Fluoride In Dentistry

Dr Mona Mustafa
BDS - MD
What is fluoride?
Why do we use fluoride in
dentistry? How does it work?
How should we use fluoride to
prevent dental caries?
What is fluorosis
What is fluoride?
Fluoride is the ionic form of the element fluorine.
Fluorine is 17th most abundant element in the earths
crust
It is negatively charged and will not remain as a free
element.
 Fluoride has a high affinity for calcium.
It is, therefore, very compatible with teeth and bone.
Fluoride is the most effective tested anticarious agent
It can be found in nature in association with calcium
as --- Fluorite or fluorospar and with calcium &
phosphorus as-- fluoroappatite and with Na&Al as ---
cryolite .
Also it can be found in water, food e.g sea food such as
sardin& salamon
In drinks e.g fresh fruit juice, breast milk , beer and
wine
In tea , leafy plants
In pharmmacetical products such as fluoride
dentifrice, F. gels and solutions and F. tabs that are
used for caries prevention
Sources of fluoride
Milk formulas ( .05 to .35 ppm)
Soy Beans Formula ( 0.17 to 0.38 ppm)
In beverages :
Tea ( raw tea leaves 400 ppm)
Brewed tea ( 0.1 to 4.2 ppm_
Daily consumption of 1 cup (200 ml) would yield 0.6
mg F/day
Sources of fluoride
Fish and seafood products
Dried seafoods (can contain 290 ppm)
Canned seafoods ( can contain 40 ppm)
Chicken products (0.6 to 10.6 ppm)
Salt with Fluoride, Sugar with Fluoride
Sources of fluoride
Dental Products
Dentifrices
Fluoride mouth rinse
Professional applied fluorides
Dietary fluoride supplements
Fluoride metabolism & Bioavailability
Water soluble fluorides- NaF, , Na2PO3F and StF
Less soluble fluorides- CaF2 , Ca10(PO4)6F2

Rapid absorption occur in stomach

With milk, F bioavailability decrease
 Fluoride metabolism and excretion
Fluoride in •50 % of the
Food, water absorbed fluoride
will be associated
with calcified tissue

75 to 90 % absorbed from the •50% excreted in

alimentary tract, more from urine
liquids than solids (10 to 25%
excreted via feces)

50:50 distribution is shifted strongly in favor of retention

in the very young, greater excretion in later years of life
Total daily intake of fluoride
Fluoride from Air
Minimal

Fluoride from Water

It is the most important single source of fluoride
Depending on fluoride concentration and amount
Fluctuation according to –climatic and geographical areas

Fluoride from food

0.3 to 0.6 mg/day
Breast fed infant receives 0.003 to 0.004mg/day-
Excessive consumption of tea and sea foods- increased fluoride

National Research Council 1980 states that – safe and adequate

intake is of 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 IN HARD TISSUE
Bone:-

Fluoride is abone seeker, 99% of fluoride in the body is found in

calcified tissues

Total amount-2.6mg

Most of Fluoride in the body retained in the skeleton-vary according

to the renal clearance

Remodeling bones deposit more fluoride than in older people

Fluoride deposition is a reversible process

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

Primary teeth less fluoride concentration than permanent teeth

Fluoride concentration in newly erupted teeth- higher
in incisal edge than cervical margin
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

Mechanisms of Action
Topical
Systemic
Antibacterial
 Topical
 inhibits demineralization
 promotes remineralization
Systemic
improves enamel crystallinity
reduces acid solubility
improves tooth morphology (controversial)
Antibacterial
concentrates in plaque
disrupts enzyme systems
 Fluoride inhibits bacterial metabolization of carbohydrates to produce
acid .
 When fluoride is constantly present, mutans Streptococci produce

less acid .
Summary of Anti-Caries Activity of
Fluoride
1. Fluoride prevents demineralization.
2. Fluoride enhances remineralization.
3. Fluoride alters the action of plaque bacteria.
4. Fluoride aids in posteruptive maturation of enamel.
5. Fluoride reduces enamel solubility.
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
Administration of Fluoride
It can be administered systemically or applied
topically :
1/ Systemic:
Ingested and delivered to the oral cavity via blood
stream:
1/ Water fluoridation:
a/ community water fluoridation
b/ school water fluoridation
2/ Dietary supplements:
a/ fluoride tablets & drops
b/ fluoridated salts, milk and fruit juices
c/ fluoride vitamins preparation
2/ Topical:
They are utilized intra orally for variable amount of
time to exposed crown and root surfaces to prevent
dental caries.
1/ those applied by professional:
a/ topical solutions & gels
b/ fluoride containing varnishes
c/ fluoride prophylaxis paste
d/ restorative material containing fluoride
2/ self applied fluoride agent :
a/ fluoride dentifrice
b/ fluoride rinses & gels
 Fluoride supplementation

Systemic Topical

Water fluoridation Professional application

School water fluoridation

Dietary fluorides Self
Milk fluoridation application
Salt fluoride
Fluoride in sugar
Types of fluorides
In the United States, there are three types of fluorides
approved by the FDA as safe and effective for use in
dentifrices:
 Sodium fluoride (for use in paste )
 Sodium monofluorophosphate (holds fluoride in complex form )
 Stannous fluoride (was the first used in dentifrice, has gingivitis-

reduction properties, but has an astringent taste and potential

staining)
Fluorides for Professional Use
FDA approved for professional use:
 Acidulated phosphate fluoride (APF) with 1.23% F
 Neutral sodium fluoride (NaFl) with 2% F
Fluoride for Home Use

 Neutral sodium fluoride

 .05% F –rinse

 1,000 – 1,500 ppm –Regular paste

 Acidulated phosphate fluoride
 .044% F–rinse

 5,000 ppm –Rx gel

 Stannous fluoride
 3,000 ppm –Rx gel

 .63% F--Rx rinse

Fluoride Dentifrices
Best topical application
 0.2 to 0.3 mg F can be swallowed by pre-school aged
children when brushing therefore Instructions for use of
fluoride dentifrce is recommended :
 Very small, pea-sized amount in pre-school aged children
 Parents must supervise small children during brushing

 Rinse and expectorate following brushing

Fluoride Varnish
Safe
Effective
Doesn’t take a lot of time
Fluoride varnish products
Fluoride varnish is available from 3 different
manufacturers. It consists of 5% NaF.
Duraflor
Duraphat
Cavity Shield
Fluoride Varnish
There is strong evidence for the use of fluoride varnish for
caries control in permanent teeth .
NaF varnish delivers 2.26% fluoride (22,600 ppm), the
strongest concentration of fluoride.
Application stays on tooth surface 4 to 6 hours .
Fluoride varnish has been used since late 1960 in Europe
and Canada as a primary preventive agent, with as much as
a 75% reduction in decay .
Fluoride in varnish also gradually dissolves into the plaque,
saliva, and enamel providing bacteriocidal, bacteriostatic,
and remineralizing effects.
 No toxic effects were found in the blood plasma levels in preschool and
school children after treatment with varnish. The use of varnishes is,
therefore, safer than gels with small children . Children younger than six
years of age tend to swallow 30 to 50% of gel products .
 The FDA has cleared fluoride varnish as a cavity liner or root
desensitizer.
 After 2 ½ years, fluoride varnish resulted in a higher percentage of
caries reduction than topical 2% NaF solution or 1.23% APF gel .
Advantages of fluoride varnish
easy to apply
teeth do not need professional prophylaxis
children can eat and drink following applications
potential ingestion of fluoride is low
prevents caries
Frequency of Applications
2 to 4 applications per year
Fluoride Varnish Application
Clean and Dry Teeth

2 TO 4 applications per year

Apply Varnish with small brush
Fluoride Varnish Application
Apply varnish to
Anterior teeth

Posterior teeth
Fluoride Varnish Application
The varnish hardens
quickly after
application as a yellow
film
The child can have a
drink of water
Post application instructions for parents
Varnish will set on contact with saliva.

Child can eat or drink right after application

Do not brush your child’s teeth tonight. Start brushing

them tomorrow morning

Three Months Later

Remineralized Enamel
My Videos\fluoride varnish.ram
Fluoride in Prophylactic Paste
Contains 4,000 to 20,000 ppm
 but does not adequately substitute for fluoride gel or
varnish in treating high risk caries patients .
Goals of fluoride administration
1/ do not harm the patient
2/ prevent decay on intact dental surfaces
3/ arrest active decay
4/ remineralized decalcified tooth surfaces
Water fluoridation
Definitions:-

‘Water fluoridation is defined as controlled adjustment of the concentration

of fluoride in a community water supply so as to maximize 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’

• 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
5. Teil (Netherlands)

After 1o years -DMFT of fluoridated cities 60% lower than the

control cities
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)
Optimal fluoride concentrations and climatic condition
In Temperate climates - 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
t- max daily temp in degrees Fahrenheit

WHO recommended (1994)- 0.5 to 1.0 ppm

Fluoride tablets
Provides systemic effect before mineralization

In deciduous dentition:-
 Caries reduction 50 -80%

In permanent dentition:-
 20 - 40% caries reduction
 Longest clinical trial carried out by Aasenden and Peebles 0.5mg F tab given
below 3 years and 1 mg thereafter—followed by 8-11 years
 caries reduction75 - 80%
School water fluoridation
Suitable alternative –because fluoride consumed during school days
was 4.5 to 6.3 ppm-
no fluorosis
Caries reduction 45 - 50%
Advantages:-
Effective public health measure- if fluoridated 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
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
• -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
To enhance cariostatic effect-
Chew and suck the tab

Preferably at bed time..

Continued at least until 12 to 14 years

Should not given if fluoridatedwater supply exceed 0.7ppm

Should not given with milk and milk products

Cannot replace water fluoridation if parents fail to comply with the

regimen
DEFLUORIDATION
Defluoridation means to improve the quality of water
with high fluoride concentration by adjusting the
optimal level in drinking water
common used materials: activated alumina, activated

bauxite, Zeolite, Tricalcium phosphate, activated bone

char, magnesite etc
Fluoride Toxicity: ( Acute fluoride toxicity)
Symptoms of overdose
GIT (nausea& vomiting , diarrhaea, )
Pain in abdomen, increased salivation, difficulty in speech
Weak pulse, coma
CNS (convulsions)
Cardiac arrithymias
Death occur in 4 hours

Probable toxic dose = 5 mg F/kg

Certainly lethal dose = 16 – 32 mg F/kg
 CHRONIC TOXICITY
Fluoride level Water consumption Effects

0.7 to 1.2 ppm Depending on temp of Prevents dental caries

area

1.5 to 3.0ppm Period of 5 to 10 years Mild dental fluorosis

3.0 to 8.0ppm 15 to 20 years Severe dental fluorosis

Mild skeletal fluorosis

8.0ppm or more 5 to 10 years Severe form of dental

skeletal fluorosis
Treatment:
Determine child’s weight and estimate amount ingested
<8 mg F/kg: give milk, observe > 6 hours, refer if
symptoms develop
>8 mg F/kg: give syrup of ipecac, followed by milk; refer
immediately
Unknown dose: if asymptomatic, treat as <8 mg F/kg, if
symptomatic (already vomited) give milk, refer
immediately
Contact hospital: gastric lavage, IV calcium gluconate
Those who are sleeping please
wakeup