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1. Introduction 2. Fluoride toxicity 3. The Caries Process
Fluoride in Caries Prevention
4. Fluoride Mechanism of Action 5. The Role of Low Levels of Fluoride 6. Clinical Implications 7. Policy on the use of fluoride
• Caries continues to be a major problem • Need an improved approach to prevention & therapy • Major contributor to reductions in decay during the last 20 years Æuniversal use of fluoride (F) products
(Featherstone JD, 1999) Featherstone JD. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol 27: 3131-40, 1999.
Parents of Fluoride Poisoned Children (PFPC) Fluoride Issues New York State Coalition Opposed to Fluoridation (NYSCOF) STOP fluoridation USA ...stop fluoride poisoning
Safety? Efficacy of caries prevention? How to use?
一般民眾使用的牙膏當中，經常含有氟化物，用來預 防蛀牙，但是比利時政府現在打算公佈法令，禁止藥物以 禁止藥物以 外的食品添加含氟的物質，也就是說，除了藥品和牙膏之 外的食品添加含氟的物質 外，連小朋友經常吃的口香糖，也不能添加氟化物。 一般的牙膏當中含有氟化物，是稀鬆平常的事，甚至 是飲用水當中，也經常添加氟化物，據說如此可以減少蛀 牙，但是比利時政府卻在最近打算公佈禁令，禁止在食物 當中添加任何的氟化物。比利時健康官員高梭林基表示， 氟化物是毒藥，會鎖住酵素反應 鎖住酵素反應，攝取過量還會造成氟中 氟中 毒，破壞神經系統 破壞神經系統，因此不能攝取太多氟化物。……專家 表示，由於氟化物可能會造成氟中毒，破壞神經系統，甚 至會形成骨質疏鬆症 骨質疏鬆症，這項禁令最快將在八月下旬實施， 比利時希望所有的歐盟國家，都能熱烈響應這項禁令。
(本文由東森新聞報 提供, , 2002/07/31) 本文由東森新聞報提供 2002/07/31)
2. fluorosis. The biochemistry and physiology of metallic fluoride: action. 2003. Crit Rev Oral Biol Med 14(2):10014(2):100-14. Aust Dent J 46:(2):8046:(2):80-7. Fluoride toxicity • In most of the situations. • AlAl-F complexes • Usually formed in routine laboratory solutions.2001. Sinclair MI. Fluoride toxicity . bone mineral density or fracture incidence • Results • 33 studies were identified • The majority of animal studies showed no effect or a beneficial effect of low fluoride doses Demos LL. fractures –recent developments. mechanism. Fluoride toxicity • Fluoride • Inhibit a variety of enzymes • G protein activator 2. and oral disease Li L. Fairley CK. osteoporosis. 2. Fluoride toxicity • Conclusion • Fluoride at up to 1ppm does not have an adverse effect on bone strength. Sinclair MI. Fairley CK. fractures –recent developments. neurotoxicity. mechanism.2. osteoporosis. Fluoride toxicity • Dental fluorosis 2. The biochemistry and physiology of metallic fluoride: action. Aust Dent J 46:(2):8046:(2):80-7. Kazda H. the investigators have not proved that AlAl-F complexes are present in vivo • AlAl-F complexes have clinical implications only if they are available to the biological tissues Li L. Fluoride toxicity • Methods • Research on effects on bone published since the 1991 National Health and Medical Research Council report on water fluoridation was reviewed 2. and implications. mechanism. mechanism. Cicuttini FM. Water fluoridation. Crit Rev Oral Biol Med 14(2):10014(2):100-14. strength. and implications.2001. cell culture media. Water fluoridation. 2003. Cicuttini FM. and body fluid • Play physiological or pathological roles in bone biology. Kazda H. Demos LL.
lipid & water • allow the passage of small molecules (lactic acid) and ions (hydrogen and calcium) 3. An update on fluorides and fluorosis. refer immediately • Unknown dose: dose: asymptomatic: asymptomatic: treat as <8 mg F/kg symptomatic: symptomatic: give milk. The Caries Process 3. . 2000. refer immediately • Poison control center: center: gastric lavage. other modalities should be targeted toward highhigh-risk individuals • Care should be exercised in prescribing other modalities of F delivery before age 6. J Can Dent Assoc 69(5):286– 69(5):286–91. rather than requiring a specific threshold dose • Depending on the total fluoride intake from all sources & the duration of fluoride exposure Aoba T. followed by milk.1. Crit Rev Oral Biol Med 13(2):155– 13(2):155–170. JADA 131(7): 887887-99. Fluoride toxicity • Dental fluorosis • Water fluoridation and use of F dentifrice are the most efficient and costcost-effective ways to prevent dental caries. Dental fluorosis: chemistry and biology. The science and practice of caries prevention. observe≧6 hr. & especially before age 3. Fluoride toxicity • Treatment • < 8 mg F/kg: F/kg: milk. The nature of tooth mineral • Remineralized enamel mineral • more resembling a blend of hydroxyapatite & fluorapatite • much less soluble than the original mineral Featherstone JD. The nature of tooth mineral • Enamel & dentin: millions of tiny mineral crystals embedded in a protein/lipid matrix • Tiny gaps or pores between the crystals • filled with protein. Fluoride toxicity • Symptoms of overdose • GI.2. Levy SM. death in 4 hr 2. CNS. IV calcium gluconate • Probably toxic dose Æ 5 mg F/kg • Certainly lethal dose Æ 16~32 mg F/kg (Hodge & Smith) 15 mg F/kg (Whitford) 3. 2. 2002.1. 2003. Fluoride toxicity • Dental fluorosis • Enamel fluorosis is caused by the long-term ingestion of fluoride during tooth development • Effects of fluoride on enamel formation • Causing dental fluorosis • Cumulative. Fejerskov O. 2. The Caries Process 3. because of the risk of dental fluorosis. refer if symptoms develop • ≧8 mg F/kg: F/kg: syrup of ipecac.
JADA 131(7): 887887-99. 1999. The Caries Process 3. The science and practice of caries prevention. The caries balance • Caries progression vs reversal is a delicate balance between pathological factors (bacteria & carbohydrates) & protective factors (saliva. Fluoride Mechanism of Action • ReRe-examining the literature used in support of a prepre-eruptive mechanism • Water fluoridation studies • Fluoride supplement studies 4. Driving force for remineralization • Degree of supersaturation of mineralizing fluid (saliva in the mouth) • Fluoride concentration in the oral fluids 4.remineralization cycle 3. Inhibits of demineralization • F surrounding the carbonated apatite crystals is much more effective at inhibiting demineralization than F incorporated into the crystals at the levels found in enamel • F incorporated developmentally into the normal tooth mineral is insufficient to have a measurable effect on acid solubility Featherstone JD. A rere-examination of the prepre-eruptive and postpost-eruptive mechanism of the antianti-caries effects of fluoride: is there any antianti-caries benefit from swallowing fluoride? Community Dent Oral Epidemiol 27: 6262-71.3. 2000. Fluoride Mechanism of Action • Any prepre-eruptive benefit due to ingestion of fluoride during tooth development is now believed to be relatively unimportant • Primary mode of action of F is topical • PostPost-eruptive benefit is cumulative Limeback H.1999. 3. The Caries Process 3. phosphate.4. Community Dent Oral Epidemiol 27: 3131-40. The Caries Process 3.1.1999.2. . The demineralizationdemineralization. A rere-examination of the prepre-eruptive and postpost-eruptive mechanism of the antianti-caries effects of fluoride: is there any antianti-caries benefit from swallowing fluoride? Community Dent Oral Epidemiol 27: 6262-71.3. fluoride) Featherstone JD. Fluoride Mechanism of Action 4. 4. Prevention and reversal of dental caries: role of low level fluoride. calcium. • 'Systemic topical' fluoride (or local prepre-eruptive fluoride) Limeback H.
together. & is preferentially included in the chemical reaction that takes place. Fluoride Mechanism of Action 4. Community Dent Oral Epidemiol 27: 3131-40. Prevention and reversal of dental caries: role of low level fluoride. 1999.1 ppm for 2-6 hours depending on the product and the individual subject • Children with high individual salivary F (≥0.02) .3. 5. 1999. 1999. Fluoride Mechanism of Action 4.03 & 0. Prevention and reversal of dental caries: role of low level fluoride. Featherstone JD. Inhibits of demineralization • If F is present in the plaque fluid at the time that the bacteria generate acid it will travel with the acid down into the subsub-surface of the tooth.4. Community Dent Oral Epidemiol 27: 3131-40. 5. The Role of Low Levels of Fluoride in Saliva & Plaque Fluid • F can be retained at concentrations in the saliva between 0. producing a lower solubility endend-product 4.1. Community Dent Oral Epidemiol 27: 3131-40.03 ppm F or higher were incorporated in the mineralizing solution (artificial saliva in the model) remineralization was enhanced Featherstone JD. Community Dent Oral Epidemiol 27: 3131-40. Fluoride Mechanism of Action 4. The Role of Low Levels of Fluoride in Saliva & Plaque Fluid • Small increases in the background level of F in saliva & plaque fluid could provide important caries protection via enhancement of remineralization • When levels of 0. Inhibits plaque bacteria • F from topical sources is taken up by the bacteria when they produce acid. Prevention and reversal of dental caries: role of low level fluoride. 1999. Prevention and reversal of dental caries: role of low level fluoride. Prevention and reversal of dental caries: role of low level fluoride. Enhances remineralization • Fluoride acts to speed up this remineralization process by adsorbing to the surface & acting to bring calcium and phosphate ions together. Featherstone JD. Fluoride Mechanism of Action 4.075 ppm) ppm) were more frequently caries free (p<0. adsorb to the crystal surface and protect it against being dissolved 4.2. thereby inhibiting essential enzyme (enolase) activity Featherstone JD. Enhances remineralization • The saliva is "supersaturated" with calcium & phosphate providing a driving force for mineral to go back into the tooth • The partially dissolved crystals act as "nucleators" for remineralization Featherstone JD.2. 4. 1999. Community Dent Oral Epidemiol 27: 3131-40.
0 g 8.23mg/ml) Weekly(0.97mg/ml) 0.5mg/g) Rinse Tablets Daily(0. • F mouthrinses (¾ 30﹪) • F varnishes (¾ 38﹪) 22.214.171.124 ml 2.2.1 ml 8 tab 4 tab 2 tab 4 cartons 2 litres • Minimize fluorosis ÆF ingested & absorbed as little as possible ( dose = concentration x amount) • Frequent½ Amounts¾ Concentration½ 6.0 ml 4 tab 2 tab 1 tab 2 cartons 1 litres 1.05%) (0.1.3 ml 1.2.1 mg/kg 1 y/o (10kg) 5-6 y/o (20kg) 1 y/o (10kg) 5-6 y/o (20kg) 33 g 50 g 100 g 217 ml 52 ml 200 tab 100 tab 50 tab 100 cartons (18.05% (220ppm) for daily use • NaF 0.0 g 4.25mg 0. HomeHome-based methods of delivery • F toothpaste (caries incidence ¾ 25﹪) • F tablets & supplements (primary dentition ¾ 50~80﹪. HomeHome-based methods of delivery • F mouthrinses • NaF 0. HomeHome-based methods of delivery • F tablets & supplements 6. Clinical Implications Fluoride Formulation 1500ppm (1.9 litres) 50 litres 66 g 100 g 200 g 434 ml 104 ml 400 tab 200 tab 100 tab 200 cartons (37. Maximizing benefit and minimizing risk • Maximize antianti-caries efficacy ÆF present in oral cavity as long as possible ( concentration & frequency of application) Product Dentifrice 6.0 g 2.0mg/g) 500ppm (0. Clinical Implications 6.8 litres) 100 litres 0.33 g 2.5mg 1.0mg Fluoridated milk water 2. HomeHome-based methods of delivery • F toothpaste • Frequency & time of application • Amount applied “peapea-sized” sized” / 5mm long • Rinsing behaviour permanent dentition dentition ¾ 20~40﹪) 6. Clinical Implications 6.2% (900ppm) for weekly use • Not be used by children under 7 years due to risk of swallowing excessive F . Clinical Implications 6. Clinical Implications 6. Clinical Implications 6.5mg/g) 1000ppm (1.65ppm (0.0 g 4.67 g 1.2.20%) (0.5mg in 189ml) 1ppm (1mg/l) Probable toxic dose=5mg/kg Fluorosis dose=0.
Endorses & encourages water fluoridation 2. Clinical Implications 6.2.3. HomeHome-based methods of delivery • F varnishes • Duraphat (23000 ppm F) 6.Recommends an individualized patient cariescaries-risk assessment to determine the use of FF-containing products 7.Encourages continued research on safe & effective F products including restorative materials American Academy of Pediatric Dentistry 2003 American Academy of Pediatric Dentistry 2003 . Clinical Implications 6. endorses F supplementation 3. as this combination is associated with a high risk of cosmetically disfiguring fluorosis 6. CommunityCommunity-based fluoride delivery • Water fluoridation 7.Inform medical peers of potential hazard of enamel fluorosis when F supplements are given in excess of recommended amounts 7. CommunityCommunity-based fluoride delivery • Water fluoridation (¾ 40~70﹪) • Fluoridated milk drinks • Fluoridated salt 6.3.6.Not 5.3.Whenever water fluoridation is not feasible. Clinical Implications 6.Continued research on dental fluorosis 5.Not support use of prenatal F supplements 6. Policy on the use of fluoride 1. Clinical Implications 6. discouraged. helping to maintain ½ intraintra-oral F levels • Reduction is usually greatest in young children • Use of F tablets in fluoridated areas should be strongly discouraged. Policy on the use of fluoride 4. CommunityCommunity-based fluoride delivery • Water fluoridation • Small amounts of F are delivered throughout the day.
SUMMARY 1. The Role of Low Levels of Fluoride 6. Fluoride Mechanism of Action 5. Introduction 2. Fluoride toxicity 3. Policy on the use of fluoride . The Caries Process 4. Clinical Implications 7.
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