Introduction:

Occurrence in nature: Widely distributed in the earths crust, 17th most abundant(0.06 to 0.09%)

Reactivity: It is the most electronegative of all the elements, which makes it extremely reactive. It combines with almost every element and also reacts with organic radicals. It is rarely found in the free state in nature.

Form of occurrence: Fluorine occurs as minerals as fluorspar(CaF2), cryolite(Na3AlF6) or fluorosilicates(Na2SiF6). In biological mineralized tissue, such as bones and teeth, it occurs as fluoridated hydroxyapatite(Ca10(PO4)(OH)2-X FX), where X is much smaller than 2. So, only some of the hydroxyls of the apatite lattice are replaced by fluoride ions, yet this change profoundly alters the resistance of enamel to demineralization.

Sources of fluoride: Water, Drinks(carbonated beverages, fruit juices), Tea leaves, Cereals, Meat, Fish, Infant formula

Infant formula: o Variable amounts of fluoride, the amount depending primarily on fluoride content of water used as diluent. o It has been shown that fluoride intake during infancy may be an overriding factor in the development of enamel fluorosis of the permanent teeth.

 Fluoride metabolism:

F- in diet/supplements of GA agents

F- from inhalation

F- from metabolism

Absorption in GIT

Fluoride in plasma

Mineralized tissues urine(50% of ingested dose)

Soft tissues

Excretion in

Fluoride source may be inorganic or organic. Depending upon the physical and chemical properties of compound and its solubility, varying amounts of ingested fluoride dose will be absorbed and enter the systemic circulation. NaF is rapidly and almost completely absorbed. There is detectable rise in the plasma F- conc. only a few minutes after the dose is swallowed.

CaF2, MgF2 and AlF3 are less completely absorbed. The plasma peak usually occurs within 30 min(independent of amount of Fingested) , if dentifrice is ingested on a fasting stomach. But when the dentifrice is swallowed 15mins after a meal, the peak does not occur until after 1 hour.

The height of plasma peak is proportional to -Fluoride ingested (directly proportional ) -Rate of absorption (directly proportional ) -Body weight of the subject (indirectly proportional ) Ingestion of fluoride with food retards its absorption. On a fasting stomach, degree of absorption of NaF is almost 100%. If taken with milk, it decreases to 70%. Absorption is only 60%, when F- is taken with calcium rich breakfast.(Reason---Fbinds with Ca++ and other food constituents and so fecal excretion of Fincreases). Clinical significance: If toothbrushing occurs soon after a meal, F- absorption will be inhibited to some extent, and high plasma F- peaks will not occur. This might be important for small children, who tend to retain and ingest more of toothpaste applied to the brush. (a thorough rinsing after toothbrushing will minimize the ingestion of F- following toothbrushing with fluoridated toothpaste.) Absorption of fluoride By passive diffusion

 From both stomach and intestine Rate of absorption is related to gastric acidity. F- in diet

HF is formed in stomach

Readily passes through biologic membranes Fluoride in plasma 2 forms: o Ionic/free/inorganic o Non-ionic/bound Fluoride levels in plasma are not homeostatically regulated but instead they rise and fall according to the pattern of fluoride intake. So, there is no normal physiologic concentration. The plasma fluoride level in a healthy, fasting, long term resident of a community with water fluoridation(1ppm) is approx 1M(0.019ppm) Diurnal changes in levels in subjects living in an area with a high fluoride conc. in drinking water particularly in adults.

Pharmacokinetics of fluoride

After single fluoride dose, the pharmacokinetic analysis shows 3 phases i. ii. Initial increase(represents mainly absorption): upto 1 hr Rapid fall/ phase(represents mainly distribution to soft tissues and bone initially and then followed by resting skeletal muscle and adipose tissue): for about 1 hr iii. Slower decline/ phase(represents elimination)

The plasma half-life for fluoride in human adults typically ranges from 4 to10 hrs. Higher the plasma concentration of fluoride, faster the elimination.

 Distribution: Distribution in soft tissues: More rapid in highly perfused tissues such as heart,lungs liver than for less perfused tissues as resting skeletal muscle, skin and adipose tissues Kidney tubules have higher conc of F- than that of plasma. Blood brain barrier is effective in restricting passage of F- into CNS(which has only 20% that of plasma).

Distribution in mineralized tissues: Approx. 99% of all fluoride in human body is found in mineralized tissues. The apatite has capacity to bind and integrate fluoride ion into its crystal lattice The selective affinity of fluoride for mineralized tissues is, in short term, due to uptake on the surface of bone crystallites by the processes of isoionic and heteroionic exchange. In the long term, it is actually incorporated into the crystal lattice structure in the form of fluorapatite or fluorhydroxyapatite. During the growth phase of skeleton, a relatively high portion of an ingested fluoride dose will be deposited in skeleton( more as compared to an adult). Fluoride is not irreversibly bound to bone. So, the fluoride is mobilized from bone to plasma when person moves from highly fluoridated area to low water fluoride level area.

Distribution to the fetus: The placenta is not a barrier to pssage of fluoride to fetus. There is direct relationship between the serum fluoride concentrations of mother and fetus. From the fetal blood, fluoride is readily taken by mineralizing fetal bones and teeth. Excretion

Major route- via Kidneys. Renal clearance of fluoride dependent on GFR rate(more GFR, more fluoride excretion), urinary pH(As the tubular fluid becomes more acidic, more of ionic fluoride is converted into HF which gets diffused out of tubules ).

Other routes- breast milk(limited transfer), feces(10% of ingested dose),sweat.

Fluoride in teeth and bone Approx. 99% of all fluoride in human body is found in mineralized tissues. The apatite has capacity to bind and integrate fluoride ion into its crystal lattice The selective affinity of fluoride for mineralized tissues is, in short term, due to uptake on the surface of bone crystallites by the processes of isoionic and

heteroionic exchange. In the long term, it is actually incorporated into the crystal lattice structure in the form of fluorapatite or fluorhydroxyapatite. During the growth phase of skeleton, a relatively high portion of an ingested fluoride dose will be deposited in skeleton( more as compared to an adult). Fluoride is not irreversibly bound to bone. So, the fluoride is mobilized from bone to plasma when person moves from highly fluoridated area to low water fluoride level area. Concentrations in mineralized tissues are variable due to o Level of fluoride intake o Duration of exposure o Factors as stage of tissue development, its rate of growth, vascularity, surface area and reactivity of mineral crystallites, porosity and degree of mineralization. In all mineralized tissues, fluoride levels tend to be greatest at surface since this region is the closest to tissue fluid supplying fluoride. The distribution and concentration in surfaces changes differentially with age.

Mechanism of fluoride uptake o Body fluoride mainly as inorganic fluoride, although F- binding to organic components is possible.
o

As pKa of HF is 3.4, fluoride in blood,saliva and tissue fluid will be present in fully ionized form as F-. However, fluoride at low pH eg. In

the stomach(pH of approx.2) will exist almost totally in undissociated form ie. HF. o Fluoride Superficially adsorbed on crystal surfaces or loosely entrapped in hydration shells of mineral crystallites Incorporated into interior of mineral crystallites

o When fluoride is applied to a tooth surface in a highly concentrated form(often at low pH), dissolution of apatite mineral.

Phosphate(PO43-) and hydroxyl (OH-) from tooth mineral will enter solution

F- replaces OH- ion

F- replaces CO32- ion

F- together with CO32- may replace PO43-

Most of fluoride within mineral crystallites is acquired during the period of crystal growth, a process known as accretion. But even during periods of active crystal growth, acquisition of fluoride by exchange or absorption will also be important. Fluoride loss from bones and teeth: Loosely and even some of firmly bound fluoride may be lost as crystals are destroyed. Action of fluoride Action of fluoride depends on the conditions of its use. Professional fluoride ie high fluoride conc. affects (at least temporarily)bacterial metabolism,inhibiting glycolysis and suppressing Streptococcus mutans. At low conc. eg systemic fluoride provided by water fluoridation or supplements or topical fluoride from dentifrices and mouthrinses, there is an uptake of fluoride by hydroxyapatite,

rendering it less soluble and improving its crystallinity. Fluoride also promotes and accelerates remineralization of calcium-depleted tooth structure. Hypotheses regarding fluorides anticaries mechanism of action 1. Action on the hydroxyapatite of enamel a) Decresing its solubility b) Improving its crystallinity c) Remineralizing calcium-depleted mineral 2. Action on bacteria of dental plaque a) Inhibiting enzymes b) Suppressing cariogenic flora 3. Action on the enamel surface a) Desorbing proteins and/or bacteria b) Lowering the free surface energy 4. Alteration of tooth morphology Alteration of tooth morphology: Researcher Forrest (1956) and Ockere(1949) Wallenius(1959) Finding Commented on well rounded cusps and shallow fissuresof teeth from fluoridated areas in Great Britain and South Africa, but presented no statistical data. Reported that children on water containing 0.5-1.0ppm F were 1.7% wider than those receiving <0.5ppm F, using

plaster casts of teeth from 419 children. The difference was Simpson Castaldi(1969) more significant in mandibular teeth in boys. and Reported that teeth in fluoride area were larger than in lowfluoride control area and had shallower fissures(more significant difference in mandibular molars) and obtuse inter-cuspal angels.

The results on tooth size are contradictory. There is a consensus that occlusal surfaces are more rounded under the influence of fluoride, but the effect is generally considered to be too small to be of much practical importance. Possible mechanism of morphological effects of fluoride: Depending upon the experiments by Kruger(1968), it is suggested that fluoride changes the ultrastructure of ameloblats. Large vacuoles appear in RER (organelle associated with protein synthesis). This change is suggested to affect the synthesis of protein and this reduction in amount of matrix protein further reduces the thickness of enamel and thus change in shape of fissure. In 1970, Kruger showed the reduced uptake of proline by ameloblasts. Effect of fluoride on crystallinity and reactivity of mineral: Fluoride in interior of crystal lattice: The incorporation of fluoride can significantly alter the properties of mineralized tissues since the inclusion of any extraneous element in a crystalline lattice will alters its reactivity. When F- replaces OH- ion in lattice, it can greatly increase lattice stability, presumably by attracting the protons of adjacent apatite hydroxyl ions thereby increasing degree of hydrogen bonding in so called hydroxyl column.

In addition, compared with hydroxyl , fluoride ion is better aligned within the plane formed by calcium ions and there is more electrostatic attraction between calcium ions and F- ions as compared to Ca2+ with OH-. So, the fluoridated apatite lattices are more crystalline, more stable and therefore less soluble in acid.

Superficially located fluoride: Superficially located may have relatively little effect on behavior of crystallite lattice. It can affect fluid- crystal equilibria which involves interaction between the ions at crystal surfaces and those in solutions. Studies on solubility hypothesis:

Volker, 1939

Rate of dissolution of powdered enamel decreases if it was exposed to fluoride solution prior to action of acidic buffers on powdered enamel. It was suggested that fluoride is producing crystal with apatite which is less soluble

Issac et al,1958

Reported that 2 enamel layers with fluoride containing 460 ppm and 1080 ppm differed in solubility by only 1.9%

Mechanism of topical fluorides by action on demineralization/remineralization: Enhancement of remineralization Inhibition of demineralization

The plaque fluid containing plaque bacteria is in contact with enamel surface and saliva/GCF. Plaque fluid transports organic acids as well as fluoride, calcium, phosphate and other ions to enamel surface. The balance between these factors(fluoride and pH being most important) determines demineralization or remineralization of the tooth. Dental plaque is normally richer in fluoride than the fluids to which it is exposed. Plaque appears to be able to retain and concentrate fluoride.

Fluoride in saliva: The conc of salivary fluoride from major salivary glands is about 2/3 of the plasma fluoride concentration and seems to be independent of flow rate The conc of fluoride in whole saliva is related to o Dietary fluid intake o Dental fluoride preparations The salivary fluoride levels depend upon the fluoride levels in water levels. Acc to a study by Oliveby A(1990), the children living in high fluoride

areas(1.2ppm )had higher F levels in saliva(0.9M/L) as compared to low fluoride areas(0.1ppm fluoride in water and 0.3 M/L ). A diurnal variation in salivary fluoride conc was also seen in high fluoridated area. The ductal saliva is normally not an important source of fluoride in plaque or plaque fluid. Following topical application of fluoride in the form of mouthrinses, toothpaste or any other fluoride vehicles, there is 100- or even 1000- fold increase in salivary fluoride concentration of fluoride agent. This high conc of F in saliva falls rapidly. Depending on the conc and type of fluoride agent, the saliva F conc is reduced to a few ppm within an hour, and within the next 3-6 hrs, returns to the baseline level. Clearance of salivary fluoride varies considerably because of large variations in o Salivary flow rates o Volume of fluoride distribution in oral cavity o Individual variation in anatomy and the number of teeth Fluoride from saliva to plaque: Transfer of F from saliva to plaque may occur during or immediately after mouthrinsing(0r similar procedures): a 10 mL volume of rinsing solution is diluted in only 1-2 mL of saliva, giving a high salivary fluoride concentration. When the mouthrinse is spat out, both the volume of fluid in the mouth and conc of fluoride decrease, and salva becomes less important as a source of plaque fluoride. Fluoride in plaque:

o Exists in ionic and bound forms o Sources of plaque fluoride: diet, saliva and crevicular fluid. o 5-10ppm F wet weight in dental plaque o Due to slower elimination of ion from the plaque and also due to release of F from CaF2 present in plaque, the plaque F levels are much higher than salivary F conc. o Fluoride in plaque has a large variation at various sites in the mouth eg maxillary incisor site has a much higher conc of fluoride than the other sites. o pH of plaque appears to be an important factor, low pH being associated with low fluoride concentrations. o Free form fluoride in plaque Using mouthrinses/ dentifrices containing fluoride

Fluoride Calcium in plaque becomes supersaturated CaF2 formed

Ca+ + F-

Bacterial surfaces have a net negative charge due to abundant phosphate and carboxyl groups. The acidic groups on the surface of bacteria will acquire counterions, mainly calcium(oral environment is rich in calcium). Fluoride can be associated with calcium counterions. When pH approaches pK of acidic groups, Ca+ and F- are released.

Fluoride in crevicular fluid: o Low in fluoride o F conc is closely related to plasma fluoride concentration o Not an important source of fluoride for plaque Fluoride and dental enamel Large amounts of fluoride may be acquired by enamel as calcium fluoride when exposed to fluoride toothpaste during tooth brushing, which is subsequently covered by plaque. The pH changes in plaque covering this fluoride rich enamel contributes to its rapid mobilization and transfer of fluoride to plaque fluid. So, the CaF2 in outer enamel acts as reservoir and releases Ca and F during caries challenges. Enamel and dentin not covered by plaque may also take up fluoride, which is slowly released.this source is probably less important than fluoride deposited beneath plaque. Example is when paste is applied directly to tooth enamel. This fluoride is replenished regularly and this reservoir is scarcely depleted. This probably makes tooth-paste a particularly appropriate fluoride vehicle.

Fluoride reservoirs in or on the oral soft tissue: F- is acquired during topical application(although soft tissue fluoride is not a major source) o This uptake is pH dependent, because fluoride penetrates more easily as HF. HF is dissociated after the absorption and may not necessarily be easily released. o Some of fluoride in soft tissues is associated with calcium; pretreatment with calcium ions increases fluoride retention(calcium attracted to acidic groups on the surfaces of the tissues, and retention of fluoride is based on interaction with calcium counterions. Connective tissue has sulfate- and carboxyl groups, whereas the cellmembranes contain phosphate groups).

 Professionally applied fluorides: Accoring to AAPD, Professional topical fluoride treatments should be based on caries-risk assessment. Children at moderate caries risk should receive a professional fluoride treatment at least every 6 months; those with high caries risk should receive greater frequency of professional fluoride applications (ie, every 3-6 months). A pumice prophylaxis is not an essential prerequisite to this treatment. Appropriate precautionary measures should be taken to prevent swallowing of any professionally-applied topical fluoride.

Indications:
1)

Caries-active individuals defined as those with past caries experience or those who develop new carious lesions on smooth tooth surfaces

2)

Children shortly after periods of tooth eruption, especially those who are not caries-free.

3)

Individuals who are on salivary flow-reducting medications, have diseases that decrease salivary flow or have received radiation to head and neck.

4)

Patients after periodontal surgery, especially when the roots of teeth have been exposed.

5)

Patients with fixed or removable prostheses and after placement or replacement of restorations.

6)

Individuals with an eating disorder or who are undergoing a change in lifestyle which may affect eating and oral hygiene habits conducive to good oral health.

7)

Mentally and physically challenged individuals.

Precautions: Topical fluoride agents contain relatively higher concentrations of fluoride, certain precautions need to be taken to prevent the patient from inadvertently ingesting these agents.

If solutions are used, the teeth should be carefully isolated with cotton rolls or gauze swabs and only enough solution applied to wet the surfaces of the teeth and keep them wet.

If gels are to be used,

o o

Place patient in upright position Use minimal amount of gel(no more than 2.5ml per tray), sufficient to cover the teeth but not to exude from the tray.

o o o o

Use custom-fitted or stock trays with absorptive liners Warn patient not to swallow gel Use suction, maintained during 4 minute application of agent. Remove excessive gel from teeth and gingival with gauze on removal of the tray

Instruct patient to expectorate thoroughly after treatment

Fluoride solutions General featuresCharacteristic Fluoride(%age) Fluoride(ppm) Frequency application Stability NaF 2% 9,200 of 4 at SnF2 8% 19,500 weekly 1 or 2/year APF 1.23% 12,300 1 or 2/year

intervals at ages 3,7,11 and 13 Stable Unstable Disagreeable Yes Occasional, Transient 32% Stable in plastic container Acidic No No 28%

Taste Bland Tooth pigmentation No Gingival pigmentation No Effectiveness(average) 29%

Neutral sodium fluoride solution In 1941, the first clinical study to use fluoride solution was done by Bibby using 0.1% aqueous NaF solution. After prophylaxis and drying of teeth, applications for 7-8 min were made 3 times a year at 3-4 monthly intervals. One year later, the caries increment in experimental quadrant was 45% lower than that found in the opposing control quadrant(Bibby 1943).

 In 1942, Knutson used a different technique which required four visits within a month. After prophylaxis and drying, 2% aqueous NaF solution was applied for 3 min. Knutson concluded that maximum reduction in caries was achieved from 4 treatments at weekly intervals and suggested that the series of applications should be carried out at the ages of 3,7,10 and 13 years to coincide the eruption of teeth(Knutson, 1948).this would minimize the amount of time that teeth were at risk to caries attack before preventive treatments were given. This technique was recommended by USA Public Health Service(USPHS) in public health programs Although this regimen is not convenient for private practitioners who tend to recall their patients for check-ups at 6-12 month intervals. In 1948, Gagalan and Knutson showed that 1% NaF solution was equally effective. A number of studies using NaF solution reported reduction in caries. In 1942,Knutson and Armstrong began a study involving children aged 7-15 years. The results after 3 years are as follows: quadrant No. of New DF DF s new DF DF in s s Total new in DF DF s Difference in DF surfaces(%

caries-free teeth(1945 surface surface teeth(1942 ) )

previou surface )

Treated Untreate

1870 1888

214 338

teeth 287 464

teeth 216 284

503 748

32.8

d Stannous fluoride solution: General features: o Both 8% and 10% sol of SnF2 have been tested, with little difference observed in effectiveness. o In 1962, Dudding and Muhler described a method for applying SnF2 solution to teeth. Thorough prophylaxis Teeth are kept wet for 4 mins, making the saliva ejector essential Treatments recommended at 6- month intervals

In vitro Studies: Studied in/by Conclusion Muhler and van Tin fluoride was the most effective fluoride salt in reducing Huysen ,1947 enamel solubility. Muhler and 10ppm stannous fluoride in drinking water given to rats fed on Day,1950 cariogenic diet was superior to 10ppm of sodium fluoride in reducing caries Muhler, Boyd and Stannous fluoride was 3 times more effective than sodium van Huysen,1950 fluoride in preventing dissolution of calcium and phosphorus

Scott, 1960 Brudevold, 1967

from enamel by dilute acids. Stannous ions form a coating on enamel surface Coating by stannous ions has no protective action against the carious process and may actually reduce fluoride uptake

Clinical studies: Muhler, Gish and Howell,1962 conducted a 5 year study(1957-62) to compare 8%Sn F2(single annual application) and 2%NaF(4 annual applications) and every 3 years. After 5 years, caries increment in SnF2 group was approx. 35% less than increment in NaF group.

Author Compton et al.(1959) Jordan et al.(1959) Law et al.(1961) Mercer and muhler (1961) Burgess et al.(1962) Harris(1963) Torell(1965) Wellock et al.(1965) Horowitz and lucye (1966) Houwink et al.(1974)

Study period 1 2 1 1 2 1 1 1 2 9

Reduction surfaces(%) 28 38 24 51 29 23 none none none 37

in

DMF

General features: Undergo rapid hydrolysis and oxidation, thus must be prepared freshly for each treatment. Causes brown discoloration of teeth particularly in hypocalcified areas and round margins of restorations. The problem seems to be worse in patients with poor oral hygiene Can cause reversible gingival irritation in patients with poor gingival health As it is unstable in aqueous solution, it has to be freshly prepared for each treatment.

 Disagreeable taste. As SnF2 is very reactive, so flavoring to mask the taste is contraindicated.

Acidulated phosphate fluoride: Introduced in 1963, by Forsyth Dental Center as acidified sodium fluoride solution, based on premise that greater fluoride is taken by enamel under acidic conditions. APF has pH of 3.0,buffered with 0.1M phosphoric acid and contains a fluoride concentration of 1.23% Acidic taste due to acidic pH. But flavoring can be done. Stored and is stable in plastic container because it may etch the glass if stored in glass container. Repeated or prolonged exposures of porcelain or composite restorations to APF can result in surface roughening and possible cosmetic changes. In 1947 Bibby reported that as ph of the solution was lowered fluoride was absorbed into enamel more effectively. Brudevold et al 1963 studied the effect of prolonged exposure of enamel to sodium fluoride in acid sodium fast solutions. They concluded that the fluoride concentration in enamel increased with decrease in ph of solution.

 Mellberg(1966) reported that after a 10 min exposure of a cut tooth section to APF sol, there was a high fluoride conc. In the inner layers of enamel. Clinical studies o APF sol, containing 1.23% available fluoride in 0.1M phosphoric acid at pH 2.8 are applied in a similar manner to SnF2 sol. The first clinical trial was started in 1961 by Wellock and Brudevild(1963). After 2 years, children in the study group had approx. 66% fewer carious surfaces than children in control group. o Parmeijer, Brudevold and Hunt(1963),in a study of 77 children aged 4-10 years, compared the effectiveness of neutral NaF solution with an APF solution, used on opposite sides of the mouth. on the right side(APF), 45 new DMF surfaces were recorded whereas on the left side(NaF),92 new surfaces were found. In this study, it was concluded that APF was 50% more effective than neutral NaF as a caries preventive agent. o Further studies have reported reductions of 44-49% in new DMF teeth in children given annual or bi-annual applications of APF solution compared with control groups receiving treatment with tap water only(Wellock,Maitland and Brudevold,1965;Cartwright, Lindahl and Bawden,1968). o Szwejda, Tossy and Below(1967) carried out the clinical trial of APF gels on seven years old children. They observed no reduction in caries increment after 1 year.

 APF gels: Available as thixotropic gels ie. they convert to a solution and flow more easily under pressure Gentle pressure should be maintained on the tray to force gel approximally. Gelling agent used is usually methylcellulose or hydroxyethyl cellulose. Szwejda, Tossy and Below(1967)- first published trial of APF gels on 7year old children.

Fluoride varnishes: Duraphat was the first fluoride varnish introduced in 1960s. The varnishes were originally developed to prolong the contact time between fluoride and enamel3. The varnishes adhere to the tooth surface for longer

periods and prevent the immediate loss of fluoride after application, thus acting as slow-releasing reservoirs of fluoride. Caries reductions by fluoride varnishes have been similar to those reported for fluoride solutions and gels (DeBruyn and Arends, 1987; Seppa, 1989; Ripa, 1990).3 Advantages: Safe to use: Because the amount of varnish usually used is 0.3-0.5mL, which delivers only 3-6mg fluoride. Application:

Usually biannual applications of varnish are the most widely recommended. Instructions to patients: Not to eat or brush for at least 4 hrs after varnish application. The comparison between Duraphat and Fluorprotector is as under: Properties Duraphat Introduced in 1960s General consistency Viscous resinous lacquer Fluoride content pH Application 5%wt sodium Fluorprotector 1970s Polyurethane-based difluorosilane

lacquer fluoride 5 wt%

(2.26% fluoride) Neutral Applied to dry,clean teeth.

(0.7% fluoride) Acidic Leaves a

clear

Hardens into a yellowish transparent film on the brown coating in presence of teeth Efficacy saliva 30-40%(Permanent teeth) 7-44%(Primary teeth) 1-17%

Other varnishes: DuraFlor: Another name for Duraphat Carex: 1.8% fluoride Efficacy similar to Duraphat

 Self applied fluorides o Self applied topical fluoride gels: 0.05% gel(5,000ppm F) daily self application for 5 min is effective means of caries reduction Custom fitted maxillary and mandibular trays (Toplicators) are fashioned by vacuum drawing heat-treated sheets of polyvinyl over plaster models of the teeth. Intermittent biting pressure on plastic trays tends to pump the gel into pits, fissures and interproximal spaces. Disadvantage: o Relatively high cost of fabricating individual trays for each patient o Dependence on the patients cooperation. This procedure, first tested in supervised school programs, reduced decay in a nonfluoridated community by about 75% and in fluoridated community by about 30% after 2 yrs.(Englander H.G. et al 1967,1971). 0.4% stannous fluoride gel(1,000 ppmF) has been used as an alternative. Many of these stannous gels have been accepted by ADA Council on Dental Therapeutics.

Fluoride mouthrinses: 20-50% effective in reducing caries

 The rinse should be swished between the teeth for 1 min and then expectorated. Advantages: o Safe o Effective o Relatively inexpensive o Easy to learn o Requires little time o Can be supervised by non dental personnel in school settings. 0.2% sodium fluoride(900ppm F) for 1 min- biweekly use 0.05% sodium fluoride(230ppm F) for 1 min- daily: o More effective Available as over-the- counter product. The label states that use is restricted to persons 6 yrs old and older. Fluoride dentifrices: Sodium monofluorophosphate (MFP) was first tested as a therapeutic agent in dentifrices in early 1960s. Numerous clinical trials of dentrices containing 0.76% or 0.8% MFP have since been conducted by different groups in various countries showing approx. 25% effectiveness in caries reduction. Toothpastes containing 1000 ppm fluoride

Investigators Active ingredient(% conc.)

pH

Duration(yr )

Age(yr)

Statistically significant reductions in carious surfaces saved % redn P

Brudevold

0.22% NaF+

4.85.3 4.85.3

2 2

11-17 9-15

1-2 1

* *

0.01 *

and Chilton Peterson 1.5% soluble and

Williamson Slack et al. orthophosphate * Zacherl 0.22% NaF 5.5

3 1.66

11-12 7-14

Investigators

Duration of Trial

No. carious surfaces saved year 1.48 0.87 0.84 0.28 0.46 0.6

of Reduction in Level carious surface per increment(%) 49 36 34 13 21 63* 0.0001 0.013 0.005 NS 0.01 0.0001 statistical

of

significance

Muhler et al. 1 yr Muhler et al. 1 yr Muhler and 2 yr Radike(Adults) Jordan and 2 yr Peterson Muhler Kyes et (Adults) Bixler Muhler Muhler Muhler and 2 yr 8 mo 3 yr 2 yr al. 3 yr

0.18 1.8 0.41

8 45 22

NS 0.006 0.0062

Finn Jamison Slack Martin

and 2 yr and 2 yr

1.2 No placebo

46 true No placebo

true -

CONTENTS Introduction to fluorides Sources of fluoride Metabolism Absorption Distribution Excretion Mechanism of action Professionally applied fluorides o Solutions Sodium fluoride Stannous fluoride APF o Gels o Foams Self applied fluorides o Gels

o Mouthrinses o Dentifrices

References
Fluorides in caries prevention- Murray Fluorides in dentistry- Fejerskov Dental caries- the disease and its clinical management- By Fejerskov

B. gaard, L. Sepp and G. Rolla. Professional Topical Fluoride Applications-- Clinical Efficacy and Mechanism of Action. ADR 1994 8: 190

JADA, Vol. 131, July 2000 JADA, Vol. 132, September 2001 Caries research 1998; 32:83-92

Journal Of Minimum Intervention In Dentistry, 2009; 2 (4) 225