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04-14-08 Application of F and CaP
04-14-08 Application of F and CaP
14 April 2008
Outline
Delivery means of fluoride as caries preventive agents
Effectiveness of fluoride
CPP-ACP
Consideration for clinical use
Risk factors for fluorosis
Sample questions
Objectives:
Rationale for clinical use of fluoride and calcium phosphate
Risk factors for development of dental fluorosis
community approach
Individual-based
Fluoride supplements
Individual-based
Water, salt, milk, sugar fluoridation and fluoride supplements are in the systemic category. Topical
fluoride application includes professionally-applied fluoride in various forms and over-the-counter
products. Fluoride containing restorative materials can be classified as topical form of fluoride as well.
Some of these fluoride preparations are community approach, some are individual base, and some has to
be delivered by dental personals. They are different in the effectiveness and cost-benefit ratio.
Note: Fluoride works best to prevent/control smooth surface caries, but not as effective on occlusal caries.
Effectiveness of fluoride products
Effectiveness of Fluoride
Water fluoridation
High caries prevalence : 40-60 %
Low caries prevalence & use of other F-products: ~ 20%
Ripa LW. J Dent Res 1990;69(Spec Iss):786-796.
Fluoridated toothpastes
Prevented Fraction 24 % regardless of fluoridated drinking water.
Cochrane Database of Systematic Reviews 2003
Clinical studies showed caries preventive effect of F-toothpaste to be about 24 % regardless of whether
their drinking water is fluoridated. In addition, the cariostatic effect in life-long use in population may
be much greater due to the cumulative effect.
Fluoride mouthrinse is another form of topical F application that can be prescribed or bought over-thecounter. Fluoride compounds used are NaF, SnF2, amine fluoride. Because of the risk of fluoride
ingestion, fluoride rinses are not recommended to children under the age of 6 years. High concentration
rinses, e.g., 0.2% NaF (920ppm F), are used in supervised, school-based weekly rinsing programs or
prescribed for those with high caries risk. Over-the-counter fluoride rinses are for daily basis, such as
0.05% NaF (230 ppm F) in ACT. The efficacy is highly influenced by caries risk, dental awareness, and
access to dental care. Systematic review of F-mouthrinses revealed limited evidence for the cariespreventive effect (PF 29%) of daily or weekly sodium fluoride rinses compared with placebo in permanent
teeth of schoolchildren and adolescents with no additional fluoride exposure and for a caries-preventive
effect on root caries in older adults.
Effectiveness of Fluoride
Fluoride gels
2425 ppm F (SnF2), 1.23% APF
Prevented Fraction 28 %, independent of F toothpaste or F water
Fluoride varnishes
Highest F concentration (5%) among F-containing product
Prevented Fraction 30-46 %, independent of F toothpaste or water
Cochrane Database of Systematic Reviews 2003
However, the amount of F ingested from F varnish is not high due to the small amount applied. Metaanalysis study indicated caries reductions of 30-46% independent of F-toothpaste or fluoridated water.
F-containing restorative materials. Fluoride can be released from restorative materials as part of the
setting reaction or it may be added to the formulation with the specific intention of fluoride release. Glass
ionomer cements may be the only reliable product in terms of fluoride release and substantial clinical
effect. Why do we need F-containing restorative materials? Because secondary caries is the main reason
for restoration failure. The anticariogenic effect of glass ionomers is remarkably crucial in high-risk cases
such as in xerostomic patients who did not routinely use topical fluoride (less compliance).
Milk protein derivative CPP-ACP
Anticariogenic properties of milk and dairy products are known. Studies by the University of Melbourne
in Australia showed that a particular part of the casein protein in milk, the casein phosphopeptides (CPP),
was responsible for the anticariogenic properties. Casein phosphopeptides can stabilize amorphous
calcium phosphate (ACP) in a solution. CPP binds well to dental plaque. By doing so, calcium and
phosphate ions are localized in dental plaque at higher concentration, thus inhibit demineralization and
promote remineralization.
2
A sugar-free chewing gum with CPP-ACP significantly increased enamel remineralization compared to
control. Tradename of CPP-ACP is Recaldent. Manufacturers have incorporated Recaldent in various
products, range from consumer products like chewing gum, to a dentist-prescribed Ca/P topical cream, MI
paste. The MI paste is recommended to use in patients with erosion, active caries, or xerostomia.
Milk Protein Derivative CPPCPP-ACP
100%
Reynolds EC et al.
J Clin Dent 1999;10:86-8.
CPP-ACP
Tradename:
Recaldent
Which
method?
Cost-Benefit
ratio
Save 0.055
DMFS per year
Dental fluorosis
Cost-benefit ratio should be considered. This is related to caries risk. In many European countries
without water fluoridation, children maintain their low caries prevalence just by using fluoride toothpaste.
Therefore in the area with water fluoridation plus children use fluoride toothpaste, additional fluoride
supplement is not recommended.
For example, a recent reviews show that twice a year application of fluoride gel reduced caries 22 %. In
low caries population, a mean caries incidence can be 0.25 DMFS per year. This means that 22%
reduction save 0.055 DMFS per year, therefore the cost-benefit ratio is unfavorable in this group.
Fluoride safety: The amount of fluoride exposed and the related safety is one of the most important
issues. Acute toxicity should not happen in normal practice. Chronic toxicity or long-term effect in terms
of dental fluorosis is more likely to occur, especially by multiple F exposure.
13 %
Nonfluoridated population
F supplement: (pre-1994)
Year 1
Year 2-8
Tooth brushing:
29 %
65 %
Tooth brushing:
46 %
34 %
22 %
8%
pea-sized &
> once per day
2%
Began after Y 2
> once per day
6%
45 %
Formula (powder
concentrate)
9%
Formula feeding
In the optimally fluoridated community, the highest attributable risk is using more than pea-size amount of
toothpaste in young children. If the pea-size amount of toothpaste was used, the attributable risk is small
even the child brushed more than once per day. Also noted that formula reconstituted with fluoridated
water contributed to 9 % of the attributable risk.
In the non-fluoridated community, the highest attributable risk is fluoride supplement. But that was before
the recommendation was changed to the current one. The next highest attributable risk is using more than
pea-size amount of toothpaste in young children, and the frequency of brushing in toddler.
Risk factors for dental fluorosis
A study found that about 34% of fluorosis cases in non-fluoridated area were associated with children
younger than 2 years old using F toothpaste. And 68% of the fluorosis cases in areas with optimally water
fluoridation were from children younger than 1 year old ingested F toothpaste. Odds ratio for risk of
developing fluorosis with the use of F-toothpaste is 1.6-1.8.
Fluoride supplements
dental fluorosis
no dental fluorosis
If a child (5 kg,10 lb, ? < 1 year old) is given 0.5 mg F = 0.1 mg/kg
Ingesting 0.1 mg/kg can raise plasma F level to exceed 0.2 ppm
Animal studies showed a threshold plasma F level for dental fluorosis. One spike of 0.2 ppm/day for 1
week can cause dental fluorosis. One or two spikes of 0.1 ppm/day for 1 week is fine. If a child (5
kg,10 lb) is given 0.5 mg F, equivalent to 0.1 mg/kg, plasma F can exceed 0.2 ppm, a threshold level that
can cause dental fluorosis.
Recommended Dietary Fluoride Supplement Schedule
Fluoride concentration in community drinking water
Age
0.3-0.6 ppm
None
None
None
6 months 3 years
0.25 mg/day
None
None
3 6 years
0.50 mg/day
0.25 mg/day
None
6 12 years
1.0 mg/day
0.50 mg/day
None
0 6 months
13 %
Nonfluoridated population
F supplement: (pre-1994)
Year 1
Year 2-8
29 %
65 %
My Waters Fluoride
National Center for
Chronic Disease
Prevention and Health
Promotion, CDC
The amount of fluoride a child receives on a daily basis has to be known before prescription of fluoride
supplement. How much fluoride is in my water? The information of community water fluoridation level
in the US can be found at http//apps.nccd.cdc/gov/MWF/Index.asp, a website of the National Center for
Chronic Disease Prevention and Health Promotion, Center for Disease Control and Prevention. (My
Waters Fluoride, Oral Health Resources). Example of Minneapolis as of April 13, 2008.
Where to send water to test fluoride content?
Fluoride Testing Service
School of Dentistry, University of Minnesota
Order water kit box from: Doug Magne 612-624-9123
Dr. Robert Ophaug 612-625-5198
According to the supplementation schedule for the effective F concentration, the child does not need any F
supplement. However, if you base the recommendation according to home water fluoride level alone, the
child will get 0.5 mg F supplement, which will be too much and increase risk of dental fluorosis.
Fluoridated water
Drinking optimally F water by itself is not a risk factor
Most bottled waters < 0.3 ppmF
Home filtration (distillation/reverse osmosis) removes > 90% F
Aquafina
0.05 ppm
Crystal
0.24 ppm
Dannon
0.11 ppm
Dannon Fluoride To Go
0.78 ppm
Dasani
0.07 ppm
Perrier
0.31 ppm
Risk factor - Fluoride in water: Drinking optimally F water by itself is not a risk factor for dental
fluorosis. A person lives in a community without water fluoridation can get fluoride in drinking water
from other sources such as child care or school. There is also a halo effect from water fluoridation
somewhere else. Now we also drink a lot of bottle waters, most of them contain less than 0.3 ppm, but
10% contain close to 0.7 ppmF. Home filtration systems (distillation and reverse osmosis) remove 90 %
or more F from water, but the carbon/charcoal systems do not. Juices had upto 2.8 ppm F, 42% had more
than 0.6 ppm. Fluoride level in soft drinks ranged from 0.02 to 1.28 ppmF depend on the plant they were
made. Overall, 77% of soft drinks had more than 0.6 ppmF.
There is a concern that caries increase with the increase consumption of bottled water. These are some
data of fluoride content in bottled water from an USDA website. A distillation or reverse osmosis
removed fluoride from water, so most of the bottled water does not have optimal level of fluoride. Some
bottled water has added fluoride, for example, Dannon F to go.
U.S. Food and Drug Administration's health claim notification October 14 , 2006 allowing bottlers to
claim that fluoridated water may reduce the risk of dental cavities or tooth decay. This one, which have
the picture of baby in the label has worried me, although it probably the best option in community without
fluoridated water. It is good for children and adults, but we should be aware that FDA does not allow
bottlers to make the claim for products specifically marketed for use by infants.
Risk factor - Infant formula reconstituted
with fluoridated water:
Note: Infant chicken product can have 8 ppm F; 20 times higher than infant fruit
Breast milk and cow milk are very low in fluoride (0.01-0.04 ppm). Infant formula used to have high
fluoride content. In the 80s US manufacturers voluntarily reduced F in infant formula to 0.15 to 0.3 ppm.
In November 2006, ADA has issued an Interim
Guidance on Fluoride Intake for Infants and Young
Children, stated that for infants who get most of
their nutrition from formula during the first 12
months, ready-to-feed formula is preferred to help
ensure that infants do not exceed the optimal
amount of fluoride intake. If liquid concentrate or
powdered infant formula is the primary source of
nutrition, it can be mixed with water that is fluoride
free or contains low levels of fluoride to reduce the
risk of fluorosis.
Recommended references
1. Brambilla E. Fluoride - Is it capable of fighting old and new dental
diseases? Caries Res 2001;35(suppl 1):6-9.
2. Ripa LW. An evaluation of the use of professional (operator-applied)
topical fluoride. J Dent Res 1990;69(Spec Iss):786-796.
3. Zimmer S. Caries-preventive effects of fluoride products when used in
conjunction with fluoride dentifrice. Caries Res 2001;35(suppl 1):18-21.
4. Warren JJ, Levy SM. Systemic Fluoride. Sources, amounts, and effects
of ingestion. Dent Clin N Am 1999;43:695-711.
5. Bowen WH. Fluorosis. Is it really a problem? J Am Dent Assoc
2002;133: 1405-1407.
6. Pendrys DG. Risk of enamel fluorosis in nonfluoridated and optimally
fluoridated populations: considerations for the dental professional. JADA
2000;131:746-755.