TOPICAL FLUORIDE IN DENTISTRY

2nD FifTeEn Group

Anati Hanis Shuhadah Syahirah Syamimi Ain Hana Puspa Sakina Zaharah Zulkefli Sharifah Hidayah Suhaila Huda

PRESENTATION OUTLINE
Definition Indications for fluoride therapy Sources of topical fluoride Mechanism of action Advantages Fluoride & anticipatory guidance for pediatric

patient Health risk

INTRODUCTION
In recent years, rapid changes have occurred in

prevalence of oral diseases across countries Some of the western industrialized countries have a decline in dental caries and more number of children are becoming caries free and their number is increasing. The contributing factors can be: - changes in sugar consumption - improved of oral hygiene - the use of fluorides (systemically/ topically)

FLUORIDE
A mineral that occurs naturally in many foods and water. Its essential for demineralization and remineralization process of enamel It helps prevent dental caries by making the tooth more resistant to acid attacks (from plaque bacteria and sugars) in the mouth In children under six years of age, fluoride becomes incorporated into the development of permanent teeth, making it difficult for acids to demineralize the teeth Fluoride also helps speed remineralization as well as disrupts acid production in already erupted teeth of both children and adults

CLASSIFICATION OF FLUORIDE THERAPY

SYSTEMIC FLUORIDE FLUORIDE THERAPY

TOPICAL FLUORIDE

TOPICAL FLUORIDE
Definition

- The use of systems containing relatively large concentrations of fluoride that are applied locally/ topically to the erupted tooth surface to prevent dental caries formation

RATIONALE FOR THE USE OF TOPICAL FLUORIDES

At the time of tooth eruption, the enamel is not yet completely calcified and undergoes a post eruptive period (approximately 2 years), during which enamel

classification continues (enamel maturation period) Most of fluoride incorporation into enamel occurs during the pre-eruptive period (by systemic fluoride) and post-eruptive period of enamel maturation As immediately after tooth eruption, the enamel is porous and immature, it requires fluoride rapidly Application of topical fluorides immediately after tooth eruption hastens fluoride uptakes and makes enamel become more resistant to dental caries

INDICATION FOR FLUORIDE THERAPY

Indication for fluoride therapy

white spots Moderate to high risk patients for developing

decay Active decay Orthodontic treatment Additional protection if necessary for children in areas without fluoridated drinking water To reduce tooth sensitivity Protect root surface Decreased salivary flow Institutionalized patients

SOURCE OF TOPICAL FLUORIDE

FLOURIDE DENTRIFICE

 a pharmaceutic compound used with a

toothbrush for cleaning and polishing the teeth. It typically contains a mild abrasive, detergent, flavoring agent, fluoride, and binder. Other common ingredients are deodorants, humectants, desensitizers, and various medications to prevent dental caries. Also called toothpaste.

Flouride Dentrifice for 0-7 year old

1. Colgate Oxygen 2. Colgate 2 in 1 Oxygen 3. Aquafresh Little Teeth 4. Morrisons Kids Sparkling 5. Oral B Stages Approx 1000 ppm

Flouride Toothpaste for 7 years old and above

1. Colgate total 2. Colgate Triple Action 3. Colgate Triple Cool Stripe 4. Aquafresh Approx 1450 ppm

GEL & FOAM

Acidulated phosphate fluoride

Gel and foams

Sodium fluoride Stannous fluoride

ACIDULATED PHOSPHATE FLUORIDE

Acidulated phosphate Fluoride Gel 1.23% Indications: prevention of dental caries on high risk tooth Contraindications: porcelain or ceramic dentures an unusual or allergic reaction to fluoride, other medicines, foods, dyes, or preservatives Advantages No staining of teeth. Stable when kept in polyethylene bottle. In case of gel, self-application is possible. Disadvantages Sour and bitter in taste Repeated or prolonged exposure of porcelain or composite restoration to APF can result in the loss of materials, surface roughening and cosmetic changes.

SODIUM FLUORIDE
Advantage: Chemically very stable Acceptable taste Non irritating to gingiva Preferable use in cases of enamel erosion, exposed dentine, carious dentine or where very porous enamel surfaces exist Preferred where there are glass ionomer, composite or porcelain restoration
Indications Caries protection May be used in areas where drinking water is fluoridated since topical fluoride cannot produce fluorosis Contraindications Do not use in pediatric patients under age 6 years unless recommended by a dentist

STANNOUS FLUORIDE
Indications: Patients who are at high risk for caries on root surfaces Contraindications Do not use this medication in children younger than 12 years unless directed to do so by dentist

Advantages: effective in arresting root caries treatment of hypersensitivity

Disadvantage: stain porous enamel or root surfaces metallic taste

VARNISH

Definition
Topical fluoride-containing lacquer that is

simply painted on tooth surfaces, evaporates leaving a thin resin film, that serves as a barrier Examples : duraphat, duraflor

Composition
5% sodium fluoride or 2.26% fluoride in a

viscous resinous base in an alcoholic suspension with flavoring agent (e.g. bubble gum)

Advantages
Easily applied

Available in different flavours younger patients

Do not have the bitter taste of some fluoride

gels Dry rapidly even in the presence of saliva Not require the use of fluoride trays Not appear to be a risk factor for dental fluorosis

Disadvantages
Temporary change in the surface color of the

teeth Patient compliance

EXAMPLES OF TOPICAL FLUORIDE

TOOTHPASTE
Most toothpaste today contains 0.32% (1450 ppm) fluoride,

usually in the form of sodium fluoride or sodium monofluorophosphate (MFP); 100 g of toothpaste containing 0.76 g MFP equates to 0.1 g fluoride. Prescription strength fluoride toothpaste generally contains 1.1% (11,000 ppm) sodium fluoride toothpaste. This type of toothpaste is used in the same manner as regular toothpaste. It is well established that 1.1% sodium fluoride is safe and effective as a preventive of caries. This prescription dental cream is used up to three times daily in place of regular toothpaste.

MOUTH RINSES
The most common fluoride compound used in mouth rinse is

sodium fluoride. Over the counter solutions of 0.05% sodium fluoride (225 ppm fluoride) for daily rinsing are available for use. Fluoride at this concentration is not strong enough for people at high risk for cavities. Prescription mouth rinses are more effective for those at high risk for caries, but are usually counter indicated for children, especially in areas with fluoridated drinking water. However, in areas without fluoridated drinking water, these rinses are sometimes prescribed for children.

GELS/ FOAM
Gels and foams are used for individuals who are at high risk for caries,

orthodontic patients, patients undergoing head and neck radiation, patients with decreased salivary flow, and children whose permanent molars should, but cannot, be sealed. The gel or foam is applied through the use of a mouth tray, which contains the product. The tray is held in the mouth by biting. Application generally takes about four minutes, and patients should not rinse, eat, smoke, or drink for at least 30 minutes after application. Some gels are made for home application, and are used in a manner similar to toothpaste. The concentration of fluoride in these gels is much lower than in professional products. An imprint of a person's teeth can be made by a dentist, who then uses that to make well fitting trays to put over their teeth. The patient can then use this to hold a fluoride treatment against their teeth overnight.

VARNISH

Fluoride varnish has practical advantages over gels in ease of

application, a non-offensive taste, and use of smaller amounts of fluoride than required for gel applications. Varnish is intended for the same group of patients as the gels and foams. There is also no published evidence as of yet that indicates that professionally applied fluoride varnish is a risk factor for enamel flourosis. The varnish is applied with a brush and sets within seconds. Topical application of fluoride has shown better result than systemic fluoride application to a greater extent.

CLINICAL RECOMMENDATIONS FOR THE USE OF PROFESSIONALLY APPLIED TOPICAL

LOWER RISK Younger than 6 years 6 to 18 years of age

Older than 18 years

MODERATE RISK

HIGHER RISK
Fluoride varnish applications at 3 to 6 month intervals

Fluoridated water and Fluoride varnish fluoride toothpastes applications at 6 may provide month intervals adequate caries prevention

Fluoridated water and Fluoride varnish or gel Fluoride varnish or gel fluoride toothpastes applications at 6 application at 6 may provide month intervals month intervals adequate caries prevention Fluoridated water and Fluoride varnish or gel Fluoride varnish or gel fluoride toothpastes applications at 6 applications at 3 to 6 may provide month intervals month intervals adequate caries prevention

Caries Controlled Concept

The caries-reducing effect of fluoride is primarily achieved by its presence during active caries development at the plaque/enamel interface where it directly alters the dynamics of mineral dissolution and reprecipitation, and to some extent, affects plaque bacteria. Primary mode of action of fluoride is post-eruptive topical effect. Treatment (preventive) strategy according to this concept: Topical fluoride; low level, frequent exposure, life-long

Maximize benefit (throughout life) with minimal adverse effects

Major mechanisms of fluoride on caries process:

1. Affect bacterial metabolism
Require high concentration of fluoride

2. Inhibit demineralization
Fluoride present at the crystal surfaces during acid challenge

3. Enhancing remineralization
Form a layer of fluorapatite-like material on the crystal surfaces

Featherstone JDB. The science and practice of caries prevention. JADA 2000;131:887-899

Affect bacterial metabolism

Inhibit demineralization

Fluoride enhances remineralization

Enamel crystal (Carbonated apatite)

Partially demineralized crystals = nucleators Fluoride ions adsorb to the crystal surface
Acid Demin

Partially dissolved crystal

Attract Ca, P new mineral formation The newly formed FAP-like veneer
Ca, P, F Remin

Exclude carbonate

Composition between HAP and FAP

FAP-like veneer
Adapted from Featherstone JDB JADA 2000;131:887-99.

Low solubility Crystal surfaces become less soluble

This FAP-like coating precipitated in the crystal surface, not F incorporated during tooth formation, is the major contribution to reduce enamel solubility

ADVANTAGES OF TOPICAL FLOURIDE

"Fluoride is most effective when used topically, after the teeth have erupted." SOURCE: Cheng KK, et al. (2007). Adding fluoride to water supplies. British Medical Journal 335(7622):699-702
Reaches the teeth directly Inhibits the metabolism of the decay-producing bacteria in plaque

and stabilizes minerals in the teeth

Preventing or slowing down the caries process Remineralize tooth enamel, making the teeth more resilient to acid Can be used on newly erupted teeth to prevent future decay

HEALTH RISK OF TOPICAL FLUORIDE USAGE

1-Hypersensitivity
The occurrence of allergic/hypersensitive reactions

(primarily of the skin) resulting from the use of topical fluorides. These reactions include: perioral dermatitis, stomatitis and urticaria. "It is my understanding that dermatologists frequently recommend that their patients with perioral dermatitis discontinue use of toothpastes with pyrophosphates and/or fluorides, citing that these are the most frequent causes.
SOURCE: McCaffery K. (2003). Fluoride and dermatitis. Journal of the American Dental Association 134: 1166 SOURCE: Fuchs SS. (2003). Fluoride and dermatitis. Journal of the American Dental Association 134: 1167.

2-Health risk
Fluoride ingestion has been associated with adverse health

effects such as IQ deficits in children, depression, weight gain and heart disease. The "Journal of Applied Clinical Pediatrics" reports that "high fluoride intake has a damaging effect on intellectual ability," Human studies from China, India, Iran and Mexico found that elevated levels of fluoride in children resulted in reduced performance and impaired development of intelligence. The U.S. National Research Council has also found that fluoride affects normal endocrine function, which may contribute to hypothyroidism, or reduced activity of the thyroid gland. Hypothyroidism can lead to fatigue, depression, weight gain, hair loss, muscle pains and heart disease.

 Swallowing toothpaste while teeth are

developing can cause a cosmetic defect known as fluorosis. Mild fluorosis appears as white specks on the tooth Swallowing larger amounts of fluoride can cause "mottled" brown enamel. This is unusual and occurs mainly in areas that have naturally high levels of fluoride in the water.

CONCLUSION
Topical Fluoride can be either professionally done (by dental practitioners) or self applied (at home). It can prevent dental caries formation in children, thus reduces cases of premature extraction or dental caries complication. Prevention of dental caries is much less expensive than the treatment of caries if not done

REFERENCES

http://www.livestrong.com/article/133760-side-effects-fluoride/#ixzz1ur5iOb41 http://www.colgate.com/app/CP/US/EN/OC/Information/Articles/Oral-andDental-Health-Basics/Checkups-and-DentalProcedures/Fluoride/article/Fluoride-And-YourTeeth.cvsp#Can_Fluoride_Cause_Harm McCaffery K. (2003). Fluoride and dermatitis. Journal of the American Dental Association 134: 1166. Fuchs SS. (2003). Fluoride and dermatitis. Journal of the American Dental Association 134: 1167. www.medicine.net http://www.nhsbordersdentists.scot.nhs.uk http://www.adha.org http://jada.ada.org/content/137/8/1151.full http://www.nature.com/bdj/journal/v195/n6/full/4810527a.html http://en.wikipedia.org/wiki/Fluoride_therapy

Featherstone JDB. The science and practice of caries prevention. JADA 2000;131:887-899