Fluoride use in paediatric dentistry

Question 1

3 dietary fluoride sources + examples

Answer 1

• water
• diet (fish, offal, tea)
• medicinal (OTC, prescribed)

Question 2

how much F- is ideal in water and why

Answer 2

1ppm
–> 50% less caries esp interproximal and smooth surfaces
30% less fissure caries
not enough to cause fluorosis (but can be if too much extra fluoride in diet, toothpaste etc)

Question 3

what is the critical pH for fluoride and what does this mean

Answer 3

3.5-5.5

remineralisation and demineralisation (can become encorporated in to enamel –> fluoroapatite)

Question 4

7 caries prevention strategies

Answer 4

• diet
• fluoride
• radiographs
• fissure sealants
• OH
• prevention of transmission of S mutans
• CPP-APP

Question 5

8 ways to increase F- for kids

Answer 5

• toothpaste
• mouthwash (must be at least 6yo to rinse)
• varnish (duraphat)
• drops
• tablets
• gel
• foam
• glass beads (placed subgingivally for slow release F-)

Question 6

variation in ppm F- in toothpaste

what PPM F is beneficial

Answer 6

500-1500

1000+

Question 7

fluoride supplement dose at

a. 6months-3yo
b. 3-6yo
c. 6+ yo

Answer 7

a. 6months-3yo: sodium fluoride oral drops 550mcg/ 0.15ml 7 drops daily OR half 1.1mg tablet= 0.25mg F
b. 3-6yo: sodium fluoride 1.1mg daily= 0.5mg F
c. 6+ yo: sodium fluoride 2.2mg daily= 1mg F

*halve doses if water fluoridated 0.3-0.7ppm, do not use in >0.7ppm water

Question 8

how often to apply duraphat in

a. low risk pts
b. high risk pts

Answer 8

a. low risk pts: 6 months

b. high risk pts: 3 months

Question 9

fluoride dosage per 50 mg/ml duraphat

Answer 9

5%= 22600ppm F

Question 10

how/ when to use duraphat

Answer 10

• after prophylaxis
• dry teeth only
• can be used to arrest lesions in pre-co operative pts
• refrain from eating/ drinking for 30 mins

Question 11

pts NOT to use duraphat on 3

Answer 11

• ulcerative gingivitis
• stomatitis
• history of admission to hosp bc of allergy (inc asthma)

Question 12

which topical F agent works best alone/ together

Answer 12

similar

not much advantage to using additional measures if tooth brushing with F toothpaste alone is effective

Question 13

BDH fluoride policy

Answer 13

• diet diary and sugar reducing advice
• plaque control
• fluoride sources inc local water supply and provision of additional fluoride
• pit and fissure sealant for 6s
• twice daily tooth brushing, before bed and one other occasion, supervised under 7 years, spit don’t rinse

Question 14

BDH policy for children’s brushing

a. age 0-3
b. aged 3+
c. high caries risk

Answer 14

a. age 0-3: SMEAR of 1000ppm fluoride toothpaste twice daily
b. aged 3+: PEA SIZED AMOUNT 1350-1500ppm fluoride toothpaste twice daily
plus duraphat twice yearly
c. high caries risk: duraphat every 3 months and F- mouthwash or toothpaste (prescription)

Question 15

age limit for rinsing

Answer 15

6yo

Question 16

for high risk caries, strength of F mouthwash

a. daily
b. weekly

Answer 16

a. daily: 0.05%, 10ml

b. weekly: 0.2%, 10ml

Question 17

prescription toothpaste to use when mouthwash inappropriate

a. 10+ yrs
b. 16+ yrs

Answer 17

INSTEAD OF NORMAL TOOTHPASTE

a. 10+ yrs: 2800ppm (0.619% sodium fluoride)
b. 16+ yrs: 5000 ppm (1.1% sodium fluoride)

Question 18

LEARN BDH CHILD CARIES PREVENTION FLOWCHART

2 types of fluoride overdose

Answer 18

• acute overdose

- fluorosis

Question 19

toxic dose of fluoride

LEARN TABLE

Answer 19

1mg F/ kg body weight

Question 20

lethal dose of fluoride

Answer 20

32-64mg F/kg body weight

some cases of death at 16mg F/kg

Question 21

flurodie dosage ingested by 10kg child swallowing 50g tube of 1000ppm toothpaste

Answer 21

F= 1mgx50g= 50mg
child=10kg
F dosage ingested: 50mg/10kg= 5mg/kg

Question 22

what happens with too much fluoride 3

Answer 22

• blocks cell metabolism
• interference with calcium metabolism
• nerve impulse and conduction

Question 23

signs and symptoms of fluoride overdose

Answer 23

• nausea/ vomiting/ diarrhoea
• excess savilation/ tears/ mucus/ sweat
• headache
• generalised weakness

Question 24

how to deal with F overdose 5

Answer 24

• get history
• check dose of F against packaging and check remaining vessel
• support vital signs
• management depends on dose
• as much milk as possible or milk of magnesia (anything casein-based)

Question 25

management of overdose

a. 15mg/kg

Answer 25

a. 15mg/kg: send to ED. calcium gluconate IV, activated charcoal 1g/kg (max 50g) every 4 hours, gastric lavage. life support/ cardiac monitoring

Question 26

fluorosis mechanism

Answer 26

impairs mineral acquisition of enamel

Question 27

high risk of fluorisis

a. dose
b. teeth
c. age

Answer 27

a. dose: high dose bolus or repeated low level eg India
b. teeth: central incisors
c. age: 15-30 months. not after 6yo

Question 28

appearance of fluorosis

a. mild
b. moderate
c. severe

Answer 28

a. mild: diffuse patches/ flecks
b. moderate: mottling/ striations/ yellow-brown
c. severe: enamel hypoplasia

Question 29

7 ways to prevent fluorosis/ F overdose

Answer 29

• gd history taking
• examine packaging carefully
• aim for topical rather than systemic
• avoid critical age 0-6yo
• targeted use (only high caries risk)
• good education of parents/ carers
• prescribe max 120mg supplements at any time

Question 30

% of sodium monoflurophosphate (Nampf) and ppm fluoride with sodium fluoride

a. 0.32%
b. 0.22%
c. 0.11%

Answer 30

a. 0.32%NaF: 1.14%Na mfp, 1500 ppm F
b. 0.22%NaF: 0.76%Na mfp, 1000 ppm F
c. 0.11%NaF: 0.38%Na mfp, 500ppm F

Question 31

management of F overdose 5-15mg/kg

Answer 31

send to ED

–> milk, observe vital signs, gastric lavage (stomach pumped)

Question 32

managemnt of F overdose >15mg/kg

Answer 32

ED
calcium gluconate IV
activated charcoal 1g/kg every 4 hours, gastric lavage
life support/ cardiac monitoring