The role of fluoride in caries prevention Flashcards

1
Q

what are the diff ways to target the population

A

population
community level
individual level

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2
Q

What are the fluoride therapy settings

A

community
in clinic
at home

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3
Q

What fluoride therapy can be done in the community

A
○ Water
		○ School based brushing (childsmile)
		○ Varnish
		○ Salt
		○ Milk
		○ Tablets
		○ Rinsing 
In clinic
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4
Q

What fluoride therapy can be done in clinic

A

○ Varnish
○ Gels and foams
○ Slow release
SDF (newly come in with covid)

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5
Q

What fluoride therapy can be done at home

A

○ Toothpaste
○ Mouthrinse
○ Tablets

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6
Q

How does fluoride prevent caries

A
  • Fluoride present in fluid at the plaque/tooth interface promotes remineralisation
  • Fluoro-apatite formed is less susceptible to demineralisation
  • Topical effect is greater than systemic
  • Fluoride may also have an effect on bacteria and metabolic pathways resulting in less acid being produced
  • Maintain elevated oral levels of fluoride for as long as possible (little and often)
  • Fluoride is the most effective on early lesions
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7
Q

Describe the oral reservoir for fluoride

A

• The oral reservoir is small
• Fluoride from toothbrushing disappears quickly
• Oral reservoirs consist of 2 main types
○ Mineral deposits (Calcium fluoride:fluoroapatite)
§ Calcium fluoride is found in saliva and fluid phase of plaque
○ Biologically/bacterially bound calcium fluoride

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8
Q

What is the aim for fluoride in the oral reservoir

A

• The aim is to maintain cariostatic levels of fluoride in oral fluids so that is the key goal for manufacturers of dental products

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9
Q

What is more effective, topical or systemic

A
  • Generally agreed that main effect is topical and this is important with caries
    • Water fluoridation is effective as universal and passive
    • Dentifrice use should be encouraged and should be optimised through simple advice and education
    • Public health vs. personal interventions
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10
Q

What is the method of delivering fluoride in oral care products

A

• Toothpaste
• Mouth rinses
• Varnishes and gels
Tablets

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11
Q

What is water fluoridation

A

• This is when the community water supply is adjusted so the fluoride content is 0.8-1.0ppm (natural water also contains fluoride)
○ 1ppm reduces the caries risk and has minimal fluorosis risk
• Occurs in some areas in England
• Despite fluoride being more effective topically, water fluoridation is still relevant as when water is ingested, the fluoride is incorporated into saliva meaning saliva will contain more frequent amounts of saliva

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12
Q

What are fluoride tablets

A

• Clinical trails showed reductions in caries increments but studies were flawed in design
• The best outcomes result from
○ Chewing, swishing of the tablet prior to swallowing
○ Teeth are already erupted
• Not a public health measure
• It may be applicable to high risk children

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13
Q

What is the dosage for fluoride tablets

A

• The dosage is
○ 6 months to 3 years = 0.25mg
○ 3-6 years = 0.5mg
○ >6 years = 1 mgF

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14
Q

When are fluoride tablets used

A

• Systemic method of delivery
• Poor risk benefit balance
• Can be useful for compliance issues with more vulnerable children
Generally from a dental public health perspective and a efficacy and safety perspective it is not recommended

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15
Q

What are fluoride mouth rinses available as

A

• Commonly available for home use as
○ Daily - low concentration of 0.05%
Weekly - higher concentration of 0.2%

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16
Q

What fluoride mouth rinse is more effective

A

daily but more expensive

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17
Q

What has to be done for fluoride mouth rinse to increase efficacy

A

swishing around the mouth

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18
Q

What is fluoride varnish

A

• Fluoride varnish is a means of delivering high volume concentration of sodium fluoride to the tooth surface
The varnish is able to set and get a sustained contact that aids in efficacy against caries prevention
high fluoride conc

19
Q

Who can fluoride varnish be applied by

A

dentists

DCP

20
Q

How does fluoride varnish work

A

○ Colophony resin hardens in contact with saliva to maintain contact of fluoride with the tooth
○ This allows mobilisation of calcium ions into the enamel surface of the tooth and a precipitation of calcium fluoride onto the tooth surface
These deposits of calcium fluoride can release fluoride into the oral environment over a period of time

21
Q

What is the kinetics of fluoride absorption

A
  • Rapid absorption on tooth surface (enamel and dentine)
    • Increase in fluoride content of enamel up to 77% after a single application
      Progressive release of fluoride over several months
22
Q

How does calcium fluoride work

A

• During acid attack pH falls
• Fluoride products have greater bioavailability at a lower pH
As the pH lowers, fluoride ions are released into the oral environment and these help help remineralisation

23
Q

What are acidulated mouth rinses

A

• Low pH
• Stimulate mild demineralisation on tooth surfaces
• Presence of fluoride aids remineralisation and also the low pH increases the bioavailibility of fluoride
Effective way of getting fluoride into the tooth more so than non acidulated rinses

24
Q

What are fluoride boosters

A

• Casein phosphopeptide - amorphous calcium phosphate (CPP-ACP)
• Not suitable for milk allergies
• Used to be adjunct to fluoride but now supplied with fluoride
• Can be used at home or in office trays
• Useful in markets with no access to high fluorides
Systematic reviews indicate more research needed

25
Q

Describe fluoride release from GI /RMGI

A

○ ‘early washout’ - 4 weeks from surface layer (early release)
○ Slower diffusion through bulk cement
○ Actual amount is very small but sustained which is the goal of fluoride delivery
○ Evidence says that glass ionomer can be recharged with fluoride but still unsure
The evidence of clinical benefit still is not that much

26
Q

What is the effect of fluoride at the tooth surface

A
  • The presence of fluoride during caries alters the demineralisation/remineralisation dynamic
    • Partially demineralised crystals act as nucleators
    • Fluoride ions are adsorbed to the crystal surface
    • They attract calcium and phosphate so a new mineral is formed
27
Q

What do the principal mechanism of fluoride in caries control rely upon the presence of

A

○ Fluoride in saliva
○ Fluoride at plaque fluid and tooth interface
Fluoride in fluids around lesion mineral crystals

28
Q

What is the effect of fluoride at the tooth surface optimized by

A

○ Delivery of fluoride to tooth surface, plaque and plaque fluid
§ Remember the size of the oral reservoir and ‘fluoride boosting’
Maintaining fluoride levels (frequency of exposure)

29
Q

What are factors that determine the antiquaries activity of fluoride toothpaste

A

• Fluoride concentration
• Frequency of application
• Rinsing behaviours
When brushing takes place

30
Q

What is the effect of fluoride concentration

A

• 6-7 percent reduction in caries for every 500 ppm F increase in fluoride concentration
• Use of low fluoride formulations provide less anticaries benefit.
Choice of toothpaste depends on careful risk benefit assessment.

31
Q

What is the effect of frequency of application

A

More frequent brushing results in lower caries increments

32
Q

What is the effect of rinsing behavior

A

• Rinsing with a large volume of water removes excess fluoride and reduces fluoride in the mouth
Rinsing with small volumes of water removes excess fluoride and maintains fluoride in the mouth

33
Q

What is the effect of brushing habits

A

If someone brushes twice daily, doesn’t rinse using a beaker and uses 1500ppm toothpaste they will have a lower caries incidence than someone who does the opposite to these things

34
Q

What is the effect of toothpaste quantity

A

• Quantity of toothpaste does not have a strong effect on efficacy
Not a great difference in caries prevention

35
Q

What is the negatives to fluoride

A

• Efficacy of fluoridated toothpaste is clearly demonstrated
• The higher the fluoride content the greater the caries prevention
• Despite being topical, it is inevitable that there may be ingestion particularly in the young and this increases risk of enamel fluorosis
Therefore there should be a risk/benefit assessment between caries prevention and fluorosis risk

36
Q

What is the risk of fluoride use

A
• Risk results from ingesting fluoride
		○ Acute toxicity
			§ Very rare
			§ Generally potential problem in very young
		○ Chronic toxicity (fluorosis)
			§ Development defect in enamel
37
Q

What is the amount that is toxic for fluoride use

A

• The general consensus is that 0.1mg f/kg body weight is toxic
○ 1mg per day for a 1 year old
○ 2mg per day for 5-6 year old

38
Q

What is the limit for fluorosis

A

• Some say it is still possible to develop fluorosis at recommended daily intakes of 0.05-0.07 mg f/kg
• There is no lower limit below which fluorosis does not occur
There appears to be a dose response between fluoride exposure and fluorosis severity

39
Q

How is ingestion of fluoride minimized

A
  • The bioavailibity of fluoride ingested from dentifrices is affected by stomach contents as stomach is a low pH so more bioavailable
    • Gastric absorption is rapid and complete in the absence of divalent and trivalent cations
    • Calcium, magnesium and aluminium form less soluble salts with reduced gastric absorption
40
Q

What are considerations regarding topical fluoride

A
  • Quantity of toothpaste applied is not strongly associated with efficacy
  • Efficacy is primary concentration, not dose dependent as oral fluoride reservoir is small
  • Brush after meals - most effective at time of cariogenic challenge as pH is lower and if the fluoride is ingested then less is absorbed in the stomach but need to be careful as brushing is abrasive and you would be brushing a partially demineralised surface
  • Brush before bedtime - salivary flow rate is reduced so increased oral retention
  • Anti caries benefit is topical not systemic
  • Increased risk of developing fluorosis is systemic
  • Methods favouring topical delivery whilst minimising ingestion will have the best risk/benefit profile
41
Q

What can we do to maximize caries benefit but reduce fluoride risk in children

A
  • Keep toothpaste out of reach of young children.
    • Brush frequently (twice daily: evening and one other time).
    • Supervise brushing by young children.
    • Use a small amount (pea/smear) of paste.
    • Discourage swallowing
    • Brush after meals to minimize effect of fluoride ingestion.
    • Encourage spitting out, remove slurry: avoid excessive rinsing.
    • Use a lower fluoride formulation if low caries risk, maximize fluoride concentration in relation to risk
42
Q

Where is community level prevention done

A

• Schools, nurseries, play groups
• Community groups, housing estates, local authority
○ Community health professionals (health visitor, DHSW, school nurse)
○ Local GMP surgery
○ Health centres
○ Shops
○ Shopping centres

43
Q

What are the community prevention tools

A
○ Fluoride 
			§ Tooth brushing schemes
			§ Fluoride varnish
		○ Diet 
			§ Healthy eating policies
			§ Free water/milk
			§ No sugary drinks
		○ Community at large
			§ Posting toothpaste home
			§ Out reach activities