel
This causes a decrease in — susceptibility (initiation and
progression)
caries
Fluorohydroxyapatite-
most desired form of
fluoride for enamel in caries prevention
* From prolonged exposure of enamel to
low concentrations of fluoride
Calcium fluoride-
source of fluoride for
remineralization of enamel
* Deposits of calcium fluoride are
dissolved by plaque acids and are
available as a source to facilitate
remineralization
The benefits of topical fluoride treatments is directly
related to the amount of topical fluoride treatments
provided
(3)
- The type of topical fluoride system used does not
affect the benefit - Does not benefit sound enamel
- Greater uptake with higher concentrations of
fluoride
When Should Topical
Fluoride Be Used?
(6)
- High caries risk individuals
- Sensitive teeth/exposed root surfaces
- Around margins of older restorations
- Overdentures (with natural teeth)
- Xerostomia
- Newly erupted teeth
Probable Toxic Dose (PTD)
Based on
body weight
Considered to be 5mg F/kg of body weight
- <5mg/kg:
office use of available calcium, aluminum or
magnesium products
- > 5mg/kg:
same as above plus hospital observation
- > 15mg/kg:
same as above plus emergency response (911)
skipped
Fluoride Toxicity
(4)
Concentrated fluoride salts can cause chemical burn when in contact with oral
mucosa
Inhibits enzyme systems
Binds calcium
Cardiotoxic due to hyperkalemia
Signs &
Symptoms
of too
much Fluoride
(5)
Nausea
Vomiting
Diarrhea
Abdominal cramping
Increased salivation/dehydration
Fluoride Varnish- 5% NaF
PROS
(3)
- Proven efficacious in decreasing
caries, especially in early-childhood - Easy to apply following oral exam and
prophylaxis - Easy to follow post-op instructions
Fluoride Varnish- 5% NaF
CONS
(2)
- Leaves a thin-visible film on teeth that
some patients do not like - Possible allergies linked to specific
brands of fluoride varnish
Application of Fluoride Varnish
(3)
- Applied to clean tooth surfaces (following a prophylaxis or
toothbrushing) - Varnish is retained on teeth from 24-48 hours after
application, during which time fluoride is released for
reaction with the underlying enamel - Applications should occur every 3-6 months (dependent
upon caries risk)
Clinical evidence demonstrates fluoride
treatment refusal by —% of parents
during preventive dental visits
13
Many other parents have unresolved
concerns regarding fluoride treatments
One study points out that fluoride refusal
was significantly associated with
vaccination refusal
skipped
Assess
Assess parents’ knowledge, beliefs and attitudes about
fluoride with open-ended, nonjudgmental questions
skipped
Incorporate
Incorporate caries risk into discussions with parents during
preventive visits
skipped
Obtain
Obtain information about why a parent refuses fluoride
treatment (listening is key and will help build trust with a
fluoride-hesitant parent)
skipped
Provide
Provide a tailored explanation of why topical fluoride is
important
skipped
Maintain
Maintain open communication, even when refusal continues
skipped
Communicate
Communicate with local health professionals to reinforce the
importance of fluoride
skipped
History of Silver
silver first used in dentistry un the 1840s known as nitrate of silver
it was extremely caustic and early american dentists used it to instantaneously cauterize carious lesions
popular dental medicament used through the era of GV black
in 1917, a silver nitrate solution was developed and marketed as an antimicrobial that could penetrate even deeper into dentin
in the 1970s, the wester australia school dental service used silver fluoride as the initial part of a minimally invasive treatment process for disadvantaged young children in new south wales
AgF was seen as essential to inhibiting the growth of existing lesions
stannous fluoride was then applied to act as reducing agent to AgF and to prevent new lesions from occurring
this two step metal fluoride approach resulted in 74% of the existing lesions remain unchanged and only 35% of all lesions requiring additional treatment
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Silver Diamine Fluoride
(4)
- First investigated in 1969 as part of a PhD student’s thesis in
Japan (Mizuho Nishino) - She combined the antimicrobial properties of silver with the
benefits of high dose fluoride - This formulation additionally resulted in a precipitate that
occluded dentinal tubules and reduced hypersensitivity - This product initially emerged from dental public health
researchers in the developing world, where access to oral health
care was extremely limited - Primary population studies came from
Argentina, Brazil, China, Cuba, Japan and
Nepal - 38% SDF was found to be most superior
at arresting caries compared to lower
concentrations of 10 or 12% - SDF was also superior at arresting dental
caries and preventing new caries
compared to fluoride varnish alone,
however, did not hold true when used as
a sealant over NON-cavitated molar
grooves - Multiple applications of SDF were found
to be more successful at arresting dental
caries than one-time placement
SDF gained clearance from the FDA in the US
in —
2014
SDF
Approved for use to treat dentin
— in adults
hypersensitivity
In October 2016, the FDA awarded SDF the
designation of “breakthrough therapy” based
on its
arrest of decay in children and adults,
the first for oral health therapy
- Fluoride and silver are made soluble in water
by the addition of
ammonia
- The — ions are a broad-spectrum
antimicrobial that has high biocompatibility
and low toxicity in humans
silver
- These ions act as tiny ‘silver bullets’ that
damage and degrade bacterial cell walls,
disrupt bacterial DNA synthesis and
replication and disrupt intracellular metabolic
activity, eventually leading to cell death
- The killed bacteria further act as a carrier for
silver ions and can kill living bacteria nearby in
a process known as the
“zombie effect”
- Once applied, a physical barrier precipitates out of
the
clear solution onto the carious lesion
SDF
* 2 products form–
silver phosphate which acts as a
reservoir of phosphate ions, and
calcium fluoride,
which is a pH-regulated fluoride supply available
during cariogenic challenge
major nonmedical side effect of SDF
- Free silver ions in the lesion are reduced by
environmental oxygen and turn the lesion black
- 5% SDF solution contains — ppm fluoride
44,800
(almost twice as much as % NaF varnish)
5% SDF solution contains 44,800 ppm fluoride
(almost twice as much as % NaF varnish)
* In this concentration, SDF reacts with calcium
and phosphate ions to produce
fluorohydroxyapatite crystals, which are less
susceptible to solubility and crucial to tooth
remineralization
Despite the high concentration, the small
amount of SDF required to be effective suggests
that it is
well within the margin of safety for use
One application of SDF is not sufficient for
ultimate results- may need to
place SDF a few
times for effectiveness in treating the area
When to Use SDF
(2)
- Dentin hypersensitivity
- Uncooperative patients (i.e., children or
patients with cognitive disabilities), root
surface caries on elderly patients with
existing restorations, patients without
access to restorative care, difficult to treat
lesions
Placement of SDF
(6)
Dry tooth on which SDF will be placed
Using a micro brush, apply SDF sparingly to tooth
Allow area to dry slightly (1-3 minutes) then rinse
Caries will be arrested over time and will turn black as a result
SDF has an unpleasant metallic taste
DO NOT use with a silver allergy of pulpal involvement
Prophy Paste &
Fluoride
(2)
- Fluoridate prophy paste is not considered a
therapeutic/preventive agent for caries - Polishing alone removes 0.1-1.0 microns of
fluoride-rich enamel, therefore, at best,
fluoride in prophy paste will replace the
fluoride lost by the abrasive paste
Toothpastes
(OTC)
(2)
- Average Concentration 0.22% NaF (1000 ppm)
- Sodium Fluoride (NaF) most effective dentifrice system for caries prevention
- Risk of fluorosis and toxicity if ingested (hence, pea-sized amount for small
children)
Fluoride
Rinses
ingredients (3)
alcohol free
0.02% sodium fluoride (100 ppm) in 33.8 fl oz bottle
0.05% sodium fluoride (225 ppm) in 19 fl ox bottle
Fluoride
Rinses
what fluoride rinse does (3)
remineralizes tooth structure
strengthens enamel to prevent caries
kills bad breath
Fluoride
Rinses
how to use it (2)
twice daily after brushing/flossing, swish with 10 mL for 1 min then expectorate
no eating/drinking for 30 min after
Other Types of
ACT Rinse
All the active ingredients remain
the same between – oz and
– oz bottles
18
33.8
Listerine
(3)
- 0.02% Sodium Fluoride (100 ppm)
- 21.6% v/v alcohol
- No difference in instructional use
MI PASTE PLUS (OTC)
(2)
MI paste alone used recaldent to relieve tooth sensitivity not to prevent decay
MI paste plus has 0.20% NaF (900 ppm) and can be used for caries prevention and tooth sensitivity
Prevident toothpaste:
1.1% NaF (5000 ppm)
Prevident mouth rinse:
0.2% NaF (900 ppm)
