Non-Water Community Fluoride Delivery

Question 1

What is the primary mode of action of fluoride?

Answer 1

• topical
  
  • post eruptive involvement
  • dynamic process of de/remineralisation

Question 2

How does fluoride prevent caries?

Answer 2

• formation of fluoroapatite
  
  • less susceptible to demineralisation
  • promotes remineralisation
• bacteriostatic effect
  
  • interferes with metabolic pathways
  • less acid produced

Question 3

What are the oral reservoirs for fluoride?

Answer 3

• oral reservoir
  
  • fluoride from toothbrushing disappears quickly
• 2 broad types of oral reservoir
  
  • mineral deposits
    - CaF2, FAP
    - CAF2 in saliva and fluid phase of plaque
  • biologically/bacterially bound
    - calcium fluoride

Question 4

What different types of fluoride therapy exist and what settings are they delivered in?

Answer 4

• community
  
  • water
  • school based brushing
  • varnish
• in office
  
  • varnish
  • gels and foams
  • slow release
• home
  
  • toothpaste
  • mouthrinse
  • tablets

Question 5

What is fluoridated salt and what are the advantages and disadvantages?

Answer 5

• salt with added fluoride
  
  • F-
• requires little conscious action by individual
  
  • just required to consume product
• provides element of choice
  
  • public health effectiveness diminished
• popular in some countries
  
  • effective when no infrastructure for water fluoridation
• mixed messages from health professionals
  
  • reduce salt intake to reduce risk of cardiovascular disease
• appropriate dosages difficult to manage
  
  • variable need within geographic regions

Question 6

What is fluoridated milk and what are the advantages and disadvantages?

Answer 6

• fluoride added to milk
• public health programme
  
  • high levels of childhood caries, no alternative F- delivery
  • mainly in schools
    - only consumed around term time
    - distribution delayed until nursery/school age
    - reliant on parental consent
    - some children don’t like milk
    - enables targeted delivery
  • relies on sustained function
    - shelf life and other cost issues
    - distribution system expensive
• milk natural healthy drink
  
  • rich in nutrients
• unsure on long term benefit
  
  • limited overall evidence
  • requires more RCTs

Question 7

What are fluoride supplements and what are the advantages and disadvantages?

Answer 7

• tablets or drops containing fluoride
  
  • proven topical cariostatic benefits
  • increased risk of fluorosis
  • topical effect more important that systemic
• used for at risk children over 6 years old
  
  • additional support needs
  • special care requirements
• best used with swish and swallow procedure
  
  • crunch tablet and swirl around mouth
  • erupted teeth
• UK guidelines
  
  • 6 months-3 years
    - 0.25mg
  • 3-6 years
    - 0.5mg
  • > 6 years
    - 1.0mg

Question 8

What are fluoride mouthrinses and what are the advantage and disadvantages?

Answer 8

• fluoride containing mouthrinses for home use
  
  • daily
    - 0.05% 227ppmF
    - slightly more effective
  • weekly
    - 0.2% 909ppmF
    - more cost effective
• reduction in caries of around 30%
  
  • swishing around mouth important for efficacy
• good benefit-risk ratio
  
  • cost-benefit ratio also low
• generally good compliance

Question 9

What are acidulated mouthwashes?

Answer 9

• Low pH mouthwashes
• stimulate mild demineralisation on tooth surface
  • fluoride stimulates remineralisation
    - low pH makes fluoride more bioavailable
  • effectively gets fluoride into teeth
    - more so than non-acidulated rinses

Question 10

What are fluoride boosters?

Answer 10

• tooth mousse
  
  • contains CPP-ACP
    - not suitable for those with milk allergies
• at home application or in office application using trans

Question 11

What are acidulated phosphate fluoride gels and what are the advantages and disadvantages?

Answer 11

• professionally applied gels
  
  • can be self-applied under supervision
  • custom made tray or toothbrush
• fluoride concentration of 12,300ppmF
• applied twice a year
  - time consuming application, around 30 minutes
• acute toxicity risk
  
  • if ingested
  • sickness
  • not recommended for young children

Question 12

Which dental materials release fluoride?

Answer 12

• glass ionomer/resin modified glass ionomer
  
  • around 4 weeks from surface layer
  • slower diffusion through bulk of cement
  • small but sustained amount

Question 13

What is fluoride toothpaste and what are the advantages and disadvantaged?

Answer 13

• most widely used method of fluoride delivery
  
  • considered single most important factor in caries decline
• factors determining antiquaries activity
  
  • fluoride concentration
    - 1,450ppmF
    - 1,000-5,000ppmF depending on risk
  • frequency of application
    - twice daily
  • rinsing behaviours
    - do not rinse
    - removes excess fluoride
    - spit don’t rinse
  • when brushing takes place
    - before bedtime
  • quantity not strongly associated with efficacy

Question 14

What are the risks of fluoride use?

Answer 14

• ingestion
  
  • particularly in young children
  • systemic risk
  • acute toxicity
    - very rare
• enamel fluorosis
  
  • chronic toxicity
    - due to ingestion
  • fluoride required for fluorosis
    - ~0.1mgF/kg body weight
    - ~1mg daily for 1 year old
    - ~2mg daily for 5-6 year old
    - no lower limit for fluorosis

Question 15

How can caries benefit be maximised but fluorosis risk be reduced in young children?

Answer 15

• keep toothpaste out of reach of young children
• brush twice daily
• supervising brushing of young children
• use a pea/smear of toothpaste
• discourage swallowing
• encourage spitting to remove slurry