PROFESIONALLY APPLIED

TOPICAL FLUORIDES

PRESENTED BY
B.SHIVA KUMAR
II MDS
CONTENTS

1) Introduction
2) Types of Fluorides delivery

3) Types of topical Fluorides

 Professionally applied

 Self applied

4) Indications for topical fluorides

5) Sodium Fluoride (Knuston technique)

6) Stannous Fluoride ( Muhlers technique)

7) Acidulated phosphate fluoride (Brudevolds technique)

8) Varnish
9) Silver diamine fluoride
10) Conclusion

11) References.
INTRODUCTION
Dental caries process is a continuum resulting from many cycles of

Demineralisation & remineralisation  CAVITATION

Fluoride Reactivity
SYSTEMIC TOPICAL

Water fluoridation Solutions

Solutions (NaF ,SnF22 ,
PROFESSIONAL APF , NH22F)
School water fluoridation APPLICATION Gels
Milk fluoridation Varnish

Dentrifices
Dietary fluorides Rinses
SELF
Salt fluoride APPLICATION  Gels
Fluoride in sugar  Chewing gum
 Tooth pick
 Floss
TOPICAL FLUORIDE THERAPY - Use

of systems containing relatively large

concentrations of fluoride that are applied

locally, or topically, to erupted tooth surfaces

to prevent the formation of dental caries

PROFESSIONALLY APPLIED SELF APPLIED FLUORIDES
PRODUCTS PRODUCTS

•Dispensed by the individual

•Medicaments typically dispensed patient but at the recommendation

by dental professionals in the of dental professional.

dental office • Includes dentifrices, gels and

• Use of high fluoride mouthrinses

concentration products i.e 5000- • Low fluoride concentration in

19000 ppm [5-19 mg f/ml] the range 200 - 1000 ppm [0.2
- 1 mg f/ml]
Robinson 2009

HYDROXYAPATITE
DEMIN – REMIN CYCLE

Usha C, Sathyanarayanan R. Dental caries - A complete changeover (Part I). J Conserv

Dent 2009;12:46-54
 INDICATIONS FOR USE OF TOPICAL FLUORIDES

Caries active children

In children shortly after periods of tooth eruption

Reduced salivary flow due to medications

Radiation of head and neck

Patients with fixed or removable appliances

PROFESSIONALLY APPLIED
TOPICAL FLUORIDES
 NEUTRAL SODIUM FLUORIDE

First applied topical fluoride

The first clinical study:

Using 0.1% aqueous NaF solution

Bibby (1940)
 Method of preparation:

20 gms of NaF powder in 1 litre of

distilled water

Stored in plastic bottles

Application technique – KNUTSON’s TECHNIQUE
 ADVANTAGES:

It is relatively stable

Taste is well accepted by the patients, solution is non irritating to the

gingiva, and does not cause any discoloration of tooth structure

Once applied the solution is allowed to dry for 3 min - Clinician in

public health programmes

The series of treatments must be only four times in the general age range
of 3-13 years
 DISADVANTAGES:

More visits in relatively short period of time

 STANNOUS FLUORIDE SOLUTION

Described first by Muhler for caries prevention in 1947.

Used at 2%, 8% and 10% concentrations.

Muhler & Howell (1950): Studied efficacy of 2% SnF2 & 2% NaF on 4 applications
and found 83% & 23.6% reduction in caries rate respectively

Nevitte et al (1950): Reported 44.4% & 35.9% reduction in caries with 2% SnF2 &
2% NaF respectively

Less acid soluble than sodium fluoride (Muhlemann, 1957)

Mercer and Muhler (1961) - Showed that a second application of

an 8% stannous fluoride solution given within a day or two after the

first application provided no additional anticariogenic benefit.

Advantage of stannous fluoride over sodium fluoride application:

Four appointments of NaF applications is avoided.

 Method of preparation:

8 % stannous fluoride solution: One capsule which is 0.8 gms is dissolved in 10 ml

of distilled water.

Solutions of stannous fluoride are not stable.

Soon after mixing they become cloudy due to the formation of tin hydroxide.

Muhler et al recommended that a fresh solution of stannous fluoride (SnF 2) be

prepared for each patient

pH – 2.4-2.8.
Application technique –MUHLER’s TECHNIQUE

Recommended frequency of application of 8% SnF2: Once per year

 Mechanism of action:

At low concentration At high concentration

Ca5(PO4)3OH + 2SnF2 Ca5(PO4)3OH + 16SnF2

CaF2 + Sn2(OH)PO4 + Ca3(PO4) CaF2+

Sn2(OH)PO4 4 CaF2(SnF3)2
TIN HYDROXY PHOSPHATE 2 Sn3F3PO4+

TIN TIN CALCIUM

TRIFLUORO HYDROXY TRIFLUORO
PHOSPHATE PHOSPHATE STANNATE
TIN TRIFLUOROPHOSPHATE - Tooth resistant to caries and tooth
structure more stable.

Hydroxyapatite crystals react with calcium fluoride to form small amount of

fluorohydroxyapatite crystals and calcium hydroxide

2Ca5(PO4)3OH+CaF2 2Ca5(PO4)F + Ca(OH)2

 DISADVANTAGES:

A fresh solution must be prepared for each treatment

Since 8% solution is quite astringent and disagreeable in taste (METTALIC),

its application is unpleasant

Pigmentation of teeth after the topical application of stannous fluoride

solutions has been reported by many investigators

 ACIDULATED PHOSPHATE FLUORIDE

By Bibby (1947): When pH of NaF solution was lowered, fluoride was

absorbed into enamel more effectively.

Introduced by Brudevold and his co-workers in 1960

Also known as Brudevold's solution

Pameijer & Brudevold (1963): comparing APF with neutral solution of

NaF found APF solution to be 50% more effective than NaF solution.
Wellock and Brudevold (1966): Reported 70% fewer carious lesions in 115

children who had a topical application of APF solution annually for 2 years

compared to the control group of sodium fluoride

Based on the known information that slightly demineralized enamel acquired

more fluoride.

The success of APF is attributed to its ability to deposit fluoride in the enamel as

fluorapatite
 Method of preparation:

APF has 1.23 % of fluoride as sodium fluoride, buffered to a ph of 3-4 in a 0.1 M

phosphoric acid.

20 gms of NaF in 1 liter of 0.1 M phosphoric acid + 50% HF acid to

adjust the pH at 3, and fluoride ion concentration at 1.23%.

Long shelf life when stored in a plastic bottle

For APF gel -Hydroxyethyl cellulose was added to the solution at a pH of 4-5
 APPLICATION TECHNIQUE

PAINT ON TECHNIQUE TRAY TECHNIQUE

Wax,Vinyl, Disposable polystyrene, Foam

A combination of disposable material lined with foam
And a more elaborate system called Air-cushion Fluoridator with an air filled
rubber tray.
AQUEOUS PREPARATION - PAINT-ON-TECHNIQUE.

After oral prophylaxis is done.

The teeth to be treated are completely isolated and thoroughly dried with air.

APF solution is recommended for application at 6 or 12 month intervals.

ADVANTAGES & DISADVANTAGES OF APF SOLUTION

 Requires only 2 applications in a year.

 Practical difficulties like the teeth should be kept wet for 4 minutes. So repeated
applications necessitates the use of suction.

 Increased chair side time making this fluoride application.

 It is acidic and sour and bitter in taste.

Repeated or prolonged exposure of porcelain or composite restorations to

APF can result in the loss of materials, surface roughening and possible
cosmetic changes.
 TRAY TECHNIQUE

Incorporation of water soluble polymer like Sodium carboxymethyl cellulose

into aqueous APF produces APF gel

Ease of application of APF gel makes it more significant than solution

Thyrotrophic effect

Displays a high viscosity at low shear rates and very low viscosity at higher shear rates

Thins out under biting forces and more easily penetrates between the teeth

when not under stress it remains in situ in the tray and does not run down the patients
throat
 METHODS OF APPLICATION

Initial cleaning & polishing

Quadrants are Isolated with cotton rolls and teeth are dried
thoroughly

For the application of Gel, position the patient upright & provide
Saliva ejector

Place enough Gel to fill 1/3rd

rd (5ml) of the trough area of tray so that

it is sufficient to cover dental arches

Place loaded tray over the arches & squeeze the buccal & lingual
surfaces forcing gel between them & allow tray to remain in mouth
for 4 min.

Instruct the patient to expectorate immediately & avoid drinking &

eating for next 30 min.
MECHANISM OF ACTION

Initially when APF is applied on teeth it leads to dehydration and

shrinkage in the vol of Hydroxyapatite crystals

Ca5(PO4)3OH + 4H- 5Ca++ +3Hpo4- +H2O

Further on hydrolysis
Ca++ + Hpo4 _ Ca.HPO42H2O (DCPD)

Ca.HPO42H2O +F- Ca5(PO4)3F + 2HPO4+ 3H+ +2H2O

Highly reactive
with F
 FLUORIDE FOAMS

Professionally applied fluoride foams deliver a high F- concentration

(9000–12,300 ppm) at a low frequency annual or semiannual application.

Fluoride foams (1.23% APF and 2% NaF) were introduced to dental

professionals in 1993.

Dent Clin N Am 46 (2002) 831–846

Application time for Fluoride foams should be 4 minutes.

Foams are equivalent to gels in term of F-release (Wei and Chik)

ADVANTAGE OF FLUORIDE FOAMS:

Requiring a smaller quantity of fluoride to fill the tray

Decreased risk of fluoride ingestion

Less clogging of suction lines in the dental operatory

Wei SH, Chik FF. Fluoride retention following topical fluoride foam and gel application. Pediatric dentistry. 1990;12(6):368-74.
Some topical fluoride gel and foam products are marketed with

recommended treatment times of less than four minutes, but there are

no clinical trials showing efficacy of shorter than four-minute

application times

Council O. Fluoride Therapy . 2018;40(6).

CHARACTERISTIC NaF SnF2 APF

% 2% 8% 1.23%F-
PPM 9200 19500 12300
FREQUENCY OF 4 at weekly intervals at ages 1 or2 / year 1 or 2/ year
APPLICATION 3,7,11 & 13

TASTE Bland Disagreeable Acidic

STABILITY Stable Unstable Stable in plastic container

TOOTH PIGMENTATION NO YES NO

GINGIVAL IRRITATION NO Occasionally , Transient NO

AVERAGE 29% 32% 28%

EFFECTIVENESS
METHODS TO REDUCE THE AMOUNT OF INGESTION OF FLOURIDE GEL

Place patient in an upright position.

Advise patient about importance of not swallowing the

gel.

Use no more than 2½ ml of gel per tray.

Use custom –fitted or proper size stock tray with

absorptive liners.

Use suction device during & following treatment.

Remove excess gel from teeth with guaze following tray

removal.

Have patient expectorate repeatedly & thoroughly

following treatment.
 DISADVANTAGES OF TOPICAL APPLICATIONS

Duration of contact with tooth surface

Depth of penetration

To overcome these, methods developed to prolong contact & depth of

penetration by sealing the surface of teeth with 2-( 2,2,2, -trifluoroethoxy –
ethyl- 2-cyanoacrylate) after fluoride application
 FLUORIDE VARNISHES

OBJECTIVES FOR THE EVOLUTION OF TOPICAL FLUORIDES

To enhance caries inhibitory effect by:

Developing methods for prolonging the contact of fluoride solutions with

the tooth enamel in vivo

Deeper penetration of F- in enamel

For a more permanently bound form of F-

A fluoride dental varnish can be defined as a lacquer or liquid made from natural or
synthetic base, in which fluoride salts are dissolved in a solvent such as ethanol.

The varnish coats the tooth surface as a thin layer that hardens a few minutes after
application.
The first fluoride varnish was developed in 1964 by Schmidt in which teeth were
coated by lacquer containing fluoride called as F- Lacquer.

It released fluoride ions to the dental enamel in high concentrations for several hours
in the moist atmosphere of mouth
On addition to concentrated fluoridation effect it also showed deeper penetration of
fluorides into the enamel
 First developed and
1970s in the form of silane
marketed in the 1960s in
fluoride (Fluor Protector,
the form of sodium
Ivoclar Vivadent,
fluoride (Duraphat,
Lichtenstein, Germany),
Colgate, New York, N.Y.)
TECHNIQUE OF VARNISH APPLICATION
Proximal
Application first surfaces
After – lower arch first
prophylaxis (saliva collects
teeth are dried more)

Pt. is made to
sit open
mouth for 4
A brush, a cotton-tip min.
Cotton applicator or a syringe-
isolation – x type applicator to apply
about 0.3 to 0.5 ml of
varnish directly onto
the teeth
Instructed not to
rinse or drink for 1
hour
Position the child

For an infant and young child:

Place the child on the parent’s lap - child’s legs

around the parent’s waist.

Position yourself knee-to-knee with the parent

and treat the child from behind the head.

Or, place the infant on an exam table and work

from behind the head.
Using gentle finger pressure, open the child’s mouth.
Remove excess saliva with a gauze.
Apply a thin layer of the varnish to all surfaces of the teeth. Avoid applying varnish on
large open cavities where there may be pulp involvement.
Post-application instructions :

Tell the family that the child should:

 Not have hot foods or beverages and avoid hard foods for the rest of the
day (Atleast 4 hrs). The child may eat warm or cold foods.

Not brush or floss until the next morning

 DURAPHAT
Viscous yellowish material containing 22600ppm fluoride as a
NaF in a neutral colophonium base

Active form of the fluoride varnish is usually NaF

sodium saccharin ( sweetener)

bees wax and ethanol for gelling

shellac and mastic to prevent dissolving the varnish in saliva

kolophonium to improve the flow

The resinous base is an alcoholic suspension which, when applied to the tooth
surface, evaporates, leaving a layer of fluoride rich varnish attached to the tooth
surface.
Applied to clean, dry teeth hardens to yellowish brown
coating in the presence of saliva

Bruyn & Arends: Caries reduction in permanent teeth by using

fluoride varnishes ranged from 18-77%

Available as a 10 ml tube.
First clinical trial of Duraphat by Heuser & Scmidt (1968): on 224 (13-14) yr old children
showed 30% DMFT reduction after a period of 15 months

Murray et al (1977): after semiannual application reported 36.6% DMFS reduction after 2
years

Koch and Peterson (1975): exceptionally good results were reported, whereby semi-annual
applications of Duraphat varnish reduced caries by 75% after 1 year.
Tewari.A et al (1984): after semiannual applications reported 73% DMFS reduction after 11/2
years
 FLUOR PROTECTOR

Was introduced by Arends -1970

It contains 7000 PPM of active Fluoride

Contains Silane fluoride 0.7% of fluoride ion in a Polyurethane based lacquer

Leaves a clear transparent film on the teeth

Fluor Protector has a lower pH than Duraphat and is acidic

Fluor Protector is less viscous than Duraphat.

 ADA recommendations on Fluoride varnishes (2013)

Fluoride varnish applied every six months is effective in preventing caries in the primary
and permanent dentition of children and adolescents

2 or more applications per year are effective in preventing caries in high-risk populations

Takes less time, creates less patient discomfort and achieves greater patient acceptability
than does fluoride gel, especially in preschool-aged children
• Efficacy of fluorides does not improve with multiple applications in a short
period of time

Recommended use: single-dose preparations be used twice yearly

The slow release of fluoride, for periods of up to 6 months, with Durafluor and
Duraphat, the greatest release occurring in the first 3 weeks and more gradual
release thereafter.
 Need for prophylaxis step??
•No difference in pumice prophylaxis and simple toothbrushing (Tinanoff,
1974)
•No effect of prophylaxis (Johnston, 1995)

•2 schools of thought :
1. 2-6 microns of enamel removal – more reactive enamel surface
2. Surface layer rich in fluoride – so considerable loss of F

Ripa LW. Need for prior toothcleaning when performing a professional topical fluoride application: review and recommendations for
change. The Journal of the American Dental Association. 1984 Aug 1;109(2):281-5.
Silver diamine
fluoride
INDICATIONS( UCSF ,2016) ADVERSE EFFECTS NON MEDICAL SIDE
EFFECTS

• Not a single adverse effects • Darkens carious lesion

• Small mildly painful white • Color change as a
• Extreme caries risk lesion in the mucosa which positive indication that
• behaviour/ medical appeared at 48 hrs treatment is effective
management
• one visit
• Patient with out access to
dental care
• Difficult to treat dental
carious lesion
 CLINICAL APPLICATION OF SDF IN DENTISTRY

Nishino et al (1969) caries arrest

Santos et al (1970) to prevent pit and fissure sealants
Murase(1969) and kimura (1971) To desensitize sensitive teeth
Yamaga et al (1972) as indirect pulp capping
Chu .(2002) arrest caries treatment in primary teeth
Braig et al (2009) SDF is effective in arresting the caries
 CLINICAL APPLICATION OF SDF IN DENTISTRY

Tan et al ( 2010) annual application is quite effective

Hirashi (2010) antimicrobial root canal irrigant

Hamama HH, Yiu CK, Burrow MF (2015) SDF and KI are effective in reducing the bacteria

Mei ML( 2016) 38% SDF can increase resistance of GIC and CR (composite resin) restorations
to secondary caries.

Sauvik Galui (2018) arrest dental caries and prevents its progression.
 CLINICAL APPLICATION OF SDF IN DENTISTRY

Hamama HH, Yiu CK, Burrow MF (2015) SDF and KI are effective in reducing the bacteria

Mei ML( 2016) 38% SDF can increase resistance of GIC and CR (composite resin) restorations
to secondary caries.

Sauvik Galui (2018) arrest dental caries and prevents its progression.
 Are topical fluorides effective for treating incipient carious lesions? A systematic review
and meta-analysis:Tathiane Larissa Lenzi, MSc, PhD; Anelise Fernandes Montagner, MSc, PhD;
The journal of the American Dental association:vol:147 feb 2016
Background. This systematic review and meta-analysis evaluated the effectiveness of professional topical fluoride
application (gels or varnishes) on the reversal treatment of incipient enamel carious lesions in primary or permanent
dentition.
 Methods. Literature searching was carried out by the authors in PubMed (MEDLINE), Cochrane Central Register of
Controlled Trials, Turning Research Into Practice, and ClinicalTrials.gov to verify the clinical trials available about the
outcome. From 754 potentially eligible studies, 21 were selected for full-text analysis, 5 were included for review, and 3 for
meta-analysis. The statistical analysis was performed only for studies assessing fluoride varnish; there were insufficient data
to perform it for fluoride gel studies. Two reviewers independently selected the studies, extracted the data, and assessed the
risk of bias. Pooled-effect estimates were expressed as the weighted mean difference between groups.
 Results. The therapeutic methods ranged considerably regarding the fluoride application protocols. There was a significant
trend of effectiveness of fluoride varnish on the reversal of incipient enamel carious lesions (P < .05). High heterogeneity
was found in the meta-analysis.
Conclusions. Fluoride varnish seems to be an effective treatment for the reversal of incipient carious lesions in primary and
permanent dentition; however, further clinical trials concerning efficacy of topical fluorides for treating those lesions are
still required, mainly regarding the fluoride gel.
Practical Implications. Considering the scientific evidence on topical fluorides, pediatric dentists can use fluoride varnishes
as an adjuvant for the treatment of active white-spot lesions in primary or permanent dentition. Key Words. Enamel caries;
topical fluorides; noncavitated cariou
 CONCLUSION

The need for additional fluoride supplementation depends on caries

activity,There is no distinct difference in the caries preventive effect of
concentrated fluoride solutions ,gels,or varnishes.thus the choice of
method depends on costs,convenience,patience acceptance and safety the
use of topical fluoride has proven to be feasible and safe method of fluoride
application and thus caries prevetion .
 REFERENCES
1) Fluoride s in Dentistry-2nd Edition Oie fejerskov

2) Fluoride in preventive Dentistry-theory and clinical application-Louis W Ripa

3) Fluorides in caries prevention-J J Murray

4) Essentials of public health Dentistry-5th Edition-Soben peter.

5) Silver diamine fluoride : A caries “silver Fluoride

bullet”,A.Rosenblatt,T.C.M.Stanford,R.Niederman.2009
 6) Efficacy of Silver diamine fluoride for arresting caries treatment, R. yee .C.holmgren,
J.mulder,2009
7) Promoting caries arrest in children with silver diamine fluoride : A review , C.H .Chu
2007.
8) Yamaga R nishino M,Yoshida s et al silver diamine fluoride and its clinical
application j Osaka university dent sch 1972