FLUORIDES: FLUORIDES CONTENTS: CONTENTS INTRODUCTION HISTORY CHEMICAL FORMS OF FLUORIDE MECHANISM OF ACTION MODES OF FLUORIDE ADMINISTRATION FORMS OF FLUORIDE PowerPoint Presentation: TOPICAL FLUORIDES SYSTEMIC FLUORIDES RECOMMENDATIONS FOR FLUORIDE USE FLUORIDE TOXICITY INTRODUCTION: INTRODUCTION Fluorine word is derived from Russian word ‘flor’ which comes from ‘floris’ meaning destruction in greek & from latin word ‘flour’ that means ‘to flow’ since it is used as flux. Fluoride is naturally occurring element found in rock, soil, air and all vegetation because fluoride is a naturally abundance substance in the earth’s crust. HISTORY: HISTORY In 1901 Dr Frederick McKay noticed permanent stains present on teeth of local inhabitants of Colorado Spring U.S.A known as Colorado stains. Stains characterized by minute white flecks, yellow or brown spots scattered all over the surface of tooth were termed as mottled enamel. In 1902 Dr J M Eager described similar stains seen on teeth of certain Italian Emigrants embarking at Naples as “denti di chiaie” PowerPoint Presentation: In 1939 Dean & McKay came out with most conclusive & direct proof that fluoride in domestic water is primary cause of human mottled enamel (dental fluorosis) CHEMICAL FORMS OF FLUORIDE : CHEMICAL FORMS OF FLUORIDE Fluorspar (CaF2) Fluorapatite (Ca(10PO4)6F2) Cryolite (Na3AlF6) MECHANISM OF ACTION OF FLUORIDES IN CARIES REDUCTION: MECHANISM OF ACTION OF FLUORIDES IN CARIES REDUCTION Increased enamel resistance or reduction in enamel solubility Increased rate of post eruptive maturation Remineralization of incipient lesions Interference with plaque microorganisms Modification in tooth morphology INCREASED ENAMEL RESISTANCE / REDUCTION IN ENAMEL SOLUBILITY: INCREASED ENAMEL RESISTANCE / REDUCTION IN ENAMEL SOLUBILITY The presence of fluoride reduces the solubility of enamel by promoting the precipitation of hydroxyapatite & phosphate mineral. When hydroxyapatite is exposed to low fluoride concentrations (about 1ppm) a layer of fluorapatite forms on the hydroxyapatite crystals. This thin layer governs the rate of dissoluton. INCREASED RATE OF POST ERUPTIVE MATURATION: INCREASED RATE OF POST ERUPTIVE MATURATION Fluoride increases the rate of mineralization. Organic material is also deposited into the enamel surface to further increase its resistance to dental caries. Both mineral ions & organic material are deposited from the saliva resulting in formation of a less soluble tooth that is more resistant to acid attack & less prone to caries. REMINERALIZATION OF INCIPIENT LESIONS: REMINERALIZATION OF INCIPIENT LESIONS Fluoride enhances the remineralization process by accelerating the growth of enamel crystals that have demineralised. FLUORIDE AS AN INHIBITOR OF DEMINERALIZATION: FLUORIDE AS AN INHIBITOR OF DEMINERALIZATION When fluoride is added to the demineralizing solution, the attack results in a lesion with a completely different histologic appearance. Well formed surface layer can be discerned with a mineral content considerably higher than that of the underlying lesion body. Fluoride also reduces the rate of demineralization. INTERFERENCE WITH MICRO-ORGANISMS: INTERFERENCE WITH MICRO-ORGANISMS In high concentrations, fluoride is bactericidal. In lower concentrations, it is bacteriostatic. Fluoride lodges in plaque & inhibits bacterial enzymes responsible for acid metabolism. MODIFICATION IN TOOTH MORPHOLOGY: MODIFICATION IN TOOTH MORPHOLOGY If fluoride is ingested during tooth development, there is some evidence to suggest the formation of a more caries resistant tooth slightly smaller with shallow fissures. FLUORIDE METABOLISM: FLUORIDE METABOLISM SOURCES OF FLUORIDE : All ground water Plants, Marine animals & even dust particles Tea : contains an average of 97 ppm Certain types of fishes, dried mackerel & dried salmon contain a large amount of fluoride i.e. 84.5 ppm Potatoes : 6.4 ppm ABSORPTION OF FLUORIDE: ABSORPTION OF FLUORIDE Readily absorbed into the body. Absorption occurs mainly in stomach. Can also occur from lungs by inhalation of fluoride dust & gases. Through skin EXCRETION OF FLUORIDE: EXCRETION OF FLUORIDE Through : Urine Faeces Saliva Hair Tears Sweat STORAGE OF FLUORIDE: STORAGE OF FLUORIDE In hard tissues of body. In saliva In plaque In enamel, dentin & cementum In bone In blood MODES OF FLUORIDE ADMINISTRATIONS: MODES OF FLUORIDE ADMINISTRATIONS Community Water Fluoridation : 50-60% Salt Water Fluoridation : 40% Dietary Supplements : 50-80% PowerPoint Presentation: Fluoride dentifrices : 20-30% Professionally applied topical fluoride : 30-40% Self-applied topical application : 20-50% FORMS OF FLUORIDE: FORMS OF FLUORIDE TOPICAL SYSTEMIC TOPICAL FLUORIDES: TOPICAL FLUORIDES They strengthen teeth already present in the mouth, making them more decay-resistant. Topical fluorides include toothpastes, mouth rinses & professionally applied fluoride therapies. Topical fluorides are of 2 types : Self-Applied Professionally-Applied SELF APPLIED : SELF APPLIED One method of self-applied topical fluoride that is responsible for a significant drop in the level of cavities since 1960 is use of a fluoride-containing toothpaste. Other sources of self-applied fluoride are mouth rinses designed to be rinsed & spit out. For patients who have unusual susceptibility to dental caries (due to dry mouth, medical conditions, or other factors) dentists may recommend a prescription fluoride gel or paste to be used in addition to regular toothpaste. PROFESSIONALLY APPLIED: PROFESSIONALLY APPLIED In the form of a gel or foam, applied by a dentist or dental hygienist. More concentrated Due to which not needed frequently METHODS OF APPLICATION OF TOPICAL FLUORIDES: METHODS OF APPLICATION OF TOPICAL FLUORIDES PAINT-ON TECHNIQUE TRAY TECHNIQUE PAINT-ON TECHNIQUE: PAINT-ON TECHNIQUE The patient is instructed to rinse the mouth & teeth are isolated using cotton rolls. 1 min air drying will result in significantly more fluoride uptake by the outer enamel treated with a professional topical fluoride application. A 2% neutral sodium fluoride is used. The aqueous solution of fluoride is continuously reapplied keeping the teeth isolated for 4 minutes. PowerPoint Presentation: During this 4 min unwaxed dental floss which has been soaked in the fluoride solution, is passed interproximally. The same procedure is then repeated for each quadrant or the other half of the mouth depending upon the method of isolation employed. After treatment the patient may expectorate, but is instructed not to rinse, eat or drink for one-half hour. TRAY TECHNIQUE: TRAY TECHNIQUE During each appointment, a total of 4gm of acidulated phosphate fluoride gel is applied to the teeth with the help of tray. Substantial oral retention of fluoride both before and after expectoration. FACTORS AFFECTING TOPICAL FLUORIDE DEPOSITION IN TEETH: FACTORS AFFECTING TOPICAL FLUORIDE DEPOSITION IN TEETH TOOTH CONDITION TREATMENT FORMULATION APPLICATION PROCEDURE TOOTH CONDITION: TOOTH CONDITION Tooth age : The mature primary enamel acquires twice the fluoride compared to the less porous mature permanent enamel. Natural fluoride concentration : Enamel with a high natural fluoride content will dissolve less & therefore will acquire slightly less fluoride. Enamel defects : Enamel defects acquire larger amounts of fluoride than sound enamel because of their greater porosity & surface. Dentin/Cementum TREATMENT FORMULATION: TREATMENT FORMULATION Fluoride agent : Fluoride uptake by enamel from a particular agent is dependent upon different pH’s, different fluoride concentration, and result in the formation of different fluoride containing compounds. pH : Lowering the pH of a fluoride treatment solution results in partial dissolution of enamel crystal surfaces. The ionic calcium thus formed reacts to form CaF2 & therefore, an increased total fluoride uptake. PowerPoint Presentation: Fluoride components : Thickening agents like hydroxyethylcellulose increases the viscosity, but tends to decrease the rate of fluoride diffusion. Humectants such as glycerol were found to reduce fluoride uptake. Abrasives : Abrasives used in prophylaxis pastes & dentifrices react with fluoride thereby decreasing the amount available for reaction with enamel. APPLICATION PROCEDURE: APPLICATION PROCEDURE Effect of time : As the duration of the fluoride treatment increases, the amount of fluoride deposited in enamel also increases. Temperature : An increase in temperature of the fluoride treatment preparation increases the amount of fluoride deposited in enamel. Number of applications Enamel pre-treatment SYSTEMIC FLUORIDES: SYSTEMIC FLUORIDES Systemic fluorides such as community water fluoridation & dietary fluoride supplements are effective in reducing tooth decay. These fluorides provide topical as well as systemic protection because fluoride is present in the saliva. DIETARY FLUORIDE SUPPLEMENTATIONS: DIETARY FLUORIDE SUPPLEMENTATIONS Fluoridated Milk Fluoridated Salt Fluoride in Sugar Fluoride in Citrus beverages Fluoride drops Fluoride drops with vitamins Fluoride tablets & lozenges Fluoride tablets with vitamins Fluoride oral rinse supplements FLUORIDE RELEASING SEALANTS: FLUORIDE RELEASING SEALANTS Helioseal-F FluroShield Teethmate-F Seal-Rite Ultra-Seal Quick seal FLUORIDE VARNISH: FLUORIDE VARNISH Duraflor FLUORIDE CAVITY RINSES Gel Kam F Topical Cavity & Crown Prep 8-10% SnF2 slolution COMPOSITE RESINS: COMPOSITE RESINS Heliomolar RO (agglomerated microfill) Pertrac-Hybrid (small particle hybrid) PowerPoint Presentation: Fluorocore (direct core- small particle hybrid) Concept (indirect restorative – homogenous microfill) LINERS / BASES: LINERS / BASES Timeline Geristore Liner-F FLUORIDE RELEASING RESTORATIVES: FLUORIDE RELEASING RESTORATIVES Low dose fluoride release has been shown to increase surrounding enamel & dentin fluoride levels & to make them more acid resistant. Recent evidence points to the possibility of benefits to other teeth in the mouth because of low dose fluoride in the saliva. RECOMMENDATIONS FOR FLUORIDE USE: RECOMMENDATIONS FOR FLUORIDE USE In case of children : Use less than a pea size amount of toothpaste with children under 2 & be careful they do not swallow it. Don’t let them lick the toothpaste tube or eat toothpaste. Weight or dental age is a better determining factor for fluoride dosage than age in years Infants past the age of 12 months should not be fed with formula made with fluoridated water. PowerPoint Presentation: Fluoride treatments may begin after the age of 3. Topical fluoride gel works on the outer surface of a tooth & is not taken in internally so a child can not overdose on fluoride. Fluoride rinses can be used after the age of 6, especially in children who are drinking soft drinks & or wearing braces, they can cut decay by about 30% if used daily. For the best result of a fluoridated toothpaste, the toothpaste should be on the teeth for 4 minutes. PowerPoint Presentation: Chewable vitamins with fluoride are recommended for children who have cavities, live in areas with unfluoridated drinking water & live in families that are prone to tooth decay or periodontal disease. The supplement for these cases is 1 mg/day. Chewing fluoride tablets puts fluoride directly in the grooves of the teeth where most decay is likely to happen. Fluoride paste should be used while cleaning the teeth of the patient. IN CASE OF ADULTS: IN CASE OF ADULTS For adults with high level of decay or dry mouth, fluoride rinses are recommended twice a day for 4 min. Do not swallow the rinse. Fluoridated rinses may decrease bleeding problems if used along with good oral hygiene. Adults wearing braces should drink fluoridated water. PowerPoint Presentation: Dietary fluoride supplements will give teeth a low, prolonged exposure to fluoride to help supplement your fluoride intake, especially in areas where fluoride is not added to the water. Before bed, rub toothpaste containing fluoride along the gum line & leave it to soak into the gum line while sleeping to ensure teeth get the fluoride they need. FLUORIDE TOXICITY: FLUORIDE TOXICITY An excess accumulation of fluoride in the body can lead to demineralization of bone & tooth enamel, to a toxic condition called fluorosis. Bony changes, characterized by osteosclerosis, exostoses of the spine usually are seen only after prolonged high intake of fluoride in adults. These changes occur due to the fact that fluoride is not biodegradable & it accumulates in the body & bones resulting in a toxic or poisoning effect. ACUTE TOXICITY: ACUTE TOXICITY The amount of 35-70 mg F/kg body weight of soluble fluoride is considered to be lethal. Signs and Symptoms : Nausea Vomiting Diffuse abdominal pain Diarrhoea Excess salivation Thirst Muscle tremors CHRONIC TOXICITY: CHRONIC TOXICITY Chronic toxicity is due to long-term ingestion of a smaller amount of fluoride which usually affects the hard tissues & kidney. The effect of chronic fluoride toxicity on enamel is dental fluorosis. Dental fluorosis occurs when dosage becomes 2 times greater than optimal. If dose exceeds 10-25mg/day, skeletal fluorosis occurs. DENTAL FLUOROSIS: DENTAL FLUOROSIS Dental fluorosis is caused by excessive intake of fluoride during tooth development. Ingestion of water with a fluoride concentration 2 or 3 times greater than the recommended amount causes white flecks & chalky opaque areas on the tooth enamel (mild fluorosis) Consumption of water containing 4 times the recommended amount of fluoride causes a brown pitted corroded appearance on the enamel surface. JACKSON SIMPLE FLUOROSIS INDEX: JACKSON SIMPLE FLUOROSIS INDEX TYPE A : White areas less than 2mm in diameter TYPE B : White areas of, or greater than 2mm in diameter TYPE C : Coloured (brown) areas less than 2 mm in diameter TYPE D : Coloured (brown) areas of, or greater than 2mm. TYPE E : Horizontal white lines, irrespective of there being any white non-linear areas. TYPE F : Coloured (brown) or white areas or lines associated with pits/hypoplasitc areas. TREATMENT: TREATMENT For less than 5mg/kg : Give calcium orally (milk) to relieve GI symptoms. Observe for a few hours. For more than 5mg/kg : Empty stomach by induced vomiting with emetic. For patients with depressed gag reflex caused by age (<6 months old), Down’s Syndrome, or severe mental retardation, induced vomiting is contraindicated & endotracheal intubation should be performed before gastric lavage. PowerPoint Presentation: Give orally soluble calcium in any form (for e.g. Milk, 5% calcium gluconate, or calcium lactate solution). Admit to hospital & observe for a few hours. For more than 1.5 mg/kg : Admit to hospital immediately. Induce vomiting Begin cardaic monitoring & be prepared for cardiac arrhythmia. Observe for peaking T-waves & prolonged Q-T intervals. PowerPoint Presentation: Slowly administer intravenously 10ml of 10% calcium gluconate solution. Additional doses may be given if clinical signs of tetany or Q-T interval prolongation develops, electrolytes, especially calcium & potassium, should be monitored using diuretics if necessary. Adequate urine output should be maintained using diuretics if necessary. CONCLUSION: CONCLUSION Fluoride makes the entire tooth structure more resistant to decay. It combines into the tooth structure to make enamel more resistant to acid attack. It is toxic to bacteria, it stops the bacteria from producing acids that cause tooth decay. Its use can encourage remineralization or replace minerals in the tooth surfaces that have been demineralised. PowerPoint Presentation: It aids in the development of enamel on baby teeth before they erupt. In spite of its so many advantages, toxicity still remains the risk factor. But if used judiciously, fluoride is the nature’s answer to tooth decay.