Public health

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Fluoridation Mechanism and Effects
What is fluoride?
Fluorine is an electronegative, naturally occurring element. It is the most reactive
of all chemical elements. The reduced form of fluorine (or its ionic form) is called
as Fluoride. Fluorine cannot occur in nature in its elemental form, but only as a
fluoride ion which introduced into dentistry over 70 years ago; fluoride has a high
affinity for calcium, therefore, very compatible with teeth and bone. The decrease
in prevalence and severity of dental caries over the second half of the 20th century
in many industrialized countries is attributed to use of fluoride.

Sources of Fluoride
1- Ground waters, rain water, sea water &river water
2- Atmosphere, fluoride- containing soils and gas, underground coal fires and
volcanic activities
3- Food: Fluoride present to some extent in nearly all foods. Certain foods contain
more F than others, e.g. tea & some sea foods.
4- Dental products: ex, toothpaste; and some drugs.
5- Pollution: In vicinity of industries involved in production of aluminum from
cryolit & phosphate fertilizers.

Water fluoridation: It is the controlled addition of fluoride to a public water

supply for optimal dental health which effectively prevents caries. It is the best
method of delivering fluoride on a population basis. Fluoridation does not affect the
appearance, taste, or smell of drinking water. It Considered as one of the "ten greatest
public health measures of the 20th century.

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The three types of fluoride that are used to fluoridate water are:

 Sodium fluoride.
 Sodium fluorosilicate.
 Fluorosilicic acid.

Level of fluoride

The optimal level of fluoride the is l ppm (parts per million equivalents to milligrams
per liter). The optimal level is not appropriate for all parts of the world, so the
optimal level is range from 0.7 to 1.2 ppm and is depending on:

• The average maximum daily air temperature; the optimal level is lower in warmer
climates, where people-drink more water, and is higher in cooler climates.

• Presence of other sources of fluorides.

The use of optimal level of fluoride is to achieved, maximum caries reduction

with minimum side effect.

History
The history of water fluoridation can be divided into three periods.
The first (1901-1933) was research into the cause of a form of mottled tooth enamel
called the Colorado brown stain.
The second (1933-1945) focused on the relationship between fluoride
concentrations, fluorosis, and tooth decay.
The third period, from 1945 on, focused on adding fluoride to community water
supplies.

Anti caries effect of fluoride

Fluoride exerts its major effect by interfering with the demineralization mechanism
of tooth decay. The caries-prevention effect of fluoride is mostly due to systemic
effect which occurs during tooth formation, as well as surface (topical) effect, which
occur after tooth eruption.

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So the anti caries effect of fluoride can illustrate as:
*Decrease solubility of enamel in acid (fluoroapatite crystal less soluble in acid).
*Enhance remineralization of enamel in area that have been demineralized by acids.
*Antibacterial action: Inhibit bacteria adsorption & decrease acid production of
plaque bacteria.
* Improve tooth morphology making them more self-cleansing.

Metabolism of fluoride
When F is ingested, the absorption occurs mainly in the stomach. F concentration in
the blood reaches a peak after about 30 minutes, and returns to the usual level after
11- 15 h. About 99% of F is associated with calcified tissue (bone & teeth). F also can
be absorbed following inhalation and through the skin. The main route of fluoride
excretion is via the kidney.

Types of fluoride:
A- Systemic fluoride: Its benefit in pre-and post-eruptive phase
1-Communal water fluoridation
2- Alternative methods for C.W. F.:
School water fluoridation: The important thing is the optimal level of fluoride in
school water fluoridation is about 4.5 times that of the communal water fluoridation
because children spend only part of their day in the school.

Fluoridated tablets: The age of the patient and area of residence in consideration.
The child instructed to chew the tablets between his teeth to have topical and the
systemic effect of fluoride.

Fluoridated salts: The effectiveness of salt fluoridation is about the same as that
of water fluoridation, if most salt for human consumption is fluoridated.
Fluoridated milk: An interesting aspect about milk fluoridation is its use among
children. This is the target age group and well conducted school-based programs have
been developed.

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B- Topical fluoride: Its benefit in post eruptive phase

1. Self applied:
Dentifrices.
Fluoridated mouth rinse.
Fluoridated gel.
These are the self-applied topical fluoride application of low concentration. It is
widely used.
2. Professional applied: In the form of solutions, gel, foam, varnishes, prophylactic
paste or pumice. These are the professional fluoride application of high concentration.

Choice of fluoride type and dose depends on:

1- Current levels of fluoride intake.
2- Caries status.
3-Age of subjects in the area.

Fluoride toxicity:
1-Chronic toxicity: It is long term ingestion of small amount of F for long period, it
can cause dental and skeletal changes referred to as dental fluorosis and skeletal
fluorosis.
A-Dental fluorosis: which can alter the appearance of children's teeth during tooth
development.

B. Skeletal fluorosis: Is a term used to describe any changes in bone.

2- Acute toxicity: It is single ingestion of large dose of F at one time. In rare cases,
it can cause acute fluoride poisoning, with symptoms that include: nausea, vomiting,
and diarrhea.

Dental Fluorosis: Hypomineralization of enamel results from prolonged

ingestion of fluoride during the period of tooth development.
Clinically: Opaque white patches in the enamel which may become striated,
mottled, pitted or stained yellow to dark brown.

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There are many indices for assessment of dental fluorosis, one of these is
Dean's Dental Fluorosis Index which was developed by Dean in1942.
Scores used in Dean's Index are as follows:
Normal (0): The enamel is smooth, glossy and translucent, usually a pale creamy-
white color.
Questionable (0.5): There are slight aberrations from the translucency of normal
enamel. Lesions may range from a few white flecks to occasional spots.
Very mild (1): Opaque paper-white areas are visible, involving less than 25% of
the facial or buccal tooth surface.
Mild (2): White opacity of the enamel is more apparent than for code 1, but still
covers less than 50% of the surface.
Moderate (3): Marked wear and brown stain, frequently disfiguring is visible.
Severe (4): Hypoplasia is so marked that the general form of the tooth may be
altered. Pitted or worn areas and brown stain are widespread. Teeth often have a
corroded appearance.

Defluoridation
It is a process to remove excessive amounts of fluorides when the level exceeds
recommended limits in naturally fluoridated waters. Defluoridation is carried out
by adding chemicals to precipitate the fluoride.

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Fluorosis Index which was developed by Dean in1942