Assignment

Commmunity Dentistry

Submitted To: Dr. Muhammad Naeem

Topics: Role of Flouride in Dentistry – Global Pesrpective

Submitted By: Zainab Ahsan

Roll No. 09

BDS, Second Year

Session: 2020

Due Date: 5th June, 2021

Role of Flouride in Dentistry – Global
Perspective
WHO and Use of Fluoride for Oral Heal
At the 2007 WHO World Health Assembly, a resolution was passed that universal access to fluoride
for caries prevention was to be part of the basic right to human health (Petersen, 2008). There are
three basic fluoride delivery methods for caries prevention; community-based (fluoridated water,
salt and milk), professionally administered (fluoride gels, varnishes) and self-administered
(toothpaste and mouthwashes).

Dental Carries Prevention

Fluorides play a pivotal role in the prevention of dental caries. It is the most effective and most
extensively tested of current anti-caries agents. The natural occurrence, metabolism, mechanism of
action and toxicology has been thoroughly studied as any other element. It is one of the best
armamentariums used in the prevention and control of dental caries.
Fluoride can be added to the diet or can be applied to teeth by self-application or by proper
treatment from a dental professional.
Fluoride can be used in many ways in the oral cavity for either prevention or treatment of diseases.

Enamel Strengthening
Fluoride is commonly used in dentistry to strengthen enamel, which is the outer layer of your teeth.
Fluoride helps to prevent cavities. It’s also added in small amounts to public water supplies in the
United States and many other countries. This process is called water fluoridation. Aside from water
fluoridation, fluoride can be added to the diet by the means of milk fluoridation, salt fluoridation,
fluoride drops and fluoride tablets.

 Fluoride helps in Enamel in the following ways;

a. rebuild (remineralize) weakened tooth enamel
b. slow down the loss of minerals from tooth enamel

Fluoride in Dental Products and CDC Survey

According to the Centers for Disease Control and Prevention (CDC), the average
number of missing or decaying teeth in 12-year-old children in the United States dropped by
68 per cent from the late 1960s through the early 1990s. This followed the introduction to,
and expansion of, fluoridated water in communities, and the addition of fluoride to
toothpaste and other dental products.
Importance of Fluorides for Children
Getting enough fluoride is particularly important to children, even when they still have their baby
teeth. Tooth decay can cause the need for dental procedures they can sometimes be distressing to
kids. As children begin to get their permanent teeth, fluoride becomes even more important. Those
teeth are irreplaceable with natural teeth and children will need them for many decades into
adulthood. Fluoride is a natural mineral that can slow or stop cavities from forming. Bacteria in the
mouth combine with sugars and make acid that can harm the outer layer of the tooth (enamel).
Fluoride protects teeth from damage and helps rebuild the enamel. Many communities have added
fluoride to the tap water to help fight cavities. Children should drink plenty of water and brush with
toothpaste that has fluoride in it.

Fluoride can be added to children’s diet by either water, milk or salt fluoridation. Carbohydrates from
sugars or other sweet substances can provide a haven for dental bacteria as they cling to teeth.
Children must be guided and mentored properly at a young age to take care of their teeth and
prevent dental plaques and carries. Aside from community water fluoridation, school water
fluoridation is also encouraged for children. Now many commercial products such as toothpaste and
fluoride drops or tablets are available which are suitable for children. Proper parent education can
make it possible for the new generation to have healthier and stronger teeth.

Tooth Decay and Dental Cavities

When bacteria in our mouth break down sugar and carbs, they produce acids that eat away at the
minerals in your tooth enamel. This loss of minerals is called demineralization. Weakened tooth
enamel leaves our teeth vulnerable to bacteria that cause cavities. Fluoride helps to remineralize our
tooth enamel, which can prevent cavities and reverse early signs of tooth decay.

 Fluoride helps in;

a. reverse early signs of tooth decay
b. prevent the growth of harmful oral bacteria
c. prevent dental cavities that are a result of tooth decay.
 Prevention of cavities by Flouride.
 Two different ways:
i. Fluoride concentrates in the growing bones and developing teeth of children,
helping to harden the enamel on baby and adult teeth before they emerge.
ii. Fluoride helps to harden the enamel on adult teeth that have already
emerged.

Role of Fluoride in Dental Carries Reversal

Dental caries is an infectious disease caused by the complex interaction of cariogenic (caries-
causing) bacteria with carbohydrates (i.e., sugars) on the tooth surface over time. Cariogenic
bacteria metabolize carbohydrates for energy and produce organic acids as byproducts. The acids
lower the pH in the plaque biofilm.

The hydroxyapatite of tooth enamel is primarily composed of phosphate ions (PO43–) and
calcium ions (Ca2+). Under normal conditions, there is a stable equilibrium between the calcium and
phosphate ions in saliva and the crystalline hydroxyapatite that comprises 96% of tooth enamel.
When the pH drops below a critical level (5.5 for enamel, and 6.2 for dentin), it causes the dissolution
of tooth mineral (hydroxyapatite) in a process called demineralization. When the natural buffer
capacity of saliva elevates pH, minerals are reincorporated into the tooth through the process of
remineralization.47

The initial stage of the caries process results in white spot formation , a result of acid penetration
and solubilization of some (but not all) of the subsurface mineral. Left untreated, this subsurface
damage can progress to a point where the crystal can no longer provide sufficient support to the
enamel surface structure, and the surface collapses (cavitates).

The caries process can be affected in several ways. One of the most effective methods to prevent
caries is by promoting remineralization and slowing down demineralization. This can be
accomplished with fluoride therapy. It is widely accepted that the regular use of fluorides, such as
in dentifrice and drinking water, is extremely effective at preventing dental caries.

In 1999, the US Center for Disease Control (CDC) stated that water fluoridation is one of the 10
most important public health measures of the 20th century . Fluoride’s presence in low
concentration and high frequency is more effective at preventing caries than high levels of
fluoride used in low frequency. Because water fluoridation is not available in many countries,
dentifrice is considered to be one of the most important sources of fluoride globally.

When fluoride is present in oral fluids (i.e., saliva), fluorapatite, rather than hydroxyapatite, forms
during the remineralization process. Fluoride ions (F–) replace hydroxyl groups (OH–) in the
formation of the apatite crystal lattice, resulting in a stronger, fluoridated tooth mineral
(fluorapatite). Fluorapatite is less soluble than hydroxyapatite, even under acidic conditions. Because
fluorapatite is less soluble than hydroxyapatite, it is also more resistant to subsequent
demineralization when acid challenged.

Caries is generally considered to be a sub-surface phenomenon. With fluoride treatment, a non-

cavitated lesion can be remineralized with fluorapatite and have greater resistance to subsequent
demineralization than hydroxyapatite. Even at very low concentrations, fluoride is effective as an
anticaries agent.

In the US, there are three commonly used sources of fluoride in oral care products; sodium fluoride
(NaF), sodium mono-fluorophosphate (SMFP) and stannous fluoride (SnF2). All three of these
fluoride sources provide the important F- ion, which both inhibits demineralization and promotes the
remineralization of damaged tooth mineral. In addition, SnF2 is considered to have unique properties,
as it provides efficacy against bacterial acids in addition to its fluoridating benefits.
Figure 1.

A) Demineralization – the caries formation process. Damage occurs in subsurface regions of the
enamel, leaving an intact outer layer on the enamel surface.

B) Remineralization – the caries reversal process. Caries is reversed through the process of
remineralization, in which calcium, phosphate and fluoride are incorporated in the areas damaged
due to demineralization processes, resulting in a stronger, fluoridated mineral.

Recommendation of Fluoride Usage by International Organizations

The Center for Disease Control has called community water fluoridation one of the 10 great public
health achievements of the 20th century. This is due to its effectiveness, and low cost. The American
Dental Association, American Academy of Pediatrics, US Public Health Service, and World Health
Organization all advocate for fluoridating community water supplies.

Usage of Fluoride for Oral Health by Different Countries

And their perspective on the use of fluoride for oral health.

WHO Report 2003

Despite great improvements in the oral health of populations across the world, problems persist
particularly among poor and disadvantaged groups in both developed and developing countries.
According to the World Oral Health Report 2003, dental caries remains a major public health
problem in most industrialized countries, affecting 60–90% of schoolchildren and the vast majority of
adults.

Dental caries is also the most prevalent oral disease in several Asian and Latin American countries.
Although for the moment it appears to be less common and less severe in the greater part of Africa,
the report anticipates that in light of changing living conditions and dietary habits, the incidence of
dental caries will increase in many of that continent’s developing countries. The principal reasons
for this increase are growing sugar consumption and inadequate exposure to fluorides.

Cochrane Review (British Medical Research Non-profit Organization)

A Cochrane review estimates a reduction in cavities when water fluoridation was used by children
who had no access to other sources of fluoride to be 35% in baby teeth and 26% in permanent teeth.
Most European countries have experienced substantial declines in tooth decay without its use.
Recent studies suggest that water fluoridation, particularly in industrialized countries, may be
unnecessary because topical fluorides (such as in toothpaste) are widely used and caries rates have
become low. For this reason, some scientists consider fluoridation to be unethical due to "the
debilitating effects of fluoride toxicity" and the lack of informed consent.

The Perspective of Different Governments on Fluoridation

Although fluoridation can cause dental fluorosis, which can alter the appearance of developing teeth
or enamel fluorosis, the differences are mild and usually not considered to be of aesthetic or public-
health concern. There is no clear evidence of other adverse effects from water fluoridation, as revealed
by the York review from 2000.

A 2007 Australian systematic review used the same inclusion criteria as York's, plus one additional
study. This did not affect the York conclusions. Fluoride's effects depend on the total daily intake of
fluoride from all sources. Drinking water is typically the largest source; other methods of fluoride
therapy include fluoridation of toothpaste, salt, and milk. The views on the most effective method
for community prevention of tooth decay are mixed.

The Australian government states that water fluoridation is the most effective means of achieving
community-wide fluoride exposure.

The World Health Organization states water fluoridation, when feasible and culturally acceptable,
has substantial advantages, especially for subgroups at high risk, while the European Commission
finds no advantage to water fluoridation compared with topical use.

Water Fluoridation and Its Alternatives in the World

 Currently, about 372 million people (around 5.7% of the world population) receive
artificially fluoridated water in about 24 countries, including Australia, Brazil, Canada,
Chile, the Republic of Ireland, Malaysia, the U.S., and Vietnam.
 With 57.4 million people receiving naturally occurring fluoridated water at or above
optimal levels in countries such as Sweden, China, Sri Lanka, Finland, Zimbabwe and
Gabon.
 Community water fluoridation is rare in Continental Europe with 97–98% choosing
not to fluoridate drinking water.
 Water fluoridation has been replaced by other modes in many countries where water
supplies are too decentralized for it to be a practical choice, or existing natural
fluoride levels were already ample, including Germany, Finland, Japan, Netherlands,
Sweden, Switzerland, Denmark and at a time Israel.
  The US recently reset the recommended optimal level of fluoride in drinking water,
lowering it slightly, because of observed increased Fluorosis levels, likely due to
additional fluoride sources like toothpaste and mouthwash which were not present
when this level was originally set.
 Most recently published estimates of population coverage include: USA (64%),
Canada (43%), Panama (18%), Republic of Ireland (73%), Australia (61%), New Zealand
(61%), Israel (75%), Malaysia (70%), United Kingdom (10%), Singapore (100%), Brazil
(41%), Argentina (21%), Chile (40%), Spain (10%), Columbia (80%).Hong Kong is also
fluoridated with 100% population coverage. Recently there have been major
extensions announced in the USA (particularly California) and Brazil.

Countries by Water Fluoridation

Africa
Of Africa's 1.1 billion people, about 400,000 get artificially fluoridated water (in Libya, data pre-2003).

Asia
Unfortunately, many countries in Asia have not been able to implement national health programs
that use fluoride. Mostly due to cost-related reasons. Although some of the countries enjoy high
water fluoridation access. China(62%), Israel(65%), Japan(1%), Malaysia(66%), Singapore(100%),
Vietnam(4%).

Some countries lack adequate water fluoridation while others are endemic due to high natural
fluoride contents in water. Such as some states of India.

Europe
Out of a population of about three-quarters of a billion, under 14 million people (approximately 2%) in
Europe receive artificially fluoridated water. Those people are in the UK (5,797,000), Republic of
Ireland (4,780,000), Spain (4,250,000), and Serbia (300,000).

Many European countries have rejected water fluoridation, including Austria, Belgium, Finland,
France, Germany, Hungary, Luxembourg, Netherlands, Northern Ireland, Norway, Sweden,
Switzerland, Scotland, Iceland, and Italy.

North America
USA(74%), Canada(50% before 2010), Mexico(Mexico has no water fluoridation program; instead it
has a table salt fluoridation program.)

Oceania
Australia(70%), New Zealand(70%).

South America
Brazil(41%), Chile(70%)

Water Fluoridation in Pakistan

Research Conducted in 2002
According to research conducted in 2002,(by Ayyaz Ali Khan, Helen Whelton and Denis O’Mullane
with the name of A map of natural fluoride in natural drinking water in Pakistan) The majority (64
per cent) of the drinking water sources of Pakistan had fluoride levels of less than 0.3ppm, 20 per
cent ranged from more than 0.3 to 0.7ppm. This study assumed that naturally occurring fluoride in
the drinking water of Pakistan has a similar effect on dental caries as artificially fluoridated water.
This assumption was based on the striking similarity of dental benefits seen to be conferred by
natural fluoridation and controlled or adjusted fluoridation and demonstrated in more than 100 long-
term fluoridation studies that compared natural or adjusted water supplies with those of fluoride-
deficient communities.

Research Conducted in 2013

To explore the possibility of fluoride toxicity, 747 water samples were collected from surface water
and groundwater sources of 16 major cities of Pakistan, adopting a uniform sampling design with the
distribution of samples: Lahore (79), Kasur (46), Faisalabad (30), Khushab (50), Chakwal (51),
Mianwali (30), Jhelum (53), Bahawalpur (60), Karachi (60), Mirpur Khas (55), Peshawar (38), Risalpur
(35), Quetta (81), Ziarat (21), Loralai (21), and Mastung (37). Comparison of analytical findings with
WHO Guidelines of Drinking Water for Fluoride (i.e., 1.5 ppm) has concluded that 16% of the
monitored water sources have fluoride concentration beyond the permissible safe limit of 1.5 mg L−1
falling in the concentration range of 1.6–25 mg L−1. (Research conducted by M. A. Tahir and H.
Rasheed under the name of Fluoride in the drinking water of Pakistan and the possible risk of
crippling fluorosis.)

Current Conditions
Tahir et al (2013 research) have reported water fluoride content from 16 different cities of Pakistan,
with the ground and underground water fluoride content ranging from 1.6-25 mg/l, which is way
above the WHO safe limit of 1.5ppm. Moreover, the highest levels were seen in Balochistan and
Punjab. (The optimal concentration of fluoride varies according to climatic conditions with the range
0.5mg-1.0mg/litre being generally recommended (WHO, 1994).)

Artificial Water Fluoridation in Pakistan

According to the 2002 report, fluoridation of water in Pakistan may not be feasible for the majority
(80 per cent) of the population, it would be possible to implement this in large urban centres. It may
be recommended that a piped water supply, wherever available in the country and deficient in
fluoride, be adjusted to provide the recommended optimal level. For the majority of the population
in Pakistan, however, there is a clear indication for the use of alternate sources of fluoride to ensure
optimal intake of fluoride necessary for the control of dental caries.

Adverse Effects of Excess Flouride

Fluorosis and Mottled Enamel

Enamel may appear yellow/ brown discolouration and/ or many and pitted white-brown lesions that
look like cavities. They are often described as “mottled teeth”.

Dental fluorosis is a common disorder, characterized by hypomineralization of tooth enamel caused

by ingestion of excessive fluoride during enamel formation.
It appears as a range of visual changes in enamel causing degrees of intrinsic tooth discolouration,
and, in some cases, physical damage to the teeth. The severity of the condition is dependent on the
dose, duration, and age of the individual during the exposure. The "very mild" (and most common)
form of fluorosis, is characterized by small, opaque, "paperwhite” areas scattered irregularly over
the tooth, covering less than 25% of the tooth surface. In the "mild" form of the disease, these
mottled patches can involve up to half of the surface area of the teeth. When fluorosis is moderate,
all of the surfaces of the teeth are mottled and teeth may be ground down and brown stains
frequently "disfigure" the teeth. Severe fluorosis is characterized by brown discolouration and
discrete or confluent pitting; brown stains are widespread and teeth often present a corroded-
looking appearance.

People with fluorosis are relatively resistant to dental caries (tooth decay caused by bacteria),
although there may be a cosmetic concern. In moderate to severe fluorosis, teeth are weakened and
suffer permanent physical damage.

References
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