Preventive dentistry Fluoride in Dentistry lec:3

Introduction
The history of fluorides in dentistry is over 100 years old. Sir James Crichton
Browne made an inspired guess about the importance of fluoride in the diet in 1892.
The man who had the greatest impact on the early history of water fluoridation was
Dr. Frederick McKay who arrived in Colorado Springs in 1901, the year following
his graduation from the University of Pennsylvania Dental School. He soon noticed
that many of his patients had a permanent stain on their teeth, which was known to
the local inhabitants as ‘Colorado stain’. McKay checked his lecture notes, but found
nothing to describe such markings, nor could he find any reference to it in any of the
available scientific literature. He called the stain ‘mottled enamel’.

The chief chemist Churchill in 1931 identified a significant amounts of fluoride

in water samples from other different endemic area with mottled enamel.

In 1939, Trendley Dean made a survey on the relationship between water

fluoride concentration and severity of mottled enamel. He showed conclusively that
the severity of mottling increased with increasing fluoride concentration in drinking
water. In 1942, Dean’s survey demonstrated inverse relationship between fluoride
concentration and dental caries in a way that the mottled enamel was no more
susceptible to decay than normal enamel.

Although the widespread of fluoride and the updated knowledge about its
mechanisms of action, the general opinion about effectiveness and risk of systemic
methods of fluoride are completely different from decades ago. Nevertheless, these
methods are still recommended in many countries and receive support from
recognized international committees and associations. In contrast, many dental

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practitioners have conflicting opinions about the safety and benefits of having a
water fluoridation program in their city.

Fluoride metabolism
Fluoride is the negatively charged ionic form of the element fluorine that has
a high affinity for calcium. In the human body, it is mainly associated with bones
and teeth. Fluoride play an important role in the prevention of dental caries.
However, it can negatively affect the quality of the developing mineralized tissues
causing dental and skeletal fluorosis. Fluoride metabolism include absorption,
distribution, secretion and excretion.

Absorption of Fluoride
Fluoride-containing compounds are extremely diverse. For this reason, their
metabolism depends on their structure reactivity, solubility, and ability to release
fluoride ions. Fluoride ion (F-) metabolized by the body in a simple manner, (F-) can
be either generated within the body by the biochemical modification of the different
fluoride containing compounds or directly ingested. Fluoride mostly enters the body
via the gastrointestinal tract and when it reach the stomach, is absorbed quickly
without the need of specialized enzymatic systems. It crosses epithelia by passive
diffusion in the form of hydrogen fluoride, which is a weak acid diffused from more
acidic environment in the stomach to more alkaline environment, and dissociate to
form fluoride ion. Recent studies have indicated that in addition to crossing the
stomach as undissociated acid, the majority of fluoride absorption occurs in the small
intestine and is not pH dependent.

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 The rate of fluoride absorption from the stomach affected by:
 The acidity of the stomach: increased acidity lead to increase dissociation of
hydrogen fluoride to form ionic fluoride and increase absorption.
 The solubility of the ingested fluoride compound: more soluble sodium
fluoride (NaF) and hydrogen fluoride would result in faster absorptions,
whereas less soluble calcium fluoride (CaF2) and magnesium fluoride (MgF2)
would slow absorption.
 Presence of food in the stomach act as a physical barrier that decrease the rate
of fluoride absorption.
 Presence of other elements in the stomach like calcium, magnesium, and
phosphate ions may bind the fluoride ion and decrease the rate of absorption.

Distribution of Fluoride
As soon as fluoride is absorbed, plasma fluoride levels increase within (10)
minutes, reaching peak level at (60) minute. A return to basal levels is achieved
within 11 to 15 hours. The plasma fluoride consider the central compartment from
which the fluoride distribute to the soft, mineralized, and specialized body fluids, or
excreted via the kidneys.

In the soft tissues, the rate of fluoride distribution depend on:

 Velocity of blood flow to the soft tissues and organs.
 Transmembrane pH gradient.
As the fluoride ion accumulate in more alkaline environment in response to
pH so, when the extracellular pH increase, the fluoride ion leaves out the cell
inversely, when extracellular pH decrease, the fluoride ion goes inside the cell. This

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is the basis of alkalinization in case of acute fluoride toxicity in order to promote
releasing the fluoride ion out of the cell.

In the mineralized tissues, the Fluoride uptake is also modified by factors such as:
 Age: fluoride ion distribute to the mineralized tissues more in younger than
older individuals.
 Dose of intake
 Duration of intake
The fluoride ions that deposited to the tooth structure is considerably lower than
that found in the bone for the same individual. In the tooth fluoride ion deposited to
the dentin 4 times than to the enamel starting in high concentration at the
odontoblastic layer and reduced at the cement enamel junction. In the outer layer of
enamel is about 4-5 times than inner layer of enamel.

Secretion of Fluoride
Fluoride ion is secreted in specialized body fluids as saliva, salivary
fluoride levels increase as plasma fluoride levels increase. Although salivary
fluoride level is only within the range of 0.01 to 0.06 ppm, it plays an
importance role as a preventive agent for dental caries. Fluoride level in whole
saliva are higher than ductal saliva because it often contaminated with by
exogenous fluoride source such as food, water, and fluoridated dental
products.

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Excretion of Fluoride
The fluoride that is not stored in bone is excreted mainly via the kidneys, with
a minimal quantity excreted through feces.
1. Urine: 45-60 % of the absorbed fluoride eliminates exclusively via the kidney,
urinary fluoride levels are higher in individuals who are exposed to high intake
of fluoride, the renal clearance of fluoride is directly related to urinary pH,
and under some condition to urinary flow rate. In alkaline urine, the fluoride
present in ionic form hence, its renal clearance is rapid while in acidic urine,
fluoride is present in non-ionic form (hydrogen fluoride) hence, it is rapidly
reabsorbed in renal tubules.
2. Feces: 10-25 % of the ingested fluoride that is not absorbed by the
gastrointestinal tract excreted in the feces.
3. Sweat: some fluoride is also lost from the body through sweat so, a
considerable amount of fluoride is lost in case of excessive sweating.
4. Other routes: a little amount of fluoride is excreted through the breast milk.