FLUORISES

• The word fluorine is derived from the latin term “Fluore” meaning “to flow”. Fluorine is an
electronegative, naturally occurring element and is the 13th most abundant on earth.
• Fluorine is the member of the halogen family with a relative atomic weight of 19 and an
atomic number 9.
• Fluoride is a naturally occurring element with multiple implications for human health

• The range of fluorine-containing compounds is extensive since fluorine is capable of

reacting with all the elements except helium and neon
• At room temperature fluorine is a pale yellow green gas.

• It is the most electronegative and reactive of all elements.

• The WHO expert committee on trace elements has included fluorine as one among the 14
physiologically essential elements for normal growth and development of human beings
 HISTORY
• The story of fluoridation begins with a mystery staining of the teeth first described by dentist
Dr. Frederick McKay in Colorado in 1901 and, independently in Naples in 1902 by Dr. J.M.
Eager, an American dentist stationed in Italy.
• Over the following years, McKay became aware of several cases that suggested that the
water supply might be responsible for the staining.
• He also noted that decay rates were much lower in areas with endemic dental staining than
they were in other adjacent areas.
 CONT..HISTORY
• In the United Kingdom, an Essex dentist Mr. Norman Ainsworth had found dental staining
similar to McKay's description of “Rocky Mountain Mottled Teeth”.
• As part of a study for the Medical Research Council in 1925, Ainsworth examined over
4,000 children and, for the first time, produced a statistical comparison of decay rates
between populations with the staining and those without.
• This study showed that those living in areas where mottled teeth were commonest tended to
have much less dental decay.
 CONT…
• It seemed clear that fluoride levels in water were related to both the staining of the teeth and
reduced decay levels.
• The US Public Health Service was anxious to investigate this relationship and appointed a
dentist, Dr. H.T. Dean, to carry out the research.
• In a series of classic shoe-leather epidemiological investigations, culminating in his famous
“21-City Study”, Dean established that mottling of the teeth was extremely rare at fluoride
levels of 1ppm or below, while the greater part of the caries preventive effect was to be seen
at 1ppm.
• Dean published the results of his work in 1942.
 CONT..
• Water naturally fluoridated at 1ppm clearly benefited dental health. Following Dean's
studies, the health authorities in the United States sought to reproduce this effect in low-
fluoride areas by adding fluoride.
• No obvious negative health effects had been noted in populations served by naturally
fluoridated water.
 CONT…
• The introduction of fluoridated toothpaste in the early 1970s has provided a very important
source of fluoride and this is thought to have been a major contributor to the fall in decay
rates.
• While we still see relative disease reduction of 50%.
• Nonetheless, in the opinion of the public health professionals involved, the value of the
additional decay reduction brought about by fluoridation is more than significant enough to
warrant the continuation of the policy
 CONT…
• Ainsworth was aware of Churchill's research and decided to compare the water supplies
from the endemic staining area around Maldon in Essex with that of the nearby town of
Witham.
• The Witham water proved to have 0.5ppm fluoride, the samples from around Maldon ranged
from 4.5 to 5.5ppm.
 ABSORPTION, DISTRIBUTION, SECRETION,
AND EXCRETION OF FLUORIDE

• Fluoride-containing compounds are extremely diverse. For that reason it is not possible to
generalize on their metabolism,
• The ionic form of fluoride, which can be either generated within the body by the
biochemical modification of the different fluoride-containing compounds or ingested
directly, is metabolized by the body in a simple manner
 CONT…ABSORPTION..
• Fluoride mostly enters the body via the gastrointestinal tract and is absorbed quickly in the
stomach without the need of specialized enzymatic systems
• Recent studies have indicated that in addition to crossing the stomach as undissociated acid,
the majority of fluoride absorption occurs in the small intestine and is not pH dependent.
 CONT….
• As soon as fluoride is absorbed, plasma fluoride levels increase (at 10 minutes), reaching
peak levels at 60 minutes.
• It is well documented that there are 2 forms of fluoride in plasma. One fraction is designated
as ionic fluoride and the second is designated nonionic or bound fluoride, composed of lipid-
soluble organic fluoro-compounds.
• The biological significance of the nonionic fraction is not well understood.
 CONT….
• Once fluoride reaches plasma, it is rapidly deposited in the skeleton or excreted via the
kidneys.
• Fluoride skeletal uptake is also modified by factors such as the activity of bone modeling
and remodeling and age.
• The degree of fluoride retained in the skeleton is inversely proportional to the age of the
individual.
• In subjects with no previous exposure to fluoride, the amount of fluoride absorbed increases
until saturation is reached.
 CONT…
• In bone, fluoride can be deposited in the adsorbed layers, the crystal structures, or the bone
matrix.
• Once fluoride is incorporated and when bone saturation is approached, the fluoride can be
slowly removed.
• Previous observations after removal of fluoride from community waters have shown that the
half-life for loss of fluoride for adults is 120 weeks, whereas it is 70 weeks for children.
 CONT…
• Fluoride is secreted in saliva; salivary levels increase as plasma levels increase.
• Although salivary levels are only within the range of 0.01 to 0.06 ppm for individuals
exposed to fluoride, they are of critical importance for the role of fluoride as a preventive
agent for dental caries
 SOURCES OF FLUORIDE INGESTION AND
EXPOSURE
• The different sources that contribute to fluoride intake and exposure can be classified as
follows:
• (a) systemic/planned—fluoridated milk, water, or salt, fluoride supplements;
Milk formulas mixed with drinking water can increase the amount of fluoride and therefore the
risk of dental fluorosis.
• (b) systemic/incidental—dentifrice ingestion, fluoride rinse ingestion, environmental pollution,
ingestion of Teflon coatings on pans; exposure to food/soil/pesticides, prescription drugs,
smoking
 CONT…
• (c) topical/planned—professionally applied gels and varnishes, toothpaste, or home use
rinses and gel; and
• (d) topical/incidental—alginate impression materials.
 CONT..
• Longitudinal studies have identified the following as major sources of fluoride intake:
• milk derivatives, water, fish and seafood, chicken, and toothpaste and other oral products
containing fluoride. However, their results demonstrated that intake levels at early ages
present wide ranges due to variations in consumption .
• Milk formulas mixed with drinking water can increase the amount of fluoride and therefore
the risk of dental fluorosis.
• The ingestion of fluoridated toothpaste in children younger than age 6 years has also been
strongly associated with increased fluoride intake.
 FLUORIDE TOXICITY

• Ingested in excessive quantities, fluoride can be toxic. The American Dental Association has
recommended that no more than 120 mg fluoride (264 mg sodium fluoride) be dispensed at
any one time.
• Statistics kept by the American Association of Poison Control Centers indicate that of all
reported cases of fluoride intoxication, 68% were related to fluoride dentifrice ingestion,
17% to fluoride mouth rinses, and 15% to fluoride supplements.
• Children younger than 6 years of age account for more than 80% of reports of suspected
over ingestion.
 CONT…..
• The minimum dose that could cause toxic signs and symptoms, including death, and that
should trigger immediate therapeutic intervention and hospitalization for fluoride
intoxication has been set at 5 mg/kg body weight.
• The lethal dose of fluoride has been set at 15 mg/kg (the literature reports lethal doses
between 7 and 16 mg/kg body weight).
• Death has occurred in infants with as little as 250 mg.
 CONT…
• Common signs and symptoms of acute fluoride toxicity include nausea, vomiting, and a
drop in blood calcium, causing local or general signs of muscle tetany.
• Signs also include abdominal cramping and pain and increasing hypo calcaemia and
hyperkalemia, leading coma, convulsions, and cardiac arrhythmias.
• Generally, death from excessive fluoride ingestion will occur within 4 hours; if the
individual survives for 24 hours, the prognosis is guarded to good
 TOXIC EFFECT…FLUORIDE…
• The toxic effects of fluoride are mainly due to 4 different actions:
(a) burning the tissues (it forms hydrofluoric acid when it comes in contact with moisture,
which has a corrosive action),
(b) impeding nerve function (through its affinity for calcium, which is needed for nerve
function),
(c) cellular poisoning (through the inhibition of enzyme systems), and
(d) impeding cardiac function (by causing an electrolyte imbalance leading to hyperkalemia).
 FLUORIDES AND DENTAL CARIES
PREVENTION

• Fluoride is widely recognized for reducing the prevalence of dental caries, Dental caries is a
site-specific, multifactorial disease.
• Numerous biological factors for each individual influence the development of caries on a
tooth surface.
• The development of caries on a specific site is the result of that site’s individual dental
plaque composition and metabolism, which is influenced by biological determinants,
including saliva, diet, and possibly genetic factors
 MECHANISM…
• Although dental caries is multifactorial and complex, it is preventable.
• That fluoride decreases the incidence of dental caries and slows or reverses the progression
of existing lesions by decreasing the rate of dental enamel demineralization and enhancing
the rate of enamel remineralization.
• Current understanding of the mechanism of action of fluoride indicates that its major effect
is topical and that this depends on fluoride being present in the dental plaque/enamel
interface in adequate amounts during caries formation and reversal.
 MECHANISM…
• A secondary mechanism for fluoride is exerted through its influence on dental plaque
bacterial metabolism.
• However, the relative importance of the direct effects of fluoride on bacterial metabolism is
still debated.
• Finally, it is recognized that there is some minor incorporation of fluoride into the enamel
crystals prior to tooth eruption, which could increase resistance to solubility in acids.
 CONT…
• The current understanding of the mechanism of action for caries prevention by fluoride
indicates that fluoride mostly acts topically, and not systemically; therefore,
• fluoride exerts its preventive effects through an individual’s life span, not just when teeth are
forming.
• Topical forms of exposure to fluoride in the United States include toothpaste, rinse, and gel
use, as well as professionally applied gels and varnishes where, has been determined to be
the most effective use of fluoride in controlling caries.
 CONT…
• Systemic sources of fluoride (such as intake of fluoridated water) also have a place in public
health, resulting in more widespread exposure to fluoride.

• The systemic fluoride is secreted into the oral cavity via saliva, where it can affect caries
formation topically.
• Addition of fluoride to public water supplies at 0.7 ppm has particular benefits for
population groups that do not have access to topical fluorides or regular dental care.
 EFFECTIVE PROTECTION….
• The precise “optimal” oral intake of fluoride to provide effective protection against dental
caries has not been determined.
• In 1997, the United States Institute of Medicine published age-specific recommendations
for total dietary intake of fluoride.
• For children aged 12 years and younger, 0.05 to 0.07 mg/kg of body weight has been
accepted as optimum amount of total daily intake of fluoride, while total daily intake should
not exceed 0.10 mg/kg of body weight to avoid an undesirable degree of fluorosis.
 FLUORIDES AND DENTAL FLUOROSIS

• Dental fluorosis is a hypo mineralization of dental enamel

that occurs as a result of excessive fluoride ingestion
during tooth formation.
• It has been suggested that for dental fluorosis to appear,
an excessive amount of fluoride has to be present in the
environment of the developing enamel during a critical
period of greater susceptibility (or “window of
susceptibility”) for that given surface.
 CONT…
• Based on the results of an epidemiological study done in Hong Kong,
China, in which investigators were able to determine precise periods of
excessive fluoride intake for groups of children because fluoride levels
in the water were adjusted downwards, a window of susceptibility was
estimated for the central maxillary incisors.
• More recent studies have estimated the window of susceptibility to cover
the first 2 years of life.
 CONT…
• The effects of ingested fluoride on dental enamel during its formation are well
documented.
• Most of the studies that have documented these effects have been conducted in
communities where the water sources are fluoridated.
• At 1 ppm in the water supply, early signs of fluorosis are visible on the enamel
surface as opacities.
• As the dose increases, the severity of the signs increases until at approximately 10
ppm the porosity of the enamel is compromised and large pieces of enamel are
fractured after eruption.
 CONT…..

• At the cellular level, dental fluorosis development depends on the levels of fluoride in the
extracellular fluid that surround the developing dental enamel.
• These levels of fluoride are determined by the plasma concentration, which in turn is a
function of daily intake of fluoride.
• There is evidence suggesting that the effects of fluoride are cumulative and depend mostly,
on the amount and duration of exposure.
 CON….
• Experimental results suggest that a linear relationship exists between
increasing fluoride doses and their effects on dental tissue.
• However, a clear-cut direct relationship between amount of fluoride
ingested and severity of dental fluorosis has not been proven; rather,
fluorosis development has a demonstrated genetic component
DISTRIBUTION OF FLUORIDE TO
MINERALIZED TISSUE
• Overexposure to fluoride over a long period of time can
cause skeletal fluorosis, a condition that results in the
weakening of the bones. However, skeletal fluorosis only
BONE
occurs when fluoride concentrations are higher than 4
mg/L—levels that are much higher than those used
• 99% of all the fluoride in the human body is found in
calcified tissues.

• Mature bones take up less fluoride compared to younger

ones.

• Cancellous bone incorporates more than cortical

• The enamel which is porous absorbs fluoride.
ENAMEL

• The accumulation of fluoride by enamel seems

largely restricted to the surface than the
interior.
• Concentration of fluoride was the highest
in the outermost layer of the enamel, and there
was a marked decrease in concentration from
the surface to a distance
 SEVERETY……….ON…PRIMARY…
• Changes vary from chalky white opaque areas, resulting from
subsurface hypo mineralization, to pits and grooves, and with
increased severity, post-eruption staining.
• Primary-tooth fluorosis may be related to occurrence of fluorosis in
the permanent dentition, so that its recognition by the clinician should
raise awareness of possible increased risk for the permanent dentition.
 DENTIN
• Dentin is like bone and cementum, it is a mesenchymal derivative unlike
enamel which is ectodermal in origin.
• hypothesized that severe fluorosis would lead to hypermineralization of
the dentin when the enamel was severely affected
• Cementum Greater tissue porosity and poor crystallinity facilitate
increased fluoride uptake in cementum.

Absorption of fluoride in ascending order:

Cementum > bone > dentine > enamel

• Fluoride is used as a cariostatic substance, the effectiveness of
fluoride as cario static agent depend the availability of free
fluoride in plaque during cariogenic challenge can arreset
caries
• Thus a constant supply of low level of fluoride in
biofilm/saliva/dental interfance is considered the most
beneficial in preventing dental caries.
 THE CARIOSTATIC MECHANISMS OF
FLUORIDE

• In the past, fluoride inhibition of caries was ascribed to reduced solubility of enamel due to
incorporation of fluoride (F-) into the enamel minerals.
• The present evidence from clinical and laboratory studies suggests that the caries-preventive
mode of action of fluoride is mainly topical.
• There is convincing evidence that fluoride has a major effect on demineralization and
remineralization of dental hard tissue, the source of this fluoride could either be fluorapatite
or calcium fluoride (CaF2).
 CAF-………
• Calcium fluoride deposits are protected from rapid dissolution by a phosphate -protein
coating of salivary origin.
• At lower pH, the coating is lost and an increased dissolution rate of calcium fluoride occurs
• The CaF2, therefore, act as an efficient source of free fluoride ions during the cariogenic
challenge.
• During acid production. Thus, a constant supply of low levels of fluoride in
biofilm/saliva/dental interference is considered the most beneficial in preventing dental
caries.
Depending on the fluoride delivery
method used it can be divided into two types:
1. Systemic fluorides: systemic fluorides are those that are ingested and become
incorporated into forming tooth structures.

2. Topical fluorides: Topical fluorides strengthen teeth already present in the mouth,
making them more decay resistant,
 DIFFERENT TYPES OF SYSTEMIC
FLUORIDE SUPPLEMENTATION
Community water fluoridation

• School water fluoridation

• Dietary fluoride supplementation

• Milk fluoridation

• Salt fluoridation
 DIFFERENT TYPES OF TOPICAL
• Professionally applied: these APPLICATION
topical fluorides are used by a
dental professional in the dental
office, and they could be in the form
of a gel, varnish, foam, or mouth
rinse .
• These products have a much
higher fluoride concentration than
self-applied fluorides
 SELF APPLIED
• Fluoride mouthwash

• Sodium fluoride
• Stannous fluoride
• Acidulated phosphate fluoride (APF)
 DENTAL VARNISHES
• Duraphat

• Fluro protector

• Carex
 WATER FLUORIDATION
• It is the upward adjustment of the concentration of fluoride ion in a public water supply.

• The concentration of fluoride ion in the water may be consistently maintained at one part per
million (1 ppm) by weight to prevent dental caries with minimum possibility of causing
dental fluorosis.
• It has been found to be the least expensive and most effective way of providing fluoride to
large groups of people of all ages.
 MECHANISM OF ACTION OF
FLUORIDE
• Number of proposed mechanisms have been identified which are assumed to work
simultaneously and can be grouped as follows:
1. Increase the enamel resistance (reduced enamel solubility)

2. Increase the rate of post eruptive maturation

3. Remineralization of incipient lesions

4. Interference with Plaque Micro-organisms

5. Modification in tooth morphology

 INCREASED THE ENAMEL RESISTANCE /
REDUCTION IN ENAMEL SOLUBILITY
• Dental caries involves dissolution of enamel by acids from bacterial plaque and that
dissolution is inhibited by the presence of fluoride,

• Because fluoride forms fluorapatite which is less soluble compared to hydroxyapatite.

• Fluoride acts as an inhibitor of demineralization.

 INCREASED RATE OF POST-
ERUPTIVE MATURATION
• The greatest importance of fluoride to the maturation process
lies in its ability to increase the rate of mineralization of hypo-
mineralized areas.
• Early detection and appropriate therapy can prevent severe
complications and improve both masticatory function and
esthetics.
• The treatment varies from a simple procedure, such as a
controlled clinical eruption, to extensive and recurrent
treatments in more severe cases.
 REMINERALIZATION OF INCIPIENT LESIONS

• Fluoride plays a critical role in reducing dental caries by enhancing

remineralization.

• It is the process of depositing minerals into previously damaged areas of the

tooth
 INTERFERENCE WITH MICRO-
ORGANISMS
• Fluoride has been known to inhibit bacterial enzymatic process involved in carbohydrate
metabolism.

• Fluoride interferes in 2 ways:

In high concentration, it is bactericidal and in low concentration, it acts as bacteriostatic
 MODIFICATION IN TOOTH
MORPHOLOGY
• If fluoride is ingested during tooth development there will be a formation of caries resistant
tooth.

• The diameter and cusp depth of teeth are smaller, the fissures are shallow thus making them
self cleansing.
 TOXICITY OF FLUORIDE
• Fluoride is always referred as a double edged sword, in low concentration it helps reduce
dental caries but in high concentration it produces harmful effects on the system.
• The toxic effects of fluoride can be divided into two types:

1. Acute fluoride toxicity and

2. chronic fluoride toxicity

CHRONIC TOXICITY caused by excessive intake of fluoride during tooth
development

• An intake above 2 ppm (particularly >5ppm)in children causes mottling

of enamel and discoloration of teeth
Clinical features
• Lustreless,opaque white patches in the enamel which may become
mottled,striatedor pitted
• Mottled areas may become stained yellow or brown
• Hypoplastic area also present
EFFECT DOSAGE DURATION

Dental fluorosis Greater than twice the Until 5 years of age

optimal level
of fluoride

Skeletal fluorosis 10–25 mg/day of 10–20 years

fluoride
 DENTAL FLUOROSIS
• It ranges from mild to severe fluorosis and is characterized as loss of translucency and white
flecks on the enamel.

• White chalky opaque areas covering 25% to more than 50% of the tooth surface, attrition of
the enamel, brownish stains and pitting of the enamel in the severe fluorosis
• Risk factor other than water, could be tobacco, drug(fluoroquinolone),antibiotics, few,
depressant ,some antifungal drugs, cholesrol-lowering drug, steroids and anti-inflammatory
drugs, antiacids,drog for osteoporosis can contribute to fluoride toxicity.
 SKELETAL FLUOROSIS
1. Osteosclerosis become more dense and diffuse, progressing to marked thickening of
cortical bone, and calcification of ligaments and tendons .(STIFNESS AND PAIN IN
JOINT
2. Knock-knee syndrome: outward bending of legs and hands.(LIGAMENT CALCIFY

3. Crippling fluorosis: This is the severest form of fluorosis. The spine becomes rigid and
the joints stiffen, virtually immobilizing the patients.(PARALYSIS AND PAIN)
KNOCK KNEE SYNDROM
 DIAGNOSIS
1.Physical tests for detection of skeletal fluorosis in endemic areas-coin test, chin test,
stretch test
2.Radiographs:
3.SA/GAG test for early detection/diagnosIs of fluoride toxicity. The value of SA/GAG will be
reduced in fluorosis and will be significantly elevated in ankylosing spondylitis
 MANAGEMENT
• There is no treatment for severe cases of skeletal fluorosis, only efforts can be made
towards reducing the disability which has occurred. However, the disease is easily
preventable if diagnosed early and steps are taken to prevent intake of excess fluoride
through provision of safe drinking water, promote nutrition and avoid foods with high
fluoride content.
• Dental and skeletal fluorosis is irreversible and no treatment exists, the only remedy is
prevention by keeping fluoride intake with in safe limits.
 DENTAL FLUOROSIS TREATMENT:

• tooth whitening for mild

fluorosis cases
• composite bonding
• Porcelain veneers
 PREVENTION

• Fluorosis can be prevented by avoiding excessive intake of fluoride by individuals /

COMMUNTY
• by using alternative water sources,
• by removing excessive fluoride from drinking water,
• by improving the nutritional status of population/individuals at risk.
• Using alternative water resources include surface water, rainwater, and low fluoride ground
water:
• Surface water: If surface water is used for drinking purposes particular caution is required, since
it is often contaminated with biological and chemical pollutants. Surface water should be used
after proper disinfection with simple and low cost method such as sand filtration, ultraviolate
disinfection; chlorination (may be adequate in some places but not all places.)
• Rainwater: It is usually cleaner and low cost simple source, but problem is for large storage of
water and large reservoir in the communities and households.
• Low fluoride ground water– fluoride content can vary in wells in the same area, depending on
the geological structure of the aquifer and the depth at which water is drawn. Deepening tube
wells and digging new wells in another site may be helpful. Fluoride is unevenly distributed in
ground water both vertically and horizontally.
• (b)Defluoridation of water (removing excessive fluoride from drinking water):
• Use of safe drinking water with safe fluoride levels is the preferred option for the prevention of
fluorosis; however access to safe water in fluorosis endemic areas is limited.
• The de-fluoridation is the only solution; this can be done by different methods:
• Chemical precipitation-Alum coagulation (Nalgonda technique), Electrolyte defluoridation
 CONCLUSION
• Fluoride is a naturally occurring element with multiple implications for human health.
• Its metabolism and toxicity have been extensively studied. However, there are still gaps in
knowledge that need to be addressed.
• Current understanding of the mechanism of action and toxicity of fluoride leads to
conclusions that at appropriate levels, fluoride has been established as a safe and effective
agent in the prevention of dental caries throughout an individual’s lifespan.
• However, a positive relationship has also been established between excessive fluoride intake
during periods of enamel formation and the development of dental fluorosis.
THANK YOU