systemic and topical fluoridesystemic and

topical fluoride2012/11/23 jah

Yang shu-han report2012/11/23 jah

Yang shu-han report

mechanism of actions of fluoride

mechanism of actions of fluorideincreases enamel resistance/reducing enamel solubility

remineralization of incipient lesion

increases the rate of post-erupitve maturation

improves tooth morphology

interferes the function of dental plaque microorganisms

Textbook of Public Health Dentistry Pb

Textbook of Public Health Dentistry Pb

systemic deliverysystemic delivery

water, salt, tablets, drops which are swallowed

tablets or drops rarely used where public water supplies are fluoridated

topicaltopical

gels, varnishes, toothpaste/dentifiecs, mouth wash...

most effetive when a low concentration of fluoride is maintained consistently in the oral environment

community fluoridated water and fluoride toothpaste rank first

acts topicallyacts topically

promoting remineralization and reducing demineralization as a post-eruptive phenomenon

Calcium and phosphate need to be present in solution to effect remineralization

remineralizationremineralizationwhen remineralization takes place in the presence of fluoride the remineralized enamel is more caries resistant than the original enamel mineral due to increased fluoroapatite and decreased carbonated apatite

this effect is evident with even very low fluoride concentrations(less than 0.1 ppm)

effect on the glycolytic pathway of oral-microorganisms reducing acid production

interefering with the enzymatic regulation of carbohydrate metabolism

This reduces the accumulation of plaque

halo effecthalo effectincrease in availability of fluoride from foods, beverages, toothpastes and topical agents

halo effect in low fluoridated communities

benefit from the widespread distribution of these products from fluoridated communities where they have been manufactured

bottled and filtered waters

bottled and filtered waters

fluoridated water: 0.8~1 ppm F- ( 1.0mg F-/L)

bottled water: very low

filtered water：

some filters may remove fluoride:reverse osmosis, bone or charcoal filters, distillation or ion exchange

ceramic and carbon filters retain fluoride in the filtered water

Home Fluoridation/Fluoride

tablets

Home Fluoridation/Fluoride

tabletsas water supplements (1ppm)

1* 2.2mg NaF containing 1.0 mg F- dissolved in 1 L water

2*1.1mg NaF in 1 L

4*0.55mg NaF in 1 L

tablets dissolve readily in water at room temperature

The fluoride water should be refrigerated and used for drinking and food preparation for the entire family

Dental fluorosisDental fluorosis

defect of enamel(hypomineralization)

threshold: unknown, but suggested to be around 0.1 mg/kg body weight

primary affects primarily permanent teeth and is a dose related condition

Dx requires a detailed history of fluoride exposure

alter composition of enamel matrix during ameloblastic secretory phase

intereferece the initial mineralization process caused by changes in ion-transport mechanism

disruption of ameloblast function affecting the withdraw of protein and water from initial mineralization of enemal during the maturation phase

disruption of nucleation of crystal growth in all stages of enamel formation, resulting in various degrees of enamel porosity(hypomineralization)

alter composition of enamel matrix during ameloblastic secretory phase

intereferece the initial mineralization process caused by changes in ion-transport mechanism

disruption of ameloblast function affecting the withdraw of protein and water from initial mineralization of enemal during the maturation phase

disruption of nucleation of crystal growth in all stages of enamel formation, resulting in various degrees of enamel porosity(hypomineralization)

dental fluorosisdental fluorosisenemel mineralization sensitive to fluoride

high dose of fluoride can

breakdown and withdraw of enamel matrix protein (e.g. enamelins, amelogenins), resulting in permanent hypomineralization of enamel (subsurface and surface porosity)

affect the activity of the ameloblasts

the first 36 months the crowns of the maxilalry permanent incisors are undergoing mineralization or enamel maturation

excess fluorideexcess fluoride

toothpaste ingestion as a significant source of excess fluoride in young children

another source is infant formula (marked variations 0.9~2.8ppm)

management of dental fluorosismanagement of dental fluorosis

remineralization

microabrasion

restorative replacement of the disoloured enamel

pretreatment with hypochlorites as deproteinizing agent (using commercially kits, or dilute hydrochloric acid, or 35% phosphoric acid and pumic paste)

remineralization with topical fluoride, CPP-ACP or CPP-ACPF

mild fluorosismild fluorosisCPP-ACP (casein phosphopeptide-amorphous calcium phosphate)

CPP-ACPF (casein phosphopeptide-amorphous calcium phosphate fluoride)

reduces the whiteness(opacity) and promotes remineralization

extensive lesionsextensive lesions

restored with labial veneers of composite resin or porcelain once the tooth is fully erupted and the height of the marginal gingiva is established

Topical fluoridesTopical fluorides

lifetime caries prevention

enhence the remineralization of white spot lesion

control initial carious lesion

limit lesions occurring around existing restorations

effective for both adults and children

optimal concentration of fluoride is required each day

Fluoridated toothpaste-25%

Fluoridated toothpaste-25%

maintaing elevated fluoride concentration at the plaque-enamel interface

added as sodium fluoride(NaF), sodiumm monofluorophosphate(MFP), stannous or amine fluoride(SnF)

greatest benefit observed on interproximal and smooth surfaces as well as newly erupted teeth 单氟磷酸钠单氟磷酸钠

children’s toothpastechildren’s toothpaste

low concentration: 250,400,500 ppm F- are available for children

250 ppm is less effective than standard 1000 ppm toothpaste

30% on a child’s toothbrush can be swallowed

good oral hygiene habits

good oral hygiene habits

brushing twice day in children younger than 2 y/o significant reduced caries

tooth cleaning before one year of age was associated with reduced caries prevalence

from the time teeth first erupt(about 6 month) to the age of 17 months, children’s teeth should be cleaned by a responsible adult, but toothpaste should not be used

18 months-5y/o, clean twice a day with 0.4-0.5mg F-/g(400~500ppmF-) toothpaste;pea-sized amount; smear across a child-sized soft tooth brush; should spit out, not swallow, not rinse

>6 y/o, twice a day or more, 1mg F-/g(1000ppmF-); should spit out, not swallow, not rinse

standard fluoridatted toothpaste

standard fluoridatted toothpaste

caries protection : less than a lifetime exposure to community water fluoridation, but effects are addictive

1000-1100ppm F-(1.0-1.1 mg F-/g)

HIGH-CONCENTRATION FLUORIDTED TOOTHPASTES

HIGH-CONCENTRATION FLUORIDTED TOOTHPASTES

treatment toothpaste

1500-5000ppmF-(1.5-5.0 mgF-/g)

teenagers, adults, older adults who are at high risk of developing caries

mouth rinse-20-50%mouth rinse-20-50%0.2% w/v (900-910 ppmF-)NaF/week

0.05% w/v (220-227 ppmF-)NaF/day

Indication:(children)

ortho Tx

post-irrafiation hyposalivation

unable adequate brushing

during high risk

should not be used under 6 y/o(before the eruption of the permanent incisors)

should not substitute for tooth brushing

varnishes-30%varnishes-30%

prolong contact times between fluoride and enamel

effective in primary and permanent dentitions

no fluorosis over twice yearly applications slow release from

the resin vehicle results in lower peak plasma fluoride levels than from swallowed fluoridated gls

slow release from the resin vehicle results in lower peak plasma fluoride levels than from swallowed fluoridated gls

varnish indicationsvarnish indications

Indicationshypersensive areasnewly erupted teethlocal remineralized of white lesionsindividuals at high caries riskindividuals in high caries groups

Duraphat (Colgate Oral Care): alcoholic solution, 50mg NaF(5%NaF), 2.26% F-, 226000ppm F-,22.6mg F-/mlvarnish resin remains on the teeth for 12-48 hr after application, slow releasing fluoride

Duraphat

primary dentition:0.25ml(6mg F-)

mixed dentition0.40ml(9mg F-)

permanent dentition:0.75ml(17mg F-)

Fluor Protector (Ivoclar Vivadent) silane fluoride varnish with lower concentration(0.8%) in a polyurethane lacquer

Fluor Protector (Ivoclar Vivadent) silane fluoride varnish with lower concentration(0.8%) in a polyurethane lacquer

gels, foams, solutions, creams

gels, foams, solutions, creams

gels more effective to permanent dentition than the primary dentition, especially first permanent molars

high concentration gels(9000-123000ppm)professional use

lower concentration gels(1000ppm)use at home

acidulated pohosphate fluoride

gels

acidulated pohosphate fluoride

gels

professional application

1.23%APF(12300ppm) mixture with NaF, hydrofluoric, and orthophosphoric acid

5000ppm with NaF, phosphoric acid, sodium phosphate monobasic

APF used for prevention of caries development

neutral NaFneutral NaF9000ppm F-(2%NaF)

for enamel erosion, exposed dentin, carious dentine, porous enamel

stable, acceptable taste, not irritating, not discolored teeth

neutral PH is prefered when restoration exist(GI, composite resin, porcelain)

SnF2 Stannous fluoride gel

SnF2 Stannous fluoride gel

for remineralization of white spot and hypomineralization lesions of enamel(incisor and molar)

localized remineralization is desired before placement of a definitive restoration

0.4%SnF2(1000ppmF- 3000ppm Sn2+) proved effective in arresting root caries

incorporated into a synthetic saliva solution to reduce caries in post-irradiation cancer patirent

stannous fluoride solution

stannous fluoride solution

10%SnF2 use to target “at-risk” surface of teeth

pit-fissue, white spot lesion, accessible proximal surfaces

cause discoloration of teeth and staining on margin of restorations,especially hypocalcified areas

CPP-ACP/CPP-ACPFCPP-ACP/CPP-ACPFcreams for topical application at home

Tooth Mousse,Tooth MoussePlus

apply to surface at risk or white spot lesion

releases fluoride, calcium, phosphate ions for local remineralization of enamel

900ppm F-; use by age > 6 y/o

apply with a clean finger or cotton-tipped applicator after brushing and flossing, not rinse out

should not used by people with a milk protein allergy

Fluoride therapy for infants and childrenFluoride therapy for infants and children

fluorosis will occur with ingestion of 2mg or more fluoride per day

parents should perform tooth brushing and flossing for children up to 8 years of age, and should supervise these children in play brushing

should use low-fluoride toothpaste 400-500ppm

reduce use of fluoridated gels for children aged under 10 years

upper limit: 0.07mg F-/kg for child between 2 and 7 years of age

sCHEDULESsCHEDULES

low risk

increas risk

0.02%NaF,APF daily mouthrinse

spot application fo topical fluoride to newly erupting permanent posterior teeth

no new caries for 1 yrtwice daily brushspot topica; F for new erupting permanent posterior teeth

no new caries for 1 yrtwice daily brushspot topica; F for new erupting permanent posterior teeth

adolescent without F waterpatient temporary high risk: ortho, under chemo radiotherapy

adolescent without F waterpatient temporary high risk: ortho, under chemo radiotherapy

moderate

0.05%NaF daily,or 0.2%NaF weekly mouthrinse

spot topical F

professional 1.23% APF (10%SnF2) every 3 month

1-2 lesions per year

cervical white spot lesions

1-2 lesions per year

cervical white spot lesions

high caries rate

initial 0.2%NaF mouthrinse daily+ 1.23% APF(10%SnF) every 3 month

spot application of F varnish to susceptible areas

>2 lesion per year>2 lesion per year