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
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