TOPICAL FLUORIDES IN DENTISTRY

INTRODUCTION
 Fluorine is a member of the halogen family and is
the most electronegative and reactive of all the
elements.
 The word fluorine is derived from the latin term
‘Fluore’ meaning to flow.
 Its selective action on the hard tissues of the body
attributes significantly to prevention and control of
dental caries.
FLUORIDE DELIVERY METHODS

 Fluoride can be delivered as…

(A) Topical Fluorides
(B) Systemic Fluorides
TOPICAL FLUORIDES SYSTEMIC FLUORIDES

 These are placed directly  These circulate through

on the teeth the blood stream and are
incorporated into
developing teeth

 Some preparations
provide high or low  They provide a low
concentrations of fluoride concentration of fluoride
over a short period of over a long period of time
time
INDICATIONS
 Caries active individuals
 Children shortly after period of tooth eruption
 Those who take medication that decrease salivary
flow or have received radiation to head and neck
 After periodontal surgery when roots of teeth have
been exposed
 Patients with fixed or removable prosthesis and after
placement or replacement of restorations
 Patients with an eating disorder or who are
undergoing a change in lifestyle which may affect
eating or oral hygiene habits conductive to good oral
health
 Mentally and physically challenged individuals
 TOPICAL FLUORIDE PRODUCTS ARE
DIVIDED INTO 2 CATEGORIES
(A) Professionally applied
 Introduced by Bibby in 1942
 Dispensed by dental professionals in the dental office
and usually involve the use of high fluoride
concentration products ranging from 5000-19000 ppm
which is equivalent to 5-9 mg F/ml

(B) Self applied

 Include fluoride dentifrices, mouth rinses & gels
 Are low fluoride concentration products ranging from
200-1000ppm or 0.2-1 mgF/ml.
RATIONALE FOR USING TOPICAL
FLUORIDE AGENTS
 To speed up the rate and increase the
concentration of fluoride acquisition above
the level which occurs naturally
 The initial caries lesion characterized by a
white spot is porous and accumulates
fluoride at a much higher concentration than
adjacent sound enamel
PROFESSIONALLY APPLIED FLUORIDES
FLUORIDE VEHICLES
 AQUEOUS SOLUTIONS AND GELS
 Gel adheres to the tooth surface for a considerable
amount of time and eliminates the continuous wetting
of enamel surfaces when solutions are used
 2 or 4 quadrants can be treated simultaneously when
trays are used for gel application which results in
substantial saving of time
 Thyxotrophic solutions are not gels but have high
viscosity under storage conditions and become fluid
under high stress
 Thyxotrophic solutions are more stable at lower ph
and don not run off the tray as readily as conventional
gels
GELS
 FLUORIDATED PROPHYLACTIC PASTES

 If prophylaxis pastes
containing fluoride are
used, the lost fluoride is
replenished & there is a
significant gain in the
concentration of
fluoride.
FOAM

 Developed to minimize the risk of fluoride over dosage

as well as to maintain the efficacy of topical fluoride
treatment.

 ADVANTAGES:
 Its lighter than a conventional gel & therefore only a
small amount of agent is needed for topical application
 The surfactant has cleansing action by lowering
surface tension, this facilitates the penetration of
material into interproximal surfaces.
 It doesn’t require suctioning so it offers advantages for
home use
FOAM
 FLUORIDE VARNISH
 It was first developed by Schimdt in Europe in 1964
 Increasing the time of contact between enamel
surface & topical fluoride agents favors the deposition
of fluorapatite & fluorhydroxyapatite.
Technique:
 After prophylaxis teeth are dried but not isolated with
cotton rolls since varnish sticks to cotton
 Total of 0.3-0.5 ml of varnish is required to cover full
dentition
 Application is done first done on lower arch then
upper, using single tufted small brush, starting with
proximal surfaces
 Patient is asked to sit with mouth open for 4 min to let
Duraphat set on teeth
FLUORIDE VARNISH
 Patient is asked to not rinse or drink anything for one
hour and advised liquid diet till next morning

 DURAPHAT:
It s a viscous yellow material, containing 22,600 ppm
fluoride as sodium fluoride in a neutral colophonium
base.

 FLUORPROTECTOR:
Its a clear polyurethane based product containing
7000 ppm fluoride from difluorosilane.
It is dispensed in 1ml ampules each ampule
containing 6.21mg of fluoride.

 CAREX:
It has low fluoride concentration than duraphat & has
equal efficacy to that of duraphat as caries preventive
agent
TOPICAL FLUORIDES USED IN PREVENTIVE
DENTISTRY:
 1.SODIUM FLUORIDE:
 2.STANNOUS FLUORIDE
 3.ACIDULATED PHOSPHATE FLUORIDE
 4.AMINE FLUORIDE

1) NEUTRAL SODIUM FLUORIDE

 Fluoride concentration - 9200ppm
 A minimum of four applications with a 2% NaF
solution gives a caries reduction of about 30%

 METHOD OF PREPARATION
 It is prepared by dissolving 20 gms of NaF powder in
1L of distilled water in a plastic bottle
 TECHNIQUE - KNUTSON’S TECHNIQUE

 At the initial appointment teeth are cleaned with pumice

slurry & then isolated with cotton rolls & dried with
compressed air.

 Using cotton-tipped applicator sticks ,the 2% NaF is

painted on air dried teeth so that all tooth surfaces are
visibly wet. The solution is allowed to dry for 3-4 min.

 This procedure is repeated for each of the isolated

segments until all the teeth are treated.

 A 2nd, 3rd and 4th fluoride application, each not preceded

by a prophylaxis, is scheduled at intervals of approximately
one week;

 The four-visit procedure is recommended for ages 3, 7, 11

and 13 years, coinciding with the eruption of different
 MECHANISM OF ACTION :

 When NaF is applied on tooth surface it reacts with

hydroxyapatite crystals in enamel to form CaF2 which is
the dominant product of the reaction
 As thick layer of Caf2 forms, it interferes with further
diffusion of fluoride from the topical fluoride solution to react
with hydroxyapatite and blocks further entry of fluoride ions.
This sudden stop of the entry of fluoride is termed as
‘chocking off effect’
 CaF2 acts as a reservoir and fluoride slowly leeches out of
it
 The CaF2 formed reacts with hydroxyapatite
fluoridated hydroxyapatite increases the
concentration of fluoride on enamel surface prevents
caries
 ADVANTAGES :

 It is relatively stable when kept in a plastic container;

 The taste is well accepted by patients;
 The solution is non-irritating to the gingiva;
 It does not cause discoloration of tooth structure;
 The series of treatments must be repeated only 4
times in the general age range of 3 to 13, rather than
at annual or semiannual intervals.

 DISADVANTAGES:

 The major disadvantage of the use of sodium fluoride

is that the patient must make 4 visits to the dentist
within a relatively short period of time.
2) STANNOUS FLUORIDE (SnF2)
 Fluoride concentration-19500ppm
 Stannous fluoride has been used at 8% and 10%
concentrations

 METHOD OF PREPARATION:
 Solutions of stannous fluoride are not stable. Soon after
mixing they become cloudy due to the formation of tin
hydroxide.

 A fresh solution of stannous fluoride be prepared for each

patient.

 To prepare 8% stannous fluoride solution, the content of

one capsule which is 0.8 grams (‘0’ No. of gelation capsule)
is dissolved in 10 ml of distilled water in a plastic container.
 TECHNIQUE - MUHLER’S TECHNIQUE

 Each tooth surface is cleaned with pumice or other

dental cleaning agent for 5 to 10 seconds;
 Unwaxed dental floss is passed between the
interproximal areas;
 Teeth are isolated and dried with air;
 Stannous fluoride is applied using the paint-on
technique and the solution is kept for 4 minutes.
Repeat applications are made every 6 months or more
frequently if the patient is susceptible to caries.
 MECHANISM OF ACTION:

 When SnF2 is applied in low concentration

tinhydroxyapatite, which gets dissolved in oral tissues
 At very high concentration Ca trifluorostannate forms
along with tin tri-fluorophosphate
 Tin trifluorophosphate is responsible for making the
tooth structure more stable and less susceptible to
decay
 CaF2 is the end product both at low and high
concentration which reacts with hydroxyapatite and a
small fraction of fluorhydroxyapatite also gets formed
 ADVANTAGES :

 Using an 8% stannous fluoride solution at 6 to 12 months

intervals conforms to the practicing dentist’s usual patient –
recall system;
 Administrative difficulties are avoided.

 DISADVANTAGES :

 In aqueous solution the material is not stable;

 8% solution is quite astringent and disagreeable in taste, its
application is unpleasant;
 The solution occasionally causes a reversible tissue
irritation manifested by gingival blanching;
 Causes pigmentation of teeth which has a characteristic
light brown colour
3) ACIDULATED PHOSPHATE FLUORIDE (APF)

 Fluoride concentration-12300 ppm

 METHOD OF PREPARATION

 An aqueous solution is acidulated phosphate fluoride

is prepared by dissolving 20 grams of sodium fluoride
in 1 liter of 0.1 M phosphoric acid and to this is added
50% hydrofluoric acid to adjust the pH at 3.0 and
fluoride ion concentration at 1.23%. It is also called as
Brudevold’s solution

 For the preparation of acidulated phosphate fluoride

gel, a gelling agent methylcellulose or hydroxyethyl
cellulose is added to the solution.
 TECHNIQUE

 APF is recommended for application at 6 or 12 months

interval
 Oral prophylaxis is done
 Teeth to be treated are completely isolated and
thoroughly dried with air
 Application of gel is done using trays; disposable foam
lined trays are preferred
 It is reapplied every 15-30sec so as to keep the teeth
moist with the fluoride solution throughout the four min
period
 The patient is instructed to eat, drink or rinse his
mouth for atleast 30 min
FLUORIDE
TRAYS
 MECHANISM OF ACTION

 When APF is applied to teeth it initially leads to dehydration

and shrinkage in the vol of hydroxyapatite crystals which on
hydrolysis forms an intermediate product called Dicalcium
phosphate dihydrate(DCPD)
 DCPD is highly reactive and starts forming immediately
after APF is applied
 Fluoride penetrates into the crystals more deeply through
the openings produced by shrinkage and forms fluorapatite
 For the conversion of whole DCPD formed into fluorapatite,
a deeper penetration and continuous supply of fluoride is
required. Because of this reason APF is applied every 30
sec and the teeth have to be kept wet for 4 min
 ADVANTAGES

 Requires only 2 application in a year;

 The gel preparation can be self applied and thus the
cost of application also gets reduced;
 It has the ability to deposit fluoride in enamel to a
deeper depth;

 DISADVANTAGES :

 Practical difficulties like the teeth should be kept wet

for for 4 minutes;
 It is acidic, sour and bitter in taste;
 It cannot be stored in glass containers.
4) AMINE FLUORIDE

 They are cariostatic agents

 Some of them are surface active agents i.e. they have
an affinity for enamel and thus will hold the fluoride for
a longer time against the tooth
 They also have anti bacterial properties. Reduced
plaque formation and anti glycolytic activity is also
reported with these compounds
 Amine fluorides have been tested in dentifrices,
mouthrinses and topical gels where they are either
brushed on teeth or applied with a tray but it is not
known if they are superior to the other currently
available fluoride agents
Characteristics Sodium fluoride Stannous Apf
fluoride
Percentage 2% 8% 1.23%

Fluoride 9200 19500 12300

concentration
(ppm)
ph neutral 2.4-2.8 3.0

Frequency of 4 at weekly biannually biannually

application intervals 3,7,11 &
13 yrs
Adverse effects no Tooth no
pigmentation
Gingival irritation
Caries reduction 30% 32% 28%
RECOMMENDATIONS FOR TOPICAL APPLICATION

 No more than 2 g of gel per tray or approximately

capacity
SELF APPLIED TOPICAL FLUORIDES
 Dentifrices
 Mouth rinses
 Gels

 DENTIFRICES
 The first clinical trial of fluoride dentifrice was initiated
by Bibby in1942
 The various compounds used in dentifrice are sodium
fluoride, stannous fluoride, monofluorophosphate and
amine fluoride
 A 200g tube of Colgate contains 1000ppm of fluoride
with the fluoride compound as Monofluorophosphate
 A single brushing with a full ribbon of paste on a
brush head provides about one gram of
toothpaste and will expose the individual to
approximately 1mgF
 For young children non fluoridated and non
abrasive toothpaste is recommended till the
child is 4 years of age
 After 6 years of age fluoridated toothpaste
should be used
 The amount should be pea sized and the paste
should be pressed into the bristles and not on
top of the brush
 MOUTHRINSES

 Fluoride mouthrinsing is one of the most widely used

caries preventive public health methods
 Caries preventive agents used are Neutral sodium
fluoride, Acidulated phosphate fluoride and Stannous
fluoride
 Sodium fluoride mouthrinses

 Formulated at concentrations of
0.2%(900 ppm F) for weekly use
0.05%(225 ppm F) for daily use
 These are used by forcefully swishing 10ml of the liquid
around the mouth for 60 sec before expectorating it

 Recommendations for fluoride mouthrinses

 Rinse and expectorate technique used for patients in

fluoride deficient communities
 In patients with increased caries risk e.g. those undergoing
orthodontic treatment or radiotherapy
 FLUORIDE GELS

 Fluoride gel products include neutral

sodium fluoride and acidulated
phosphate fluoride with a fluoride
concentration of 5000 ppm and
stannous fluoride with a
concentration of 1000 ppm
 The gels are either applied in trays or
brushed on teeth
 Professionally applied – given twice a
year
 Self applied – once a day or more
 Home fluoride gels are not
recommended for children below 6
yrs and younger
Limitations of fluoride gels

 They violate the principle of delivering low

concentration of fluoride at regular intervals
 Toxicity hazard
 Tedious to use on daily basis
TABLETS AND LOZENGES
 These are prescribed by the dentist or pediatrician
and are not available over the counter
 These provide a topical as well as systemic benefit
for both primary and permanent teeth
 The amount of fluoride is 0.25mg, 0.5mg or 1mg.
These are chewed, swished and swallowed
 Correct dosage is based on the conc of fluoride in
drinking water, age and weight of the child.
 Not more than 1 milligram of fluoride should be
ingested from all available systemic sources
 Use of these supplements from birth to age 13 or
16 yrs provides caries reduction from 60% to 65%
Conclusion
 Fluoridation is universally accepted by the dentists
and other medical professionals as being useful in
preventing tooth decay
 They can be used in areas where there are no
central water supplies, where the fluoride conc of
well water is low(tablets and lozenges)
REFERENCES

 Essentials of public health dentistry-Soben

Peter
 Topical fluorides – Amrit Tiwari
 Dental care for children – Anil Kohli