FLUORIDES

Fluoride metabolism
Systemic fluorides

Dept of pedodontics and preventive dentistry

contents
Introduction
Historical evolution of fluorides
Fluoride chemistry and occurrence
Total intake of fluoride
From Air
From Water
From Food
Fluoride metabolism and bioavailability
Physiologic distribution of fluoride
In blood and soft tissue
In hard tissue
Cont…
Excretion of fluoride
Placental transfer of fluoride
Water fluoridation
School water fluoridation
Fluoride tablets
Fluoridated salt
Fluoridated milk
Fluoridated flour and sugar
Toxicity of fluoride
Defluoridation
Introduction
 Historical evolution of fluorides-
In 1805, Morichini found fluoride in human Enamel.
Fluorine discovered by chemist Scheele in 1771- isolated by Moissan
in 1886
First report of fluoride concentration in drinking water quoted in ppm
given by Hillebrand.
Desirabode in 1847 referred to fluates-(silicate or fluate of lime and
alumine, dried and pulverized)
First reference to prophylactic role of fluoride made by Erhadt in 1874
Fluoride pills (KF) recommended in England, comes in pleasant
tasting form as “hunter pills”
Dr A. Denninger (1896)- Fluoride an agent to combat dental disease
and Appendicitis
Historical evolution of fluorides…

In 1901 Dr. Federick Mckay- “Colorodo Stains”

minute white flecks, yellow or brown spots scattered..

In 1902 Dr. J.M. Eager noticed in Italian emigrants -“denti di chiaie”

1916, Dr. Green supported Mckay work with histologic evidence “

an endemic imperfection of the enamel of the tooth

In 1918 Dr. O. E. Martin and Mckay- Britton (1898) changed water

supply from shallow wells to deep drilled artesian wells….

1931 Mr. H. V. Churchill- spectrographic analysis of Bauxite

city water 13.7ppm

Historical evolution of fluorides…

in 1933, Dr. H. Trendley Dean- conducted “Shoe Leather Survey”

in 97 localities, with a aim to find out minimal threshold level….

In 1939 came out with ‘domestic water is primary cause of human

mottled enamel ( dental fluorosis)’

In the same year- hypothesis showing ‘inverse relationship

between endemic fluorosis and dental caries’

 Fluoride chemistry & occurrence -
Greek “floris”- destruction
Latin “fluor”- flow or flux
Symbol- “F”
Atomic no.- 9
Atomic weight- 18.99
It is a pale yellow, corrosive gas, which reacts with practically all
organic and inorganic substances
Most electronegative of all elements
Reasons for high reactivity:- 1s2, 2s2, 2p5

Most electronegative of all elements

Small size of atom

High electron affinity

Small bond length

occurrence -

17th in order of abundance of all elements

Constitutes about 0.032% in earth’s crust

Fluoride containing minerals-

Fluorspar (CaF2) - 48.8%

Cryolite (Na3AlF6) – rare

Fluorapetite Ca10(PO4)6F2- 3.8%

occurrence -
Fluoride in Air-
HF or Gaseous F2
Dust of f2 containing soils, gaseous industrial, coal smoke,
and volcanic emulsion.
Levels of air borne- Aluminum factories: 5micro grams/ m3
Fluoride in plants-
Roots form soil and Leaves form air
Camellia sinensis –acidic soils,
Indian Tea leaves – 70 to 375 ppm
Vegetables- factories- 10ppm
Fruits and vegetables- 0.2 to 0.5 microgram/gram wet wt.
grown near aluminums
occurrence -

Fluoride in animal products-

Beef, pork and mutton-0.3ppm
Higher in Chicken- contamination bone and cartilage
fragments
Fish products- up to 20ppm
Dried sea foods also fluoride rich 84.5ppm (South East Asia)

Fluoride in beverages-
Ranges from 0.05 to 1.05 ppm
Fluoride content in alcoholic beverages generally reflects
that of water used.
 Total daily intake of fluoride
Fluoride from Air
Minimal
Fluoride from Water
Most important single source of fluoride
Dependent on fluoride concentration and amount
Fluctuation –climatic and geographical areas
Fluoride from food
0.3 to 0.6 mg/day
Fluoride intake 6months of life-bottle/breast fed
Breast fed infant receives 0.003 to 0.004mg/day- formula
fed infants (1.2ppm) fluoride intake increased 50 times
Total daily intake of fluoride…

Excessive consumption of tea and sea foods- increased flr

National Research Council 1980 – safe and adequate

1.5 to 4.0 mg/day in adults

0.05 to 0.07 mg/day in children for optimal dental health

Threshold level drinking water 2.0ppm- dental fluorosis

 Fluoride metabolism & Bioavailability
Therapeutic action and safety of fluoride – kinetic process
Mechanism and site of absorption:-
Water soluble fluorides- NaF, HF, H2SiF6, Na2PO3F and StF
Less soluble fluorides- CaF2 , Ca10(PO4)6F2
Passive in nature
Rapid absorption stomach- nonionic diffusion of HF
Ph of gastric fluid-free F in the form of HF
With milk, F bioavailability decreased..
Formation of low soluble calcium fluoride
Binding to casein and colloidal calcium phosphate
Clotting of milk (acidity)-physical barrier over mucosal surfaces
 Fluoride metabolism & Bioavailability…

Absorption from solid foods is less compare to liquid

80% of ingested is absorbed

From fluoride preparation and dental materials:-

Dentifrices- less
Alginate (4450 to 24,240 ppm)- systemic absorption peak in 30
min
Single impression Zelgan- 119ng/ml in plasma level
Double impression -200ng/ml
150 ng/ml from 3mg F in aqueous solution
Fluoridated anesthesia- halothane, methoxyfluorane, Enflurane
-630ng/ml
 Physiologic Distribution of fluoride
Fluoride in Blood:-
Blood plasma is most reliable indicator
¾ in plasma and ¼ in RBC
Fluoride exists in both forms
-bounded from
-ionic form- varies concentration F in drinking water
Increase in plasma F with age and in presence of renal failure
Drinking water 0.25 or 1.25 ppm –plasma level 0.01 or 0.025ppm
Increased reactive sites and voids in old bone is more saturated
and filled with F than young bone
Physiologic Distribution of fluoride…

Fluoride in soft tissue:-

Tissue/ plasma ratio = 0.4 to 1

Ectopic calcification loci- F accumulation in Aorta, tendon,
cartilage and placenta
 Effects on kidney

Fluoride is normally cleared from the blood by

deposition in bone, excretion in urine- unable to
find toxic effect on kidney endemic fluorosis.

Patients with chronic renal failure- dialysed

with fluoridated have additional load of fluoride

So fluoride free water is used for kidney dialysis

 Fluoride in hard tissue
Bone:-
Total amount-2.6mg

Most of F in the body retained in the skeleton-vary according

to the renal clearance

F enter in mineralized tissue-replacing 0H-, C032- and HC03-

Remodeling bones deposit more fluoride than older people

Fluoride deposition is a reversible process

 Fluoride in hard tissue…

Teeth:-
Deposition occurs in successive stages.
Initial deposition – organic and mineral phases are laid down
Pre-eruptive maturation phase-before eruption
Post eruptive maturation and aging period
Dentine contains 4 times more than enamel
Fluoride concentration not uniform
Fluoride concentration –initial stages is higher than on completion

( mineralization process- release of F to the bathing fluid)

Primary teeth less fluoride concentration than permanent teeth
Fluoride in hard tissue…
Fluoride concentration in the outer enamel (2micrometer)-
1700ppm-non fluoridated areas (0.1ppm)
2200 to 3200ppm- optimally fluoridated areas (1ppm)
4800ppm- 5 to 7ppm

Depth 5 micrometer-
Permanent Primary
teeth teeth
Non- 1100ppm 670ppm
fluoridated
areas
 Fluoride in hard tissue…

F concentration in newly erupted teeth- higher in in

incisal than cervical margin
Diffusion of F in enamel NaF and
monoflurophosphate(100pmm)-
10-9cm2/sec
Speed at which F penetrates in enamel-
38 micrometer/ hour (186micrometer/ day)
Fluoride in hard tissue…
Concentration in dentin:-
more than enamel-apatite crystals are smaller
-surface area and capacity to take is much larger

In permanent teeth:
Highest near the pulpal surface
low in secondary dentin

In primary teeth
complicated –physiologic resorption occurs towards pulpal
side
greatest rise and fall – Pulpal surface of multirooted teeth
 Fluoride in hard tissue…

Fluoride concentration in Cementum:-

Higher than any skeleton or dental tissue

Tissue is very thin

Near the tissue surface- accessible to fluoride present in

blood

Increases with age

 Mechanism of action of fluoride in
caries reduction.
Increased enamel resistance (or) reduction
in enamel solubility
Increased rate of post eruptive maturation
Remineralization of incipient lesions
Interference with plaque microorganisms
Modification in tooth morphology
 Enamel fluorosis
Enamel mottling described by Eager in 1901 in Naples & Italy

Black and Mckay In 1916 in Colorodo and Arizona

Relationship between enamel mottling & excessive intake of

fluoride in 1931 by Smith etal, Churchill JV, and Velu R etal

H. Trendley Dean and Arnold –Mottling : Concentration of

fluoride in drinking water

Moderate to severely pitting and staining: pre-eruptively

induced enamel porosity

Enamel fluorosis…

2 to 10 ppm- direct inhibitory effect on enzymatic

function of Ameloblasts: resulting in defective

matrix formation and subsequent hypominerlization

Hypocalcified enamel easily becomes hypoplastic

after eruption due to abrasion and wear

No fluorosis- additional intake of F once crown

formed and topical applications

 Criteria for Diagnosis of enamel
fluorosis.
Dean Criteria
score
0 -Normal enamel
0.5 -Questionable mottling: normal
translucency is varied by a few

1.0 white flecks or white spots.

-very mild mottling: white

2.0 opaque areas are scattered over

the teeth; <25%
3.0
-Mild mottling: not more than
 Osteofluorosis
Common in workers of aluminum factory
Endemic fluorosis :India, China, South Africa
Fluoride dosage: 10 to 25 mg/day for a period of 10 to 20 years
Threshold level for osteofluorosis appears: 4000 to 6000 mg/kg of dry
fat free bone
First stage: asymptomatic (radio graphically – increase density of
vertebrae pelvis)
Advanced cases: bone density increased
bone contours and trabeculae uneven and blurred
extremities show thickening of compact bone
irregular periosteal growth ( exostoses and osteophytes)
increased in calcification in ligaments, tendons, and
muscle insertion
Osteofluorosis…

At this stage complaints: vague pain in small

joints. knee joints and joints of spine
Increased severity “crippling fluorosis”:
stiffness of spine
limitation of movements
severe pain
 Soft tissue fluorosis are we
neglecting????
A team of Japanese professors found that children with mottled

teeth have high incidence of heart damage than those without

mottling (Tokushima J 1961)

Chronic exposure to F showed stomatitis and oral ulcer (Sheajjet

etal 1967)

Optical neuritis and visual disturbance may result from direct

effect of fluoride ion on neural tissue (Ellenhorn MJ 1988)

Soft tissue fluorosis are we
neglecting????

Increased cases of reduced IQ, and mentally retarded pt. in

endemic fluoride region (Xang et al 2003)

Pineal gland contains more fluoride than any other soft tissue in

the body (Jennifer Luke,1997)

Chronic atrophic gastritis (Dasavathy et al 1996)

Decreased testosterone concentration (Susheela et al)

Damaged sperms, reduced sperm count and reduced fertility

(Gosh et al 2002)
 Excretion of fluoride
3 main avenues are urine, feces and perspiration
Via kidneys:-
40 t0 50% of single dose excreted in urine during 24 hours
Factors influencing are
Previous exposure to fluoride
Age
Urinary flow
Urine PH
Kidney status

Glomerular filtration –tubular reabsorption in the form of HF-

greater the acidic urine
Excretion of fluoride…

PH- < 5.6: Excreted fraction of filtered fluoride <5%

Reobsorbtion-95%

Above 5.6: increased fraction of F excretion

In acute poisoning: increased PH urine alkalizing agents

enhance the elimination of F

Excretion of fluoride…

Via the Gut:-

Undissolved and not absorbed excreted unchanged in feces

10% of total fluoride intake is excreted in feces

Via sweat:-
Varying proportions of absorbed fluoride may lost from the

body in perspiration

Under normal conditions of F intake-concentration of Fin

sweating range of 0.07 to 0.5ppm
Excretion of fluoride…

Via saliva:-
Less than 1% of absorbed from saliva was recovered from
saliva

0.01 to 0.05ppm

Via breast milk:-

0.01 to 0.05ppm

Selective in taking up fluoride- no evidence of transfer of F

from plasma to milk

Cow’s milk higher F content than human milk

 Placental transfer of fluoride

Fluoride in primary teeth and bones:

placental transfer
Placenta does not selectively inhibit
fluoride transfer
Higher the fluoride ingestion: partial
barrier may exist
 0.01 to 0.1 ppm

Ingested fluoride
<½ of plasma F

Fecal excretion
5%

50% 45 %

0.067 – 0.5ppm
 7

40 10- 15

9.9

11

21
15
 Fluoride supplementation

Systemic Topical

Water fluoridation Professional application

School water fluoridation

Dietary fluorides Self
Milk fluoridation application
Salt fluoride
Fluoride in sugar
 Water fluoridation
Definitions:-

‘Water fluoridation is defined as controlled adjustment of the

concentration of fluoride in a communal water supply so as to

maximum caries reduction and a clinically insignificant level of

fluorosis.’

Defined as’ upward adjustment of the concentration of fluoride ion in a

public water supply in such way that the concentration of fluoride in the

water may be consistently maintained at 1 ppm by weight to prevent

dental caries with minimum possibility of causing dental fluorosis’

Water fluoridation…

First began in Grand Rapids, U. S. A., in 1945

Studies on water Control

fluoridation (city)
1. Grand Rapids Muskegon
(Michigan) Kingston
2. Newyork Sarnia
3. Brantford (Ontario-
Canada) Oak-Park
4. Evanston (Illinois) Culemberg
After 1o
5. years -DMFT of fluoridated cities 60% lower than the
Teil (Netherlands)
control cities
Water fluoridation…
Murray and Rugg-gunn
compiled the status of water fluoridation globally
using over 90 studies he compared cariostatic benefits in primary
and permanent dentition.
Early 1960’s successful water fluoridation program –in Singapore
and Hongkong
Backer Dricks conformed caries protection….
Buccal, lingual and gingival smooth surface- 85%
Interproximal surface- 75%
Pit & fissure and occlusal surfaces- 35%
First study on deciduous dentition in UK by Weaver in North and
South Sheilds (41%)
Water fluoridation…

Fluoride compounds used in water fluoridation-

Fluorospar
Sodium fluoride- most expensive source
Silicofluoride
Sodium silicofluoride- cheapest form
Hydrofluorosilicic acid
Amonium silicofluoride
Types of equipments for water fluoridation-
Saturation system- 4% NaF (recommended for small towns)
Dry feeder system-NaF or silicofluoride (medium sized towns)
Solution feeder- Hydrofluosilicic acid (large towns)
Water fluoridation…
Optimal fluoride concentrations and climatic condition
In Temperate climates (formative stages) - 1ppm
Children living in this area- 1mg/daily

Galagan and Vermillion emperical formula:

Based on daily fluid intake, body wt and temp
ppm F =0.34/E E = -0.038+0.0062 t
E -daily water intake in oz/lb of body wt
t- max daily temp in degrees Fahrenheit

WHO recommended (1994)- 0.5 to 1.0 ppm

 Water fluoridation…
Simple modified method to determine opt fluoride
concentration and mean annual temp… Richard etall

o
C o
F Recommended
ppm
<18.3 <64.9 1.1 - 1.3
18.9- 26.6 66.0-79.9 0.8 - 1.0
>26.7 >80.1 0.5 - 0.7

In addition to climatic condition total fluoride intake from sources

other than water..
Reasonable goal 60 to 65% caries reduction without fluorosis
 Water fluoridation…
Benefits:-
Both pre eruptive and post eruptive effects
Topical effect through release in saliva
Least expensive and most effective
“Halo effect” or “Diffusion”

Feasibility in INDIA
Ground water btw 1 and 5mg/ml.. (21mg/ml)
Ministry of Health Govt of India prescribed 1.0mg/ml and
2mg/ml
1983 Nanoti & 1988 Nawlakhe given Indian standard
specification desirable limit as 0.6 – 1.2 mg/ml
Short coming- only implemented only in areas have central
pipe water supply system.
Only 30% of population have piped water supply
 School water fluoridation
Suitable alternative –b’cos f consumed during school days
4.5 to 6.3 ppm- no fluorosis
Caries reduction 45 to 50%
Venturi system is most suitable- almost no maintainance
Advantages:-
Effective public health measure-water supply is not possible
Disadvantages:-
5 to 6 years old upon starting school- will not provide
preeruptive contact..
Intermittent fluoride exposure-less than 180 days in a year
 Fluoride tablets
Provides systemic effect before mineralization and topical effect after..

In deciduous dentition:-
Caries reduction 50 -80%, started before2 years continued of 3-4
years
Hoskova 1968(4 years)
- fluoride tab started prenatally-93%
- since birth- 54%

In permanent dentition:-
20 to 40% caries reduction
Longest clinical trial carried out by Aasenden and Peebles-0.5mg F
tab below 3years and 1mg thereafter—followed by 8-11 years
mean caries75 to 80% lower
Fluoride tablets…

Fluoride level in surface enamel (1-2micrometer)

Increased to 3000ppm
Fluoridated water- 2300ppm
Non fluoridated water- 1800ppm
0.5mgF/day –upper limit desirable level first year of life
Concluding that fluoride supplements during developing
dentitions results in caries reduction than water fluoridation
Recommended dietary fluoride supplements (1999)
Age in Concentration of fluoride
years in drinking water ppm

< 0.3 to >0.6pp

0.3pp 0.6ppm m
 Fluoride tablets…
Commercially available NaF (fluoraday, tymaflour and luride)
2.2 mg NaF- 1mg of F
1.1 mg NaF -0.5mg of F
0.55 mg NaF – 0.25mg of F
Neuromuscular coordination not fully developed until 16- 18
weeks
-up to 2 years drops are preferable
Daily recommended dose:-
Below 2 years – 0.5mg
2 to 3 years -0.5 to 0.7mg
Above 3 years- 1 to 1.5mg
Fluoride tablets: topical caries preventive agent to be used as
Dental Public Health Measure in Rural India
Fluoride tablets…

To enhance cariostatic effect-

Chew and suck the tab

Preferably at bed time..

Continued at least until 12 to 14 years

Should not given –water supply exceed 0.7ppm

Should not given with milk and milk products

Cannot replace water fluoridation –parents fail to comply with

the regimen
 Salt fluoridation
Fluoridated salt in Switzerland for the first time in 1955 (90ppm)

90ppm -20 to 25% caries reduction

Optimum level of fluoride in salt –Toth suggested

Urinary fluoride excretion from salt should be similar to that

obtained from fluoridated drinking water

200 to 350 ppm salt- 0.85 and 1.05 similar to populations

ingested fluoridated water for 10 years.

250ppm did not achieve cariostatic effect – optimal fl content water

Salt fluoridation…

Advantages:-
Low cost
Negligible waste
Ease of implementation
Free choice for individual households

Disadvantages:-
Fluoride dosages of different age in different regions
Lower salt consumption during tooth forming years
 Salt fluoridation…

Feasibility in India:-
Viable and feasible method

Easily monitored
Effective control- supply
Individual monitoring not required
Freely available
Readily acceptable- does not alter the colour
 Milk fluoridation
First mentioned by Ziegler in 1956
Stephen et al –daily ingestion of 200ml (7ppm) for 4 years, 38.8% reduction
( 1st permanent molar)
Hellestrom and Ericsson—fluoride uptake by enamel from salt is greater..

Advantages:-
MILK
FLUORIDATION
Need to drink under 14 years of age

Disadvantages:-
Incompletely ionized in milk
Lower absorption from milk than water
Variation in intake
Milk fluoridation…
Requires parental or school efforts
Technical difficulties
Problem in distribution
High cost

Feasibility in India:-
Binding with calcium and protein in milk
Not seem to viable and feasible
Cannot afford milk daily
No central milk supply system
Variation in intake and quantity of milk
 Fluoridation of flour and sugar

Advantages requiring much less of chemical

Fluoridation of sugar has adv –combining the culprit and

cure (difficulty to provide proper dosage)

 Exception to school water fluoridation, salt
fluoridation most promising alternative to water
fluoridation.

Method Average %
caries
reduction of
dental caries
Community water 50 to 65%
fluoridation
40%
School water
50 to 65%
 Fluoride toxicity
Toxic effects of fluorides: Acute and chronic
Acute toxicity:
Accidental contamination of food by NaF and NaSiF salts
Certainly Lethal 5 to 10 gm NaF
Dose (CLD) or
32 to 64
mgF/kg

Safely Tolerated ¼ CLD

dose (STD) 1.25 to 2.5mg
NaFof an infant weighing
To prevent accidental poisoning
(10kg) Council on Dental Therapeutics
or of ADA recommended
that: no more than 264 mg of NaF (120mg of F) dispensed at
8 to 16 mgF/kg
one time
Acute Fluoride toxicity…

Acute poisoning:
Causes death by blocking normal cellular metabolism
Inhibits enzymes causing vital functions-Initiation and
transmission of nerve impulses to cease
Interferences with essential body functions controlled by
calcium.

Low dosages High dosages

Nausea Convulsions
Common signs and symptoms Cardiac
Vomiting of acute fluoride toxicity:
Hyper salivation Arrhythmias
Abdominal pain Painful spasms
Diarrhea Paresis
Parathesia
Acute Fluoride toxicity…

Death usually results: cardiac failure or respiratory failure

Serious symptoms : with in 1 to 2 hours after ingestion

Death occurs from 2 to 4 hours after ingestion

Nausea and vomiting : dose 30 t0 80 mg of NaF

Vomiting diarrhea and severe abdominal pain: 100mg NaF

Gastrointestinal symptoms: corrosive effect on gastric mucosa by HF

acid

Treatment : administration of calcium or magnesium or aluminum salts

 Chronic toxicity

Fluoride Water Effects

level consumption

0.7 to Depending Prevents

1.2 ppm on temp of dental caries
area

1.5 to Period of 5 to Mild dental

 Defluoridation
Defluoridation means to improve the quality of water with high
fluoride concentration by adjusting the optimal level in drinking
water

Absorption and ion exchange method:-

exchange negative ions such OH- group for fluoride ions
depends up on PH, temperature, flow rate, grain size of the
material

common used materials: activated alumina, activated

bauxite, Zeolite, Tricalcium phosphate, activated bone char,
magnesite, magnesite etc
Defluoridation…

Precipitation method:-
In a high PH condition, co-precipitation of several
elements in water with fluoride ions forms fluoride salts-
flocculation (Aluminum ions)

Alum

Alum and lime

Lime softening

Calcium chloride
 Membrane separation

Reverse osmosis process

Expensive developing countries

30% of raw water is lost in the process

 Indian technology for defluoridation
Nalgonda Technique:
India in 1975
most simple
least expensive
Easiest to operate
 NALGONDA TECHNIQUE

Alum
Fluoride water Flocculation settling

Supply Disinfection Filtration

Nalgonda Technique:

Advantages:

domestic and community levels

manually possible

cost effective

flexible design to use in different location

 Prashanthi technology

Activated Alumina- most popular

cost effective

Bio-Science, Department of Sathya Sai

University of Higher Learning in Prasant
Nilayam
 Other methods tried in India.
Fish bone charcoal- University of Roorkee
Drumstick Moringa cleifera- Reduce water turbidity
-calcium and magnesium levels in plants
Askali- extract mycetial biomass-Osmania university
Aspergillus riger
Clay materials-Montmosllonite KSF, Kaolin and a Silty
Clay Sediment series
Tricalcium phosphate(TSP)
References :-

Text book of pedodontics- SHOBA TANDON

Fluorides and Dental caries- AMRIT TEWARI

Pediatric dentistry- STEWART

Essentials of preventive and community dentistry- SHOBAN

PETER

Pediatric dentistry: STEPHEN WEI

Fluorides in caries prevention- J.J. MURRAY