GOOD MORNING

TOPICAL FLUORIDES
DEPT OF PEDODONTICS &
PREVENTIVE DENTISTRY
CONTENTS
• Introduction
• History
• Rationale of using topical fluoride
• Mechanism of action
• Professional application
• Fluoride varnishes
• Newer topical fluoride agents
• Self applied topical fluorides
• Fluoride in dental materials
• Methods for enhancing fluoride fixation in enamel
• Conclusion
TOPICAL FLUORIDES…
HISTORY…
• Dean (1941) proved that individuals continuously living in a fluoride rich area
had less caries compared to the individuals who lived in the same fluoride rich
areas during calcification of teeth but had shifted to non-fluoride areas thereafter

• Simultaneously in 1940’s, it was demonstrated that extracted teeth when

exposed to dilute solutions of fluoride ion for a few seconds were less soluble
than the original enamel surface.

• These two facts brought forth the idea of topical application of fluoride solution
for dental caries prevention.
CLASSIFICATION
• PROFESSIONAL APPLICATION - 5000 to
19,000 ppm
• SELF APPLICATION - 200 to 1000 ppm.
RATIONALE
• Speed the rate
• Increase the concentration
• Hypomineralised regions are principle sites of
fluoride uptake (Brudevold, 1956 & Briner , 1967)
• vulnerable enamel sites - white spot lesions
MECHANISM OF ACTION

• On bacteria
• Fluoride enamel interaction
• 10 – 30 micro meter on enamel
INDICATIONS
• Caries – active individuals
• Shortly after eruption – not caries free
• xerostomia; receive radiation
• After periodontal surgery (roots exposed)
• Fixed and removable prosthesis
• Mentally & physically challenged children
SODIUM FLUORIDE
• first topically applied fluoride compound.
• In 1941, Bibby did the first clinical study using 0.1% NaF solution,45%reduction in
first yrs, 33% 2nd yrs & 36% 3rd yrs.
• Knutson and colleague (1942 to 1948) began a series of clinical trials regarding
the number of applications to be done in a year. (utilizing 2% solution for 3-
4minutes)
• They recommended a technique of 4 applications & also recommended 7, 10 and
13 years as specific age groups of NaF application “Knutson’s Technique”
• Galagan and Knutson (1947) divided the children of 7-15 years into three groups
and gave 2,4,6 applications per year and the results after 1 year showed 21%,
40.7% and 41.0% caries reduction respectively.
PREPARATION
• 9040 ppm
• 2% Neutral NaF solution
• 20 grams of NaF powder in 1 liter of distilled water
• plastic bottle
• pH of 7.
APPLICATION
• Pumice prophylaxis
• Ripa 1984 - not reduced if teeth remain uncleaned.
• According to Knutson Technique:
• Isolated & dry
• Using cotton tip applicator sticks, the 2% NaF solution is painted on
the air-dried teeth
• dry for 3-4 minutes
• avoid eating, drinking or rinsing for 30 minutes
• A second, third and fourth fluoride application - one week.
• 3,7,11 and 13 years
MECHANISM OF ACTION
• CaF2
• Chocking off
• Fluoridated hydroxyapatite
• By acting as a diffusion barrier.
• Reducing enamel solubility.
• Acting as a reservoir for the enamel
microenvironment.
• Desorbing proteins and microorganisms from the
enamel surface.
ADVANTAGE OF NEUTRAL NAF
• It is relatively stable
• The taste is well accepted by patients
• It is non-irritating to hard and soft tissues
• It does not discolor the tooth.
• The series of treatments must be reported only four times
in the general age range of 3 to 17years, rather than at
annual or semiannual intervals
DISADVANTAGES
• Patient must make four visits to the dentist within a
relatively short time.
• It has very limited effectiveness as a professionally applied
topical fluoride,
• At lower concentration, sodium fluoride has become the
most widely used self applied fluoride mouthwash agent
and fluoride dentifrices .
 STANNOUS FLUORIDE
• Muhler and coworkers Stannous fluoride is effective than sodium fluoride
in preventing dissolution of calcium and phosphorus from enamel by
dilute acids

• Muhler et al (1947) observed that enamel powders treated with stannous

fluoride solution greatly reduced the rate of acid dissolution.

• Muhler et al (1950) SnF2 to be three times more effective than NaF

• Howell & Muhler (1956) studied the relative efficacy of four applications of
2% SnF2 & 2% NaF & reported 83% & 23.6% reduction in caries rate
respectively.
• Stannous fluoride - Second topical fluoride agent to gain
wide acceptance
• Stannous fluoride -8% and 10% concentrations
• 10% solution - for adults and 8% - for children (No
evidence of actual clinical difference between the two).
• Most commonly used is 8% stannous fluoride
preparation.
• 19360 ppm
• pH 2.1 – 2.3
 METHOD OF PREPARATION OF 8% SNF
• The content of one capsule which is 0.8 gms SnF is dissolved in
10ml of distilled water in a plastic container
• The solution is shaken briskly.
• The 10ml of the solution - sufficient to treat the whole mouth of a
single patient
• Solutions of stannous fluoride are not stable. Soon after mixing -
cloudy due to the formation of tin hydroxide.
• Since stannous contribute to the anti-caries benefits of stannous
fluoride, aged solutions is less effective.
MECHANISM OF ACTION OF SNF2
• Muhler (1968) - Stannous fluoride reacts with Hydroxy
apatite, in addition to fluoride, tin of stannous fluoride
also reacts with enamel and a new crystalline product
gets formed which is different from fluorapatite
• Stannous tri fluorophosphate – Jorden et al 1971
• In low concentration of stannous fluoride -
• Tin hydroxy phosphate [Sn2 (OH) Po4] , tin-tri-fluoro phosphate (Sn3F3PO4)
(AC) and CaF2
• Fluorhydroxyapatite (AC)

• At very high concentration of stannous fluoride

• Calcium-tri-fluoro stannate [Ca(SnF3)2] , Tin hydroxy phosphate (metal
taste) ,Tin-tri-fluorophosphates (AC) and CaF2
• Ca5 (PO4)3OH+16SnF2 → 2Sn3F3PO4 +Sn2(OH)PO4+4CaF2(SnF3)2
+2CaF2
• CaF2 further reacts with hydroxy apatite to form Fluoro hydroxy apatite (AC)
• 2Ca5(PO4) 3 OH + CaF2 → 2Ca5(PO4) F +Ca (OH)2
METHOD OF APPLICATION OF SNF2
• Muhler’s technique
• Each tooth is thoroughly cleaned and polished with pumice including the
proximal surface
• Isolated with cotton rolls and dried with compressed air.
• Either a quadrant or half of the mouth can be treated at one time and kept
free of saliva
• A freshly prepared 8% SnF2 is applied continuously with cotton applicators
(Paint on Technique).
• Apply stannous fluoride for as long as 4 minutes,(30 or even 15 seconds is
also considered adequate Mercer and Muhler (1964), Scola and Ostrom
(1968)
• The recommended frequency of 8% SnF2 applications is once per year.
ADVANTAGES OF SNF2
• highly effective when applied to teeth on a semiannual application

• the rapid penetration of the tin and fluoride ions, resulting in the
formation of highly insoluble ions, and amorphous layer of tin
phosphate complex on the enamel surface.

• effective against radiation caries as well as for patients undergoing

orthodontic treatment.
DISADVANTAGES OF SNF2
• Unstable solution, Very low pH of 2.1 to 2.3.
• Metallic and astringent taste.
• Gingival tissue irritation.
• Light or dark brown discoloration in partially
demineralized and hypo calcified areas of tooth
• Grayish discoloration of margins of restorations,
particularly composite restorations.
• Solutions of stannous fluoride (8%) are no longer used
because other products with less objectionable taste are
now available.
STANNOUS FLUORIDE GEL

• Shannon developed a gel containing 0.4% stannous fluoride in

methyl cellulose & glycerin base. Flavored with cinnamon or
grape; it remains stable for 15 months
• However for the Fluoride to be released, the gel should be diluted
following its application to the teeth.
• Effective with a synthetic saliva gel in reducing caries in post –
irradiation cancer patients.
• Enamel decalcification around bands in orthodontic patients.
ACIDULATED PHOSPHATE FLUORIDE

• Bibby (1947) Reported that as the pH of NaF solution was lowered, fluoride was
absorbed more effectively. Inherent limitations, as indiscriminate lowering of pH
of NaF solution will cause decalcification &demineralization of enamel
• Brudevold et al (1963) Found out that phosphate-containing fluoride provided
maximal fluoride deposition with minimal demineralization.
• Pomeijer and Brudevold (1963) Compared the effectiveness of a solution of
natural NaF with APF using half mouth technique, reported APF to be 50% more
effective than neutral NaF as a caries prevention.
• William 1970 – gel > solution
METHOD OF PREPARATION OF APF SOLUTION
• APF contain 1.23% of fluoride in 0.1M phosphoric acid at a pH of
3, has long self life when stored in opaque plastic bottles.

• It is prepared by dissolving 20 grams of NaF in 1 liter of 0.1M

phosphoric acid.

• To this 50% hydro fluoride acid is added to adjust the pH at 3 and

Fluoride concentration at 1.23%.
• 12300 ppm
MECHANISM OF ACTION OF APF
• Deeper
• Dehydration and shrinkage of hydroxy apatite crystals, which further on hydrolysis
forms an Dicalcium phosphate dihydrate (DCPD)
• This DCPD is highly reactive with fluoride ion
• Fluoride penetrates more deeply through the openings produced by shrinkage and
forms fluorapatite
• The amount and depth of fluoride deposited - amount and depth at which DCPD
gets formed
• Deeper penetration and continuous fluoride supply is required for conversion of
whole of DCPD into fluorapatite
TECHNIQUE OF APPLICATION OF APF
• The preferred method of Application is the paint-on- technique
• oral prophylaxis is done
• Isolated with cotton rolls and dried with compressed air.
• The fluoride is then applied repeatedly with a cotton applicator – 15 – 30 sec
• Not necessary to prepare freshly
• After all the teeth are similarly treated, the patient is instructed not to eat drink or
rinse his mouth for at least 30 minutes
• Acidulated phosphate fluoride is recommended for application at 6 or I 2 month
intervals
ADVANTAGES OF APF SOLUTION
• Requires only 2 applications in a year

• Deeper penetration of fluoride

DISADVANTAGES OF APF SOLUTION
• Practical difficulties like the teeth should be kept wet for 4 minutes
(repeated applications necessary)

• It is acidic, sour and bitter in taste.

• It cannot be stored in glass containers because it may remove

mineral from (etch) the glass.

• Repeated or prolonged exposure of porcelain or composite

restorations to APF can result in the loss of materials, surface
roughening and possible cosmetic changes.
APF GEL
• To overcome the problem with APF solution, APF gels were introduced.

• Bryam and Williams (1968) reported a 45% reduction in carious teeth after a single application
of APF gel.

• Englander et al (1969) after 2 years of study showed 60% caries reduction.

• Ingraham and Williams (1970) carried out a 2-year study to compare the effectiveness of APF
solutions and gels and concluded that solution was approximately only half as effective as the
gel.
METHOD OF PREPARATION OF APF GEL
• For the preparation of APF gel, a gelling agent
methyl cellulose or hydroxy ethyl cellulose is to
be added to the APF solution and the pH is to be
adjusted between 4-5
 TECHNIQUE OF APPLICATION OF APF GEL
• Clinical application is done using trays that fit the patients
upper and lower dental arches, Disposable foam lined trays
are preferred.
• The patient should sit upright in the chair.
• The teeth should be clean and dried as practicable
• A minimum amount of fluoride gel that will permit complete
coverage of the tooth surfaces should be dispensed
• After the tray has been properly positioned, the saliva ejector
is used to evacuate the stimulated saliva and excess fluoride
• The patient is told not to swallow the gel but to exert
slight pressure using the cheeks and tongue as well as
light biting forces in order to cause the gel to flow inter
proximally.

• The fluoride gel should be in the mouth for 4 minutes.

• The patient should be told to expectorate the remaining

oral fluid and not to eat or drink for 30 minutes after
application.
ADVANTAGES OF APF GEL
• Requires only 2 applications in a year

• Gel adheres to the teeth, and the continuous rewetting of

enamel surface with a solution is eliminated.

• Full mouth can be treated simultaneously, resulting in a

substantial reduction in the time of total treatment.
DISADVANTAGES OF APF GEL
• It is acidic, sour and bitter in taste.

• It cannot be stored in glass containers because it may remove

mineral from (etch) the glass.

• Repeated or prolonged exposure of porcelain or composite

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

• Fluoride is retained in the mouth leading to fluoride toxicity

APF FOAM
• In an attempt to minimize the risk of fluoride over dosage
& to maintain the efficacy of topical fluoride treatment, a
foam based APF agent has been developed.

• Wei et al (1988) stated that topical application of an APF

foam significantly increased the fluoride concentration in
the outer 5mm enamel; similar to that of an APF gel.
ADVANTAGE OF FOAM- BASED APF AGENTS
• It is lighter, therefore only a small amount of the agent is needed
for topical application (1gm of foam/mouth).

• The surfactant in the foaming agent has cleansing action by

lowering the surface tension - penetration of the material in to
interproximal surfaces

• Since APF foam does not require suctioning; it offers advantages

for home use, treatment of young children & disabled persons
FLUORIDE VARNISH

• NaF, SnF and APF in aqueous form

• Remain in contact with teeth for a very short time i.e. 5

to 10 minutes

• Superficial effect
INDICATIONS FOR USE OF A FLUORIDE VARNISH

• Caries prevention in children: biannual application of a fluoride

varnish gives 35 to 45% caries reduction

• Nervous children: An excellent atraumatic introduction for

demineralized areas.

• Failed Fissure sealants: etched and not sealed

• uncooperative child

• Children with medical/physical conditions – precaution

• difficult to treat

• Nursing bottle caries .

• Adults with dentine hypersensitivity: weekly applications in the sensitive

areas over a three-week period progressively reduces pain.

• Root caries - preventive program in elderly.

• Community program for children : WHO recommendation.

• In orthodontic patients to reduce decalcification around brackets.

CONTRAINDICATIONS

• History of allergies (sensitivity to colophonium component)

• Asthmatics are also included in this category.

• Ulcerative gingivitis & stomatitis - short term burning sensation,

staining of the teeth.

DURAPHAT
• Is a 5% sodium fluoride formulation in a viscous colophonium base.
• One milliliter of the varnish contains 50 mg of NaF (2.26 mg fluoride /ml).
• It is available as a 10ml tube.
• The resinous base is an alcoholic suspension
• when applied to the tooth surface, evaporates, leaving a layer of fluoride rich
varnish attached to the tooth surface.
FLUOR PROTECTOR
• Contains 1% difluorosilane in a polyurethane base.
• Each milliliter of varnish contains 1mg of fluoride ion (1000 ppm).
• Fluor protector has a lower pH than duraphat
• Supplied in a box containing 20 vials. Each vial contains a 0.4ml (0.4 mg F) of
the varnish solution.
• Fluor protector is less viscous than duraphat or Durafluor.
DURAFLUOR
• 5% NaF varnish in an alcoholic suspension of natural resins.
• The one additional ingredient in Durafluor (2.26 mg /ml) is Xylitol
which improves taste & patient acceptability.
• Less viscous in nature than Duraphat
• Supplied as 10 ml tube.
CAVITY SHIELD
• Recent fluoride varnish in the market
• 5% NaF varnish in a resinous base.
• Each milliliter contains 50mg NaF.
• The difference between cavity shield & other varnishes is that it is a unit – dosed
fluoride varnish.
• Each individual package contains either 0.25 ml (12.5 mg NaF) or 0.4 ml (20 mg
NaF) depending on the number of teeth to be treated.
ADVANTAGES

• It avoids wastage & therefore improves cost-

effectiveness
• Each patient gets a controlled amount of fluoride & this
prevents over – application
• It reduces the chance of over ingestion & prevents
fluoride toxicity.
FLUORITOP
• The first fluoride varnish manufactured in India with Fluorprotector.
• FluoritopSR is a new indigenously produced fluoride varnish
produced by ICPA Health Products Ltd, Mumbai.
• It contains 50 mg Sodium Fluoride per ml equivalent to 2.26 mg of
fluoride in slow release form.
• Presentation is in the form of plastic bottle with 30 ml varnish.
• Fluoritop SR may offer a better alternative to existing topical
fluoride agents as a caries preventive agent in our country.
FORMULATION OF A TYPICAL FLUORIDE VARNISH
• Sodium saccharin – used as sweetener
• Flavours – Various tastes such as raspberry essence
• Bees wax & Ethanol – forms a gel type structure to stabilize Na+
ions
• Shellac & Mastic – provides a flexible permeable hard surface that
prevents the varnish dissolving quickly in saliva
• Flow enhancer – some varnishes contain colophonium
APPLICATION OF FLUORIDE VARNISH
• Prophylaxis (toothbrush or professional)
• Isolate quadrant using cotton rolls, meticulous drying of is not
critical.
• Dispense fluoride varnish as per manufacturer’s instruction.
Usually 0.5 – 1 ml - for the entire dentition.
• Apply varnish on tooth surface using a disposable brush or cotton
applicator.
• The entire surface of the tooth must be treated.
• Avoid getting varnish on the soft tissue.
• The entire process takes 3-4 minutes.
PATIENT INSTRUCTIONS
• Durafluor & Duraphat causes temporary change in tooth
color
• Discoloration is temporary & will vanish once tooth
brushing is commenced.
• Avoid brushing for the rest of the day
• Avoid eating for the next two hours.
• Soft diet for the rest of the day is advisable.
MECHANISM OF ACTION
• Reduces demineralization.
• Remineralization is encouraged.
• high concentration of fluoride in the surface results in deposition of
calcium fluoride
• Calcium fluoride dissolves slowly and releases fluoride at the
plaque enamel interface
• The topical fluoride varnish reduces hypersensitivity by the
deposition of globular calcium fluoride in the exposed dentinal
tubules
APPLICATION OF FLUORIDE VARNISH

• F varnishes are not intended to adhere permanently to the tooth but to remain in
close contact with the enamel for several hours.
• Tooth brushing may be sufficient to clean the teeth before application and
prophylaxis is not required.
• During application, the clinician uses a brush, a cotton tip applicator, or a
syringe type applicator to apply about 0.3 to .05ml of varnish directly on to the
teeth. A dental floss may be used to ensure that the varnish reaches the inter-
proximal areas.
• 1- 4 min application time
• drying is not required before application and wiping with gauze or cotton rolls is
adequate to maximize contact between varnish and teeth.
• avoid eating for two to four hours after application and to avoid
brushing the night of application.
• Microscopic evaluation of the enamel surface has shown that
small blocks of varnish remain attached to enamel even after in
vitro demineralization challenge and sonication.
• DA: NaF- temporary change in tooth color.
• reapplied. semi annual application .
• Intensive treatment protocols, using three applications of Duraphat
in week per year for three to four years' showed caries reduction of
46 to 67% in the proximal surface.
 RECOMMENDATIONS ON AGE TO BE USED

• Centers for Disease Control and Prevention (CDC)(2001) :

children below 2 years do not use fluoridated toothpastes
• Australian Research Centre for Population Oral Health (ARCPOH)
(2006) : children below 18 months are not recommended to use F
toothpaste
• But EAPD (Marks and Martens, 1998) and Scottish Intercollegiate
Guidelines Network (SIGN) (2000) recommend its use in children
as soon as primary teeth erupt
Shani Ann Mani; Evidence-based clinical recommendations for fluoride use: a review; Archives of Orofacial
Sciences (2009), 4(1): 1-6
 RECOMMENDATIONS ON CONCENTRATION TO BE
USED

• F toothpastes are available in regular concentrations of 1000 to 1500ppm for

adults and in lower concentrations of 600ppm and below, primarily for
children.

• Higher concentrations are available but WHO (1994) recommends that the
limit be maintained at 1500ppm.

• EAPD (Marks and Martens, 1998) and ARCPOH (2006) recommends low
fluoride toothpastes for all children less than 6 years.
 RECOMMENDATIONS ON AMOUNT TO BE USED

• For children below 6 years, a general agreement between all

organizations is that a pea sized amount should be used with
parental supervision; the child being encouraged to spit with
restricted use no more than 2 times a day

• children below 2 years, a smear is recommended

 AAPD

< 2 years 2-5 years

AAPD: Guideline on Fluoride Therapy

STANNOUS FLUORIDE AND SODIUM FLUORIDE ARE NOT WIDELY
USED TODAY BECAUSE OF:
• Lack of compatibility with abrasives
• Staining of anterior restorations of composite resins (By SnF 2)
which have completely replaced by other materials.
• Metallic astringent taste, which is not acceptable.
• Poorly accepted by children.
• (SnF2) pigmentation of hypoplastic areas.
 MONOFLUORO PHOSPHATE DENTIFRICES
• Monoflorophosphate dentifrices are considered to be more
advantageous than SnF2 and NaF because:

• MFP has a neutral pH (6.5) compared to SnF2 (pH=4.8)

• Greater stability to oxidation and hydrolysis than SnF2 providing
it a greater shelf life.
• Increased availability of fluoride and No staining of teeth.
 AMINE FLUORIDE DENTIFRICES
• Amine fluorides are a group of organic fluoride

• Properties are :
• Enhanced fluoride uptake by enamel
• Antimicrobial activity against certain plaque microorganism
 FLUORIDE MOUTH RINSE

• Fluoride Mouth rinsing is a simple well accepted, safe and in

expensive adjunct to the use of a Fluoride dentifrice for reducing
decay

• Burrell, K (1983) recommends that children should not use rinse

under six years of age because control of their swallowing reflexes
is not good.
• Ericcsson and Forsmann (1969) found that before the age of 4, children often
cannot control their swallowing reflexes and may consistently swallow 100%
of the rinse

• 5ml for young children

• 7ml for 10-15 years old children

• 10ml for older children & adults

• 1-2 minutes appears suitable for ages above 5 years

COMPOUNDS USED FOR MOUTH RINSING
Sodium fluoride mouth rinses :

• Sodium fluoride mouth rinses are usually formulated at

concentrations of either 0.2%(a fluoride concentration of 900 ppm)
for weekly use or 0.05%(fluoride 225 ppm) for daily use.

• These rinses are intended to be used by forcefully swishing 10ml

of the liquid around the mouth for 60 seconds before expectorating
it.
NaMFP containing toothpastes (0.75% Sodium
Monofluorophosphate - 0.15% F-)
• Colgate CAVITY PROTECTION (1000 ppmF-)
• Colgate SENSITIVE (1000 ppmF-)
• Pepsodent KIDS (500 ppmF-)
• KIDO DENT (500 ppmF-) & CHEERIO (480 ppmF-)
NaF containing toothpastes (0.24% NaF → 0.14% F-)

• Colgate TOTAL Advanced Clean (1000 ppmF-)

• CLOSE UP (1000 ppmF-)
• Colgate KIDS (500 ppmF-)
Stannous fluoride containing toothpastes (0.454-% SnF2 - 0.16%
F-)

• CREST pro-Health
• ORAL – B
Amine Fluoride containing toothpastes

• Elmex children's toothpaste - 1250 ppm F,

• Meridol - 1400 ppm F.
Fluoride containing Mouthrinses

• Colgate NEUTRAFLOUR (0.05% NaF / 0.2% NaF)

• CHLOROFLUOR (0.003% NaF, 0.2% Chlorhexidine Gluconate)
• ACT (0.05% NaF)
• Colgate PHOSFLUR (0.044% NaF/ APF)
• PROFLO mouth rinse (0.05% NaF)
Fluoride containing Brush-On gels

• Colgate GEL KAM / PERIO CHECK / OMNII gels → 0.4% SnF2

• Colgate PRO DENT / Omnii CAVAREST → 1.1% NaF
Dental floss plays an essential part in the plaque control of
inter proximal enamel surfaces, if the inter proximal areas
receive the benefit of additional fluoride during dental
flossing this may increase its value as a caries preventive
aid.
CONCLUSION
• Fluoride is still considered the best strategy to control caries at
either the community or individual levels. Water fluoridation and
fluoride dentifrice should be recommended for all individuals.
Fluoride rinse, professional fluoride application and fluoride-
releasing dental materials may be considered complementary
methods of fluoride delivery. Fluoride may be used to control
caries with efficiency and safety regarding general health or dental
side-effects such as fluorosis.