fluoride therapy for caries prevention/control Flashcards
“_______/________ remains the most prevalent chronic disease in both children and adults, even though it is largely ________.”
- ___________ and __________
“Dental caries (tooth decay) remains the most prevalent chronic disease in both children and adults, even though it is largely preventable.”
-National Institute of Dental and Craniofacial Research
caries is a _______ infectious disease
primary modifying factors: (8)
secondary modifying factors: (7)
caries is a multifactorial infectious disease
primary: tooth anatomy, saliva, biofilm ph, use of fluoride, diet specifics, oral hygiene, immune system, genetic factors
secondary: socioeconomic status, education, life style, environment, age, ethnic group, occupation
what four categories make up the inner circle for caries in the absence of protective factors and if other risk factors are present
host, time, fermentable carbohydrates, and cariogenic bacteria
describe the process of demineralization
3 bacteria
4 carbs
=
cariogenic bacteria such as S. mutans, S. sobrinus, and Lactobacilli
combine with fermentable carbohydrates such as sucrose, glucose, fructose, or cooked starch
and create organic acids that penetrate enamel and dentin and dissolve tooth minerals
describe the process of remineralization
calcium in tooth water/saliva
+ phosphate in tooth water/saliva
= remineralization: builds on existing crystal remnants; new mineral is less soluble; fluoride speeds up remineralization
pH
- ranges from:
- lower number =
- higher number =
- neutral ph =
- when does demineralization occur
0 (acidic) - 14 (alkaline)
lower number = more acidic
higher number = more alkaline/basic
neutral = 7
demineralization occurs at 5.5 or less!
demineralization/remineralization
______ process
demineralization starts with _______: the ph drops to ____
how long does it take for ph to return to normal
what plays a key role in neutralizing acids
remineralization occurs when ph _______ and minerals are available for ______
imbalance of _______ results in caries
ONGOING process
demineralization starts with CARBOHYDRATE ATTACKS: the ph drops to 5.5 OR LESS
how long does it take for ph to return to normal: 30-60 MIN
what plays a key role in neutralizing acids: SALIVA
remineralization occurs when ph NEUTRALIZES and minerals are available for UPTAKE
imbalance of PATHOGENIC FACTORS results in caries
think of a see saw
pathologic factors balancing protective factors
pathologic: (caries)
- acid producing bacteria
- frequent consumption of fermentable carbohydrates
- subnormal salivary flow/function
protective: (no caries)
- high saliva flow and components
- fluoride: remineralization
- antibacterials: chlorhexidine, xylitol
risk factors for caries (9)
- med/high S. mutans and lactobacilli counts
- visible heavy plaque
- frequent snacking between meals
- deep pits/fissures
- Recreational drug use
- Inadequate salivary flow
- Saliva-reducing factors (medications)
- Exposed roots
- Orthodontic appliances
caries protection factors (8)
- Drinks fluoridated water
- Uses fluoride toothpaste at least twice daily
- Uses fluoride mouthrinse daily
- Had fluoride varnish/topical applied in the last 6 months
- Use of prescribed chlorhexidine
- Use of xylitol gum or lozenges
- adequate salivary flow
Fluoride: _____ occurring element in many ____, ____, ______
Fluoride can have a dramatic caries _____ and ________ effects
Fluoride: NATURALLY occurring element in many WATER, FOODS, AND MINERALS
Fluoride can have a dramatic caries PREVENTIVE and REPARATIVE effects
what are the 3 mechanisms of action for fluoride
- inhibits demineralization
- enhances remineralzation
- inhibits plaque bacteria
DEMINERALIZATION
- ________ metabolism
- Rapid ___ in plaque pH
- Diffusion of acids into _____
- ________ and ______ dissolve
- Carious lesion formation
REMINERALIZATION
- _____ pH of oral environment
- ______ flow
- Re-deposition of minerals
- _____ of carious lesions
DEMINERALIZATION
- Carbohydrate metabolism
- Rapid drop in plaque pH
- Diffusion of acids into enamel
- Calcium and phosphate dissolve
- Carious lesion formation
REMINERALIZATION
- Neutral pH of oral environment
- Salivary flow
- Re-deposition of minerals
- Repair of carious lesions
mechanism 1: inhibits demineralization
- fluoride flows into ______
- _______ acidic environment
- reduces the _____ of tooth material
- fluoride flows into TOOTH SURFACE
- NEUTRALIZES acidic environment
- reduces the SOLUBILITY of tooth material
mechanism 2: enhances remineralization
- Presence of ___ is mandatory
- Allows for influx of _____, ______, ______ onto tooth surface
- _______ bond formed: ______ than original tooth structure
- Remineralized lesions are less susceptible to _________
- Presence of SALIVA is mandatory
- Allows for influx of CALCIUM, PHOSPHATE, AND FLUORIDE onto tooth surface
- FLUORAPATITE bond formed: STRONGER than original tooth structure
- Remineralized lesions are less susceptible to FUTURE DEMINERALZATION
mechanism 3: inhibits plaque bacteria
- Fluoride in biofilm is taken up by ________
- Interferes with ____ production
Fluoride in biofilm is taken up by acid-producing bacteria
Interferes with acid production
COMMUNITY WATER FLUROIDATION
defined as:
- most common ________
- i_____
- e______
- s____
defined as: The adjustment of the natural fluoride ion content in a municipal water supply to the optimum physiologic concentration that will maximize caries prevention and limit enamel fluorosis
- most common FLUORIDE DELIVERY SYSTEM
- INEXPENSIVE
- EFFECTIVE
- SAFE
what is the number 1 way to prevent dental decay
community water fluroidation
statistics from CWF
first communities fluoridated in ___
in ___, ___% of the US population served by _____ water systems received fluoridated water (CDC)
Healthy People 2030 goal: ___% of people receive fluoridated water
Starting in ____, the Public Health Service recommended fluoride level in water to be ___ppm
first communities fluoridated in 1945
in 2020, 72.7% of the US population served by PUBLIC water systems received fluoridated water (CDC)
Healthy People 2030 goal: 77% of people receive fluoridated water
Starting in 2015, the Public Health Service recommended fluoride level in water to be 0.7ppm
Benefits of community water fluoridation (4)
- reduces cost of dental treatment
- no licensed professional needed
- client compliance
- caries reduction among children and adults!
prescription fluoride supplements
Forms:
Warnings:
concentrations:
who is it for
Forms:
- drops for children 6months-3years
- tablets/lozenges for ages 4+, chew or let dissolve in mouth at bedtime
Warnings:
- avoid milk: calcium interferes with fluoride by binding to it in the digestive system and reducing the fluoride absorption
concentrations:
- 0.25mg
- 0.50mg
- 1.0mg
who is it for
- children with high caries risk and don’t receive enough or any fluoridated water (below 0.7ppm)
FLUORIDE SUPPLEMENT DOSE SCHEDULE (less than .3ppm, 0.3-0.6ppm, greater than 0.6ppm)
0-6months
6months-3years
3-6 years
6-16 years
0-6months: 0, 0, 0
6months-3years: .25mg, 0 , 0
3-6 years: .50mg, .25 mg, 0
6-16 years: 1mg, .5mg, 0
TOPICAL FLUORIDE
Low-concentration (_____) products are applied ______
High-concentration (_______) products are applied ___ frequently
3 forms:
Low-concentration (LOW POTENCY) products are applied FREQUENTLY
High-concentration (HIGH POTENCY) products are applied LESS frequently
3 forms:
- self applied OTC
- self applied prescription
- professionally applied presciption
self applied fluoride mouthrinses
_____ NaF - ___ppm fluoride
__ potency, ___ frequency
adjunct to _____
_____% reduction in caries
EX: 2
USE:
- pour dose according to instructions
- swish for __ then spit
- once or twice a day
- do not eat for __ after
0.05 NaF - 220 ppm fluoride
low potency, high frequency
adjunct to toothpaste
30-35% reduction in caries
EX: act, listerine total care
USE:
- pour dose according to instructions
- swish for 60 sec then spit
- once or twice a day
- do not eat for 30 min after
SELF APPLIED DENTIFRICES
Other than _________, dentifrices are the most widely used fluoride
Dentifrices in the United States contain _______ ppm fluoride
Most dentifrices contain one of the following: (3)
Brushing ___ daily with fluoride-containing dentifrice is effective for _______
Do not _____ afterward
Other than DRINKING WATER, dentifrices are the most widely used fluoride
Dentifrices in the United States contain 1000-1100 ppm fluoride
Most dentifrices contain one of the following: STANNOUS FLUORIDE (SnF2), SODIUM FLUORIDE (NaF), or SODIUM MONOFLUOROPHOSPHATE (NaMFP)
Brushing TWICE daily with fluoride-containing dentifrice is effective for PREVENTING DECAY
Do not RINSE afterward
SELF APPLIED DENTIFRICES
Recommended for ___ patients no matter their caries risk
Foundation for all patients ______ regimens
Look for _____
____ concentrations of fluoride
Promotes enamel ________
Higher concentrations available by _________
Recommended for ALL patients no matter their caries risk
Foundation for all patients FLUORIDE regimens
Look for ADA SEAL
LARGE concentrations of fluoride
Promotes enamel REMINERALIZATION
Higher concentrations available by PRESCRIPTION
SELF APPLIED PRESCTIPTION DENTIFRICES
Prescription dentifrice with ____ fluoride concentration is more effective for _______ patients
____ ppm
Available in the _____ office
Examples: (2)
Prescription dentifrice with HIGH fluoride concentration is more effective for HIGH-RISK patients
5000 ppm
Available in the DENTAL office
Examples:
- Clinpro 5000
- PreviDent 5000 plus
SELF APPLIED FLUORIDE GELS
_____ use
Brushed on teeth after brushing with fluoride _______
Keep in mouth for __ then expectorate
Types: (3)
DAILY use
Brushed on teeth after brushing with fluoride DENTIFRICE
Keep in mouth for 1 MIN then expectorate
Types:
- stannous fluoride (SnF2) with 1000ppm (OTC)
- sodium fluoride (NaF) with 5000ppm (Rx)
- acidulated phosphate fluoride (APF) with 5000ppm (Rx)
FLUORIDE AND CHILDREN
Involve the client’s ____ or _____
Emphasize key information:
- Importance of _____ of children when brushing their teeth
- Limit the _____ of _______
- younger than __ (grain-sized)
- ages ___ (pea-sized)
- No _____ or _____ prior to age __
- Importance of _________
- Store products out of the ______ of children
Involve the client’s parent or caregiver
Emphasize key information:
- Importance of SUPERVISION of children when brushing their teeth
- Limit the AMOUNT of DENTIFRICE
- younger than 3 (grain-sized)
- ages 3-6 (pea-sized)
- No MOUTHRINSE or GELS prior to age 6
- Importance of SPITTING/EXPECTORATING
- Store products out of the REACH of children
NaF gel/foam: neutral/7ph
form
concentration
application mode/frequency
notes
FORM: 2% gel or foam
CONCENTRATION: 9050ppm .9% F ion
APPLICATION: tray (4 min)/no currently recommended interval; most commonly applied every 3-6 months
NOTES: do not overfill
Acidulated phosphate: 3.5 ph
form
concentration
application mode/frequency
notes
form: 1.23% gel or foam
concentration: 12300ppm 1.23% F ion
application mode/frequency: tray (4min)/at least every 3-6 months
notes: do not overfill
NaF (varnish): neutral/7ph
form
concentration
application mode/frequency
notes
form: 5% varnish
concentration: 22600ppm 2.26% F ion
application mode/frequency: apply thin layer with a soft brush (1-2min)/at least every 3-6 month
notes: sets up to a hard film
SDF: ph 8-10
form
concentration
application mode/frequency
notes
form: 5-5.9% Fluoride
concentration: 44800ppm 4.48% F ion
application mode/frequency: apply thin layer with a microbrush (1min and let dry, then rinse with water)/at least every 6-12 months
notes: goes on clear, becomes black/gray upon application to cavitated areas
NaF GEL
____% NaF
Sometimes called ____ NaF due to neutral pH of __
_____ ppm fluoride ion
__-minute tray application
Most commonly applied every 3-6 months
2.0% NaF
Sometimes called Neutral NaF due to neutral pH of 7
9,050 ppm fluoride ion
4-minute tray application
Most commonly applied every 3-6 months
APF gel
___% APF
___ pH increases fluoride uptake
Uptake greatest during the first __ minutes
_____ ppm fluoride ion
__-minute tray application
Apply every ___ months
Not indicated for patients with ___, _____, or _______ because it may etch the materials
1.23% APF
Low pH increases fluoride uptake
Uptake greatest during the first 4 minutes
12,300 ppm fluoride ion
4-minute tray application
Apply every 3-6 months
Not indicated for patients with porcelain, composites, or sealants because it may etch the materials
foams
___% NaF or ____% APF
__-minute tray application
Limited evidence to support effectiveness in ______
2.0% NaF or 1.23% APF
4-minute tray application
Limited evidence to support effectiveness in CARIES PREVENTION
procedure for topical gel/foam
PATIENT: determine need based on ______ assessment (not for children under __), pick a fluoride (__/__, data supports ___ gel), seat pt ____, explain procedure and duration (__ min), instruct pt not to ____, tilt head ______ slightly
TRAY COVERAGE: choose right ___, must cover full dentition and areas of ______ (if unable to cover root surfaces, use _______)
PLACE GEL/FOAM: use _____ amount of product, fill tray __ w/ gel. Fill ______ will foam but do not ____
DRY TEETH: use saliva ejector and dry teeth before insertion of trays starting with ______ teeth then ____ (facial, occlusal, lingual)
INSERT TRAY: place both filled trays in mouth, may need to do one tray at a time, if doing a 2-step procedure, pt can not ___ in between but should ____
ISOLATION: use a ____ ejector with max suction
ATTENTION: do not leave pt ______
TIMING: use a ___, do not _____ (4min). 2 step takes __ min
COMPLETION: tilt head _____ for tray removal, have pt ___ several times without swallowing, wipe excess fluoride off teeth, instruct pt to not eat, drink, or brush teeth for ___ min
PATIENT: determine need based on caries risk assessment (not for children under 6), pick a fluoride (APF/NaF, data supports APF gel), seat pt upright, explain procedure and duration (4 min), instruct pt not to swallow, tilt head forward slightly
TRAY COVERAGE: choose right size, must cover full dentition and areas of recession (if unable to cover root surfaces, use varnish)
PLACE GEL/FOAM: use minimum amount of product, fill tray 1/3 will gel, fill completely will foam but do not overfill
DRY TEETH: use saliva ejector and dry teeth before insertion of trays starting with maxillary teeth then mandibular (facial, occlusal, lingual)
INSERT TRAY: place both filled trays in mouth, may need to do one tray at a time, if doing a 2 step procedure, pt can not rinse in between but should spit
ISOLATION: use a saliva ejector with max suction
ATTENTION: do not leave pt unattended
TIMING: use a timer, do not estimate (4min). 2 step takes 8 min
COMPLETION: tilt head forward for tray removal, have pt spit several times without swallowing, wipe excess fluoride, instruct pt to not eat, drink, or brush teeth for 30 min
NaF varnish
__% NaF
_____ ppm
Higher concentration of fluoride than __ or ___
___ amount used
Only _______ topical fluoride application for children under __
5% NaF
22600 ppm
Higher concentration of fluoride than gel or foam
less amount used
Only professional topical fluoride application for children under 6
BENEFITS OF NAF VARNISH (12)
Prolonged exposure
Safe
Ease of application
Short delivery time
Good for children
Acceptable taste
Cost effective
Small amount needed
Can eat and drink immediately after application
Can apply over demineralized lesions
Ortho patients
Decreases caries and hypersensitivity
SILVER DIAMINE FLUORIDE
Contains ____ and ______
Mechanisms of action:
- ________ biofilm pH
- Reduces ______ demineralization
- Fluoride-aids in ______
- Creates an ___ and ______-resistant tooth
- _____-_____ action
Contains SILVER and FLUORIDE
Mechanisms of action:
- Increases biofilm pH
- Reduces dentin demineralization
- Fluoride-aids in remineralization
- Creates an acid and abrasion-resistant tooth
- Silver-Antimicrobial action
SILVER DIAMINE FLUORIDE
FDA APPROVAL
- 2014:
- 2016:
CARIES ARREST FOR: (3)
FDA APPROVAL
- 2014: dentinal hypersensitivity
- 2016: granted breakthrough therapy designation for preventing and arresting caries
CARIES ARREST FOR:
- pediatric
- adolescents
- special needs
SILVER DIAMINE FLUORIDE
___% concentration
Can be applied to _____ caries
________ carious lesions in primary and permanent dentition
Procedure:
- _____ area and thoroughly ___
- Apply ____ amount to indicated surface
- Apply ______ to the rest of the mouth
No special instructions:
- Routine brush and floss ___ times per day
-Use fluoridated _____
38% concentration
Can be applied to dentinal caries
Arresting carious lesions in primary and permanent dentition
Procedure:
- Isolate area and thoroughly dry
- Apply small amount to indicated surface
- Apply NaF varnish to the rest of the mouth
No special instructions:
- Routine brush and floss 2-3 times per day
-Use fluoridated mouth rinse
benefits (4) VS adverse effects (2) of SDF
benefits
- cavitated and noncavitated caries arrest and prevention
- dentinal caries arrest
- inexpensive
- no reported systemic effects
adverse effects
- pulpal and soft tissue irritation
- permanent black dental stain
chronic fluoride toxicity: skeletal fluorosis
___-term intake of ____ amounts
Osteosclerosis:
___ painful joints
______ in later years
Elevation in bone _____
__+ years of excessive intake
____ppm fluoride in water
Never a concern in the ____
LONG-term intake of EXCESSIVE amounts
Osteosclerosis:
STIFF painful joints
CRIPPLING in later years
Elevation in bone DENSITY
10+ years of excessive intake
8-10ppm fluoride in water
Never a concern in the US
chronic fluoride toxicity: dental fluorosis
_____ of excess fluoride in ___
_________ of the enamel
Only during _________ of the crown
Greatest risk: _____ years old
No _______ symptoms
Protection against _______
ingestion of excess fluoride in water
Hypo-mineralization of the enamel
Only during the development of the crown
Greatest risk: 0-16/18 years old
No systemic symptoms
Protection against dental caries
acute fluoride toxicity
____ intake, over a _____ period of time
rare
occurs within __min of ingestion
may last up to ____ hours
Rapid intake, over a short period of time
Rare
Occurs within 30 minutes of ingestion
May last up to 24 hours
acute fluoride toxicity symptoms
GI symptoms: (3)
Blood symptoms: (1)
CNS symptoms: (3)
Cardiac symptoms: (1)
GI symptoms:
- nausea, vomiting
- increased salivation
- abdominal pain
Blood symptoms:
- hypocalcemia
CNS symptoms:
- hyperreflexia
- convulsions
- paresthesia
Cardiac symptoms:
- cardiac failure
acute fluoride toxicity TREATMENT
- induce ______
- call 911
- administer ___/______, why?
- support ______
- induce VOMITING
- call 911
- administer MILK/MILK OF MAGNESIA: calcium interferes with fluoride by binding to it in the digestive system and reducing the fluoride absorption
- support RESPIRATION
FLUORIDE DOSING
CERTAINLY LETHAL DOSE (CLD)
- ___g NaF at once for adults
- _____g NaF at once for children
SAFELY TOLERATED DOSE
- __ of CLD
- ________g of NaF for adults
- age 2: CLD and STD
- age 4: CLD and STD
- age 6: CLD and STD
- age 8: CLD and STD
- age 10: CLD and STD
- age 12: CLD and STD
- age 14: CLD and STD
- age 16: CLD and STD
- age 18: CLD and STD
CERTAINLY LETHAL DOSE (CLD)
- 5-10g NaF at once for adults
- .5-1g NaF at once for children
SAFELY TOLERATED DOSE
- 1/4 of CLD
- 1.25-2.5g of NaF for adults
- age 2: 320mg and 80mg
- age 4: 422mg and 106mg
- age 6: 538mg and 135mg
- age 8: 655mg and 164mg
- age 10: 771mg and 193mg
- age 12: 931mg and 233mg
- age 14: 1206mg and 301mg
- age 16: 1338mg and 334mg
- age 18: 1382mg and 346mg
