Preventive Procedures - Outcome 6

Question 1

Fluoride - What is it?

Answer 1

• is a naturally occuring mineral known for its role in preventing dental decay
  -orginates fromthe element fluorine, which is widely found in the earth’s crust
  -fluorine forms fluoride ions that are present in minerals in soil and water (both fresh and salt)
  -weathering of rocks and volcanic activity release fluoride into the environment, leading to daily exposure through various foods and beverages

Question 2

Fluoride in Water & Food

Answer 2

-Fluoride is often added to drinking water and food supplies to enhance dental health
-when fluoride concentrations on the ename surface are optimized, they significantly boost the teeth’s resistance to cavities

Question 3

What is “Optimal” Fluoridation?

Answer 3

• refers to adjusting the fluoride concentration in drinking water to strike a balance between preventing tooth decay and minimizing the risk of dental fluorosis
• fluoride is also incorporated into various oral health products, such as toothpaste, mouth rinses and suppliments which can increase fluoride ingestion

Question 4

What is the “halo effect”?

Answer 4

-describes how foods and beverages processed in fluoridated areas can have high fluoride levels than those from non-fluoridated regions.

• ex. a study found that tea brewed in fluoridated area contained more fluoride compared to tea from a non-fluoridated area
• this effect can lead to high fluoride intake from products distributed to non-fluoridated areas, potentially skewing the overall assessment of the benefits of water fluoridation, especially in regions where such products are widely consumed

Question 5

How Fluoride is Absorbed

Answer 5

When fluoride is ingested, such as through fluoridated water or dietary sources, it is primarily absorbed in the stomach and small intestine. Approx 75% to 90% of ingested fluoride is absorbed into the bloodstream through the gastrointestinal tract. The rate of absorption can vary based on factors like the form of fluoride and the presence of other substances in the digestive system.

Question 6

Once in the bloodstream, fluoride is distributed throughout the body. It travels in the blood plasma and is either:

Answer 6

• Deposited: fluoride becomes incorporated into calcified tissues, including teeth and bones. This is where 99% of fluoride in the body is found. During periods of growth, like childhood/adolecense, fluoride is absorbed ito developing bones and teeth at a higher rate compared to mature tissue

Excreted: The body eliminates excess fluoride through various routes

Question 7

Excretion of Fluoride

Answer 7

Fluoride is mainly excreted through urine. Additionally, small amounts are lost through:
-Perspiration
-Saliva
-Breast Milk
-Feces

Question 8

How Fluoride Helps Prevent Dental Caries

Answer 8

It protects the teeth through 2 main methods:

-Systemic Fluoride - This involves fluoride being ingested and then incorporated into developing teeth via the bloodstream

-Topical Fluoride - This involves fluoride being applied directly to the surface of erupted teeth

Question 8

Systemic Fluoride

Answer 8

Systemic fluoride is ingested and becomes part of the tooth structure during development. When fluoride is regularly consumed during tooth formation, it is incorporated into the tooth structure, providing long-term protection against decay.
Ingested fluoride also provides topical protection by being present in the saliva, which continually bathes the teeth and helps with remineralization.

Question 8

Sources of systemic fluoride include:

Answer 8

-fluoridated water
-fluoridated salts
-dietary fluoride supplements (eg. tables, drops, lozenges)
-fluoride in food and beverages

Question 9

Mechanism of Systemic Fluoride

Answer 9

-fluoride integrates into the enamel’s crystal structure, transforming hydroxyapatite into fluorapatine
-fluorapatite is more resistant to acid attacks compared to hydroxyapatite.
- this makes enamel less soluble to cids, thus reducing decay
-however, the presence of fluorapatite is relatively minor, and fluoride uptake is dependent on the exposure duration and amount

Question 10

Topical Fluoride

Answer 10

is applied directly to the teeth and strengthens enamel already in the mouth

Question 11

Topical Fluoride works in several ways:

Answer 11

-Inhibits Bacterial Activity: Fluoride disrupts bacterial metabolism and reduces the ability of bacteria, like Strep mutans, to produce acids

Inhibits Demineralization: Fluoride creates a stronger enamel surface that resists acid dissolution and helps in the uptake of fluoride by demineralized enamel

Enhances Remineralization:
Fluoride accelerates the natural process of remineralization, where minerals lost during demineralization are replaced. This helps strengthen enamel and make it more resistant to future decay.

Question 12

Examples of topical fluoride sources:

Answer 12

-Toothpaste
-Mouth rinses
-Professional fluoride gels and varnishes
-Dental sealants and restorative materials
-Dental floss
-chewing gums
-professional dental prophylaxis pastes

Question 13

Mechanism of Topical Fluoride

Answer 13

-integrates into the enamel and helps reduce the effects of acid produced by bacteria
-fluoride binds to enamel, making it more resistant to acide attacks by aiding in the repair of early carious lesions.
- it enhances the natural remineralization process by recombining calcium and phosphorus from saliva

Question 14

Dental Fluorosis

Answer 14

• occurs when excessive fluoride is ingested during the formative years of tooth enamel, leading to permanent enamel changes
• can cause white spots or streaks on the teeth anad in severe cases, pitting and staining

-Enamel formation for most teeth occurs from birth until about the age of five

• once enamel formation is complete, fluorsis cannot develop, making older children and adults not at risk

Question 15

Summary of Fluoride’s Mechanisms

Answer 15

1. Pre-eruptive: reduces enamel solubility to acids by incorporating fluoride into hydroxyapatite crystals
2. Post-eruptive: inhibits bacterial acid production, reduces demineralization, and promotes remineralization of early carious lesions

Question 16

Topical Vs. Systemic

Answer 16

Fluoride’s preventive effects on dental caries are maximized when it is available both systemically (during tooth development) and topically (after tooth eruption).

Question 16

Fluoridation of public drinking water

Answer 16

• is a well established method for preventing tooth decay and is supported by extensive scientific research
• for over 50 years, fluoridated water has been used globally
• CDC states that daily, low level exposure to fluoride from drinking water is the most effective way to prevent dental decay across all age groups

Question 17

Studies - % of tooth decay

Answer 17

CHMS reveals that..

• 56.8% of Candian children aged 6 to 11
  -58.8% of adolescents aged 12 to 19

…have experienced dental caries.

Nearly 96% of Canadians will encounter tooth decay by adulthood

Question 18

Fluoridation and lower socioeconomic communities

Answer 18

Fluoridation also helps reduce dental health disparities among different socioeconomic groups. Studies show that water fluoridation has a more significant impact on communities with lower socioeconomic status, where the difference in tooth decay between fluoridated and non-fluoridated areas is more pronounced. This benefit is crucial for those who may lack access to other fluoride sources or professional dental care.

Question 19

Optimal concentration of fluoride in drinking water

Answer 19

• in Canada, optimal concentration is 0.7 mg/L to maximize benefits while minimizing the risk of dental fluorosis
• maximum allowable concentration is 1.5 mg/L to prevent potential health risks

At recommended levels, fluoride in drinking water does not pose health risks.

Question 20

Antifluoridation Arguments

Answer 20

-opponents of water fluoridation often argue that it represents unnecessary government intervention or overspending

while some have raised concerns about potential health risks, scientific studies have not found credible evidence linking optimal levels of fluoridation (0.7ppm) to adverse health effects

Question 21

Fluoride supplements

Answer 21

• for communities without fluoridated water, fluoride supplements can provide necessary fluoride.
• CDA recommends supplements primarily for children at high risk for dental caries, considering their age, physical development and fluoride levels in the local drinking water

Question 22

Fluoride and Pregnancy

Answer 22

-Fluoride is classified as a Category C drug by FDA, indicsting while animal studies show adverse effects, there are no well-controlled studies in preganant women

-Fluoride may be recommended to manage dental issues related to severe gastric reflux during pregnancy, but topical fluoride varnish is preferred due to lower nausea risk

• Breast milk contains low levels of fluoride, but fluoride from fluoridated water used in infant formula can benefit infant’s dental health. Health Canada regulates fluoride levels in commercial infant formulas to ensure appropriate fluoride intake

Question 23

Professionally Applied Fluoride Compounds

Answer 23

• dental pros use high concentration fluoride treatments to prevent decay, promote remineralization and reduce tooth sensitivity

Question 24

Fluoride Gel & Foams

Answer 24

• often have acidic pH to enhance fluoride absorption into enamel.

Available gels include:
-Acidulated phosphate fluoride (1.23% or 12300 ppm fluoride)
-Sodium Fluoride (2% or 90,40 ppm fluoride)
-Stannous fluoride (0.15% or 1000 ppm fluoride)

Clinical evidence supporting the effectiveness of fluoride foams is limited

Question 25

Fluoride Varnish

Answer 25

Applied directly to teeth

-maintains a high fluoride concentration in contact with teeth for extended periods

• it is effective in preventing caries and has practical advantages, including ease of application and less fluoride requirement compared to gels

Question 26

Fluoride Prophylaxis Paste

Answer 26

• used during polishing, this paste contains 4000 to 20000 ppm fluoride
• helps restore fluoride levels on the enamel surface but is not a substitute for fluoride gels or varnishes for high-risk individuals

Question 27

Self-Applied Fluoride Compounds

Answer 27

• like tooth paste and mouthrinses
  -increase intral-oral floride levels, primarily through topical mechanisms.
  -gels and high concentration toothpaste also help to inhibit bacterial enzymes

Silver Diamine Fluoride (SDF): A colorless solution containing silver, fluoride, and ammonia, SDF arrests carious lesions and reduces dentinal hypersensitivity. Approved by the FDA in 2014 and Health Canada in 2017, it has gained recognition for its effectiveness in caries managemen

Question 28

Who Should Receive Topical Fluoride?

Answer 28

Topical fluoride should not be applied routinely. Instead, it should be used based on an individual’s caries susceptibility and sensitivity, with a personalized preventive care plan.

Question 29

Assessment for Fluoride Needs

Answer 29

A Fluoride Needs Assessment or Caries Risk Assessment determines the need for fluoride therapy and helps choose the appropriate fluoride treatment.

Question 30

When to Use Fluoride Gels and Varnishes

Answer 30

Moderate to High Risk: Both fluoride gels and varnishes are recommended for individuals at moderate to high risk of dental decay. Due to a lower risk of dental fluorosis, fluoride varnishes are preferred for children under 6 years old.

SAIT Dental Clinic: Both fluoride gels and varnishes are utilized to prevent tooth decay.

Question 31

Professional Application Guidelines

Answer 31

Low Risk: Fluoride application may not be necessary.

Moderate Risk: Apply fluoride every 6 months.

High Risk: More frequent applications (every 3 to 6 months) may be needed

Question 32

Contraindications for Topical Fluoride Application

Answer 32

1. Hypersensitivity to Fluoride - no confirmed allergic reactions to fluoride itself but sensitivities to other components in topical fluoride products (like flavorings, colorings, or colophony/rosin in varnishes) can occur A thorough health history should be taken to identify any known allergies before administering fluoride.
2. Ulcerative Gingivitis and Stomatitis - Fluoride varnish should not be applied to individuals with ulcerative gingivitis or stomatitis, or on large open lesions. An intra-oral examination is necessary to identify any large lesions before applying fluoride varnish.
3. Sealants and Porcelain/Composite Restorations - Acidulated phosphate fluoride (APF) can etch porcelain and composite restorations. For patients with these restorations or sealants, neutral sodium fluoride (NaF) should be used to prevent damage. An intra-oral check should be conducted to identify any porcelain or tooth-colored restorations before using APF fluoride.
4. Children - To avoid unintentional ingestion and the risk of dental fluorosis, fluoride rinses and topical gels should not be used at home by children under 6 or those with oral/facial musculature problems. For toothpaste use:

Children under 2: Use a smear of toothpaste.
Children 3-5 years: Use a pea-sized amount.
Children should be instructed not to swallow toothpaste and to rinse and expectorate after brushing

Question 33

Contraindications for Topical Fluoride Application

Answer 33

1. Hypersensitivity to Fluoride
2. Ulcerative Gingivitis and Stomatitis
3. Sealants and Porcelain/Composite Restorations
4. Children

Question 34

Fluoride Safety

Answer 34

Fluoride is beneficial in small amounts but can be harmful if ingested in large quantities. Familiarize yourself with recommended procedures, potential toxic effects, and general emergency protocols

Question 35

Factors Contributing to the Effectiveness of Topical Fluoride in Preventing Dental Caries

Answer 35

1. Concentration Factor
2. Reaction (Exposure) Time Factor
3. Frequency of Application

Question 36

Effectiveness of Topical Fluoride - Concentration Factor

Answer 36

Topical fluoride products contain much higher concentrations of fluoride compared to fluoridated community water. This higher concentration helps enhance caries prevention.

Question 37

Effectiveness of Topical Fluoride - Reaction (Exposure) Time Factor

Answer 37

The time that fluoride remains in contact with tooth enamel affects its effectiveness. Longer contact time allows more fluoride to be absorbed. Professional fluoride gel treatments typically last 4 minutes. Shorter application times, such as 1 minute, are common but have not been thoroughly tested in clinical trials for their efficacy.

Question 38

Effectiveness of Topical Fluoride - Frequency of Application

Answer 38

Fluoride Gels:
-The optimal frequency for fluoride gel applications is not well-established, with studies showing mixed results. Generally, fluoride gel is applied every 6 to 12 months.
-Since applications are infrequent, the risk of enamel fluorosis is low, even for children under 6 years. Proper application technique helps prevent swallowing of the gel.

Fluoride Varnishes:
- applied semiannually, are as effective as fluoride gels. Some experts recommend applying varnish up to four times a year, but evidence supporting more than two applications per year is limited.
-There is no evidence linking fluoride varnish with an increased risk of enamel fluorosis, even in children under 6 years. The varnish is applied in a way that minimizes the risk of swallowing.

Question 39

To support decision-making on type of fluoride to use, dental healthcare professionals should…

Answer 39

Regularly perform a Caries Risk Assessment or Fluoride Needs Assessment for each patient.

After completing the assessment, the Dentist or Dental Hygienist will decide on the appropriate fluoride treatment, including the type, frequency, and timing of re-evaluation

Question 40

Fluoride for patients at low risk for dental caries..

Answer 40

maintaining this low risk can be achieved through regular exposure to small amounts of fluoride, such as from drinking fluoridated water, using fluoride toothpaste, and practicing good oral hygiene.

Question 41

Fluoride for patients at moderate to high risk of caries..

Answer 41

professionally applied fluoride products can be beneficial. All relevant risk factors should be considered to accurately determine

Question 42

Fluoride Gel Effectiveness

Answer 42

High Effectiveness: Fluoride gel is proven to be effective in preventing and controlling dental caries, especially in children. Studies show it significantly reduces the incidence of new cavities when used as recommended. It works by enhancing the tooth enamel’s resistance to decay and promoting remineralization.

Evidence: Most high-quality evidence for fluoride gel comes from well-conducted randomized clinical trials. However, historical studies were done when caries rates were higher, which might affect current applicability.

Question 43

Fluoride Varnish Effectiveness

Answer 43

High Effectiveness: Fluoride varnish is also highly effective in caries prevention and control. It is particularly useful for children and individuals at higher risk of caries. The varnish provides a concentrated fluoride application that remains in contact with the teeth longer than other methods.

Evidence: Strong evidence supports the use of fluoride varnish, with studies showing it reduces caries rates significantly. This evidence is consistent across different regions, including Europe, the U.S., and Canada.

Question 44

Fluoride Toothpaste Effectiveness

Answer 44

Very Effective: Regular use of fluoride toothpaste is highly effective in preventing dental caries. It helps by increasing fluoride levels in the mouth, which strengthens enamel and aids in the repair of early carious lesions.

Evidence: Numerous studies have confirmed the effectiveness of fluoride toothpaste in reducing caries incidence. The consistency and quality of these studies support its widespread use.

Question 45

Fluoride Rinses Effectiveness

Answer 45

Moderately Effective: Fluoride rinses can reduce caries risk, particularly in individuals at higher risk. They are often used as an adjunct to other fluoride treatments but are generally less effective than gels and varnishes.

Evidence: Evidence supports the use of fluoride rinses, though they are less impactful compared to more concentrated fluoride treatments.

Question 46

Silver Diamine Fluoride (SDF) Effectiveness

Answer 46

Effective for Arresting Caries: SDF is effective in halting the progression of dental caries, especially in high-risk populations. It is particularly useful for arresting carious lesions rather than preventing new ones.

Evidence: Recent studies have shown that SDF is effective in caries management and is increasingly accepted as a viable treatment option.