Dr.
Khulood Tariq
BDS, BSc, MPH
Asst. Professor
Dept. of Community & Preventive Dentistry
• Understand different ways of caries prevention
• Understand the role of fluoride in prevention
• Explain the mechanism of action of fluorides
• Describe the methods of fluoride delivery
• Elaborate the Toxicity of fluoride and its
management
• Explain methods of Fluoridation and
Defluoridation
Dr. Khulood
It is defined as the efforts, which are made
to maintain normal development,
physiological function and to prevent
diseases of the mouth and adjacent
parts.(Blackerby)
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Levels of Primary Secondary Tertiary
Prevention
Priorities of Prevention of Prevention of Prevention of
Prevention Disease Initiation Disease Loss of Function
Progression &
Recurrence
Taxonomy of Pre-Pathosis Intervention Placement
Prevention
Preventive Health Promotion Early Diagnosis & Disability
Services Specific Prompt Limitation
Protection Treatment Rehabilitation
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Universal problem
Preventable condition/disease
Life-style associated
All age groups affected
Expensive to treat BUT
Easier to prevent
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Bacteria ---
streptococcus
mutans, lactobacillus
Tooth --- smooth
surface, pit and
fissures
Substrate --- sugars
Time – frequency,
duration
A natural mineral found in soil, water, plant
tissues, animal tissues and atmosphere.
Plays
a key role in the prevention and
control of dental caries
Affects mineralization of teeth
Exerts its cariostatic effect
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However, higher quantity of fluoride can
cause serious problems in the form of
fluorosis.
“Colorado brown stains” an example of
fluorosis
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Michigan vs muskegon
New york vs kingston
Brantford vs sarnia,stratford...
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Caries reducing property established
Deliverypossible at population and
individual levels
A number of delivery mechanisms/
vehicles available
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Dentifrices Drops
Mouthwashes Tablets
Chewing gums Gels
Varnishes
Solutions
Fissure Sealants
Glass Ionomer
Slow Release
Devices
Systemic Topical
1. Water fluoridation 1. NaF preparation
2. Milk fluoridation 2. SnF preparation
3. Salt fluoridation 3. Acidulated
4. Fluoride phosphate fluoride
supplements 4. Fluoride varnish
5. Dentifrice
6. Fluoride
mouthwash
7. Prophylactic paste
1. Decreasing solubility
2. Improving Crystallinity
3. Remineralization
4. Bactericidal action
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Enamel which mineralizes under the influence
of fluoride has a lower carbonate content,
thus giving a reduced solubility
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Presence of fluoride improves
crystallinity.
Voidsare present between hydroxyl and
calcium ions which get replaced with
fluoride hence, stabilizing crystal
structure.
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Even small quantity (0.03 ppm) can
initiate remineralization process.
Whitespots are rapidly mineralized by
Calcium phosphate containing fluoride.
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high fluoride
conc
Calcium
fluoride
breaks down to
Ca and F
React with
hydroxy
apatite
FHA
Fluor
oapat
ite
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Fluoride at high concentration inhibits
and kills bacteria.
Prevents entry of glucose into bacterial
cell
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Fluoridation is the upward adjustment of the
fluoride ion content of a domestic water
supply to the optimum physiology
concentration, that will provide maximum
protection against dental caries and
enhance the appearance of the teeth with
a minimum possibility of producing
objectionable enamel fluorosis”
Dr. Khulood
Theoptimum fluoride level for water in
temperate climate is 1 ppm.
For
warmer and colder climates the amount
can be adjusted from approximately 0.7
ppm - 1.2 ppm.
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The choice of equipment and of
fluorides to be used will depend on:
¡ Cost and installation
¡ Maintenance
¡ Surveillance
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The following general characteristics of
the system need to be considered:
¡ The equipment must be adapted to local
conditions and needs of water network
¡ Equipment must be efficacious, safe and
precise
¡ Should have well defined precision
limits
Dr. Khulood
1. There is a municipal water supply reaching
a reasonable number of homes.
2. People drink this water rather than water
from individual wells
3. Suitable equipment is present.
4. Supply of fluoride is assured.
5. Workers available in the water treatment
plant to maintain the system
6. Money should be available for initial
installation and running costs.
Dr. Khulood
1. Appearance of teeth
2. Dental caries reduction in primary and
permanent teeth
3. Root caries
4. Tooth loss
5. Malocclusion
6. Interproximal and coronal caries
7. Economy
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Teeth exposed to an optimum or slightly
higher level of fluoride frequently are
clear, white, shining, opaque
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Primaryteeth was between 40% - 50%
Permanent teeth was between 50% - 60 %
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Stamm and Banting reported that life long
consumption of fluoridated water reduces the
incidence of root caries by approximately
50%.
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According to Arnold F.A., there is a 50 %
reduction in the prevalence of extracted
first molars in fluoridated areas compared
with those that are non-fluoridated.
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According to Salzman, orthodontic problems
are approximately 20% less prevalent among
children 6-14 years of age living in a fluoride
area compared to those living in the areas
without the benefits of fluorides.
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There is about only 5% prevalence of
interproximal dental caries and a
reduction of 60% coronal caries in
fluoridated communities compared to
those of non-fluoridated.
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Among other means of fluoride usage – fluoride
tablets, school dentifrices, prescription
fluorides, water fluoridation is most
economical in reducing the cost of public
health expenditure.
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Saturation system
Dry feeder (NaF, NaSiF)
Solution feeder (Hydroxyfluorosilicicacid)
Venturi fluoridator system
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1. Sodium fluoride (NaF) (Dry feeder)
2. Sodium SilicoFluoride (Dry feeder)
3. Hydroflurosilicic acid (Solution feeder)
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1. Ignorance and confusion--- on the part of
PUBLIC about the dental health benefits.
2. Ambivalence of the public towards science
and its by-products.
3. Mis-representation of the scientific and
technical information involved.
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First
initiated as a pilot study in 1954 at St.
Thomas Virgin Islands, USA.
One of the several effective alternatives for
prevention of dental caries in children or
communities where water fluoridation is not
feasible is the fluoridation of the school
water supply.
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It can be used only if the surrounding areas
from which the students come have a low
fluoride content.
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The conc. of fluoride in the school water
system is 4.5ppm in contrast to 1ppm of
community water supply.
Thisupward adjustment is to compensate for
the reduced water intake since the school
day and year is shorter, hence the time spent
at school.
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The greater advantage of school water
fluoridation is that no effort is required by
the recipient.
Reductionin caries of about 57% was
observed in children with post-exposure
eruption who drank fluoridated water
containing 5ppm.
Dr. Khulood
1. Subject to confrontation by antifluoridation
groups.
2. The cost of installation, supplies and
maintenance competes with other needs of
the school budget.
3. Custodial and backup personnel must be
trained and used for continual operation
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4. The major concern is by age 6 all teeth
except 3rd molars are in an advanced stage of
mineralization
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Most effective method where water
fluoridation is not possible. (Avoiding the
antifluoridationist opposition)
First introduced in 1955 in Switzerland
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Ref: Estupiñán-Day, S. (2005). Promoting oral health: the use of salt fluoridation to prevent
Dr. dental
Khuloodcaries.
Ref: Estupiñán-Day, S. (2005). Promoting oral health: the use of salt fluoridation to prevent
Dr.dental
Khuloodcaries.
The possibility of fluorosis is minimal.
Safe and low cost.
Individual monitoring not required.
Freely available.
Distribution can be easily monitored.
Supply can be effectively controlled.
Readily accepted- no change in color of
salt upon addition of fluoride
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1. There is no precise control.
2. There is now international efforts to reduce
sodium intake to help control hypertension.
3. Salt is ingested in minute quantities by
children
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Reasonable vehicle
Food
used universally by infants, pregnant
women and children
Caries reduction is about 60%
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Advantages: Disadvantages:
Staple food for Cost of fluoridated milk
children and infants would be considerably
higher
Centralized milk supply
should exist
Variation in intake and
quantity of milk
Parent co-operation
needed
Includes TABLETS,DROPS and LOZENGES
Can result in upto 30-70% reduction in caries
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Effect
on deciduous teeth:
Tablets started before 2 years of age and
continued for a minimum of 3-4 years
reduces caries by 50%- 80%
Effect
on permanent teeth:
Majority of the studies showed marginal
reduction of 20%-40%
Dr. Khulood
Commercially available as:
¡ NaF tablets of 2.2mg,1.1mg and 0.55mg
yielding 1mg, 0.5mg and 0.25mg
fluoride respectively.
¡ For
best topical effect, fluoride tablets
should be first chewed and then
swallowed.
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Chew swish the saliva between the teeth
swallow.
Both topical and a systemic dosage of
fluoride would be achieved.
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Daily recommended dose of fluoride:
¡ Forchild 6 mnths- 3years is 0.25mg
¡ Between 3-6 years is 0.5-0.7mg
¡ Above 6 years is 1.0-1.5mg
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1. Ready for use.
2. Requires little time to dispense
(distribute).
3. Some tablets have a flavor that enhance
child motivation to participate in the daily
ingestion of fluoride tablet.
Dr. Khulood
Usedto supplement fluoride
intake until a child is old
enough to swallow fluoride
tablets.
Usuallyadministered by use
of a Plastic Dropper Bottle,
where 10 drops equal 1mg of
fluoride.
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Theuse of drops can be expected to
produce a caries reduction on the order
of 40%.
Parentsshould be cautioned to use the
prescribed number of drops
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The use of systems containing relatively large
conc. of fluoride that are applied locally, or
topically, to erupted tooth surface to prevent
the formation of dental caries.
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1. Operator administered:
Fluoride solutions
Ø Sodium fluoride 2%
Ø Stannous fluoride 8%
Fluoride gels
Ø Acidulated Phosphate Fluoride 1.23%
Ø Fluoride varnishes
Ø Duraphat
Ø Fluorprotector
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2. Self-administered
Fluoride dentifrices
Fluoride mouth rinses
Dentifrices containing monofluorophosphate
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Most commonly used dentifrices:
Sodium monofluorophosphates
Sodium fluoride
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Monofluoro phosphates are considered to
be more advantageous than NaF and SnF2
because it has:
ØNeutral pH
ØGreater stability to oxidation and
hydrolysis
ØGreater shelf life
ØIncreased availability of fluoride
ØNo staining of teeth
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Dental caries prevention:
Caries risk patients:
Desensitization:
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Dr. Khulood
Fluoride
tooth paste generally contains
around 1200-1450 ppm of fluoride and
about 30mg fluoride in a tube of 50gms.
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A practical and effective means
for self-application of fluoride
Theonly person excluded from
the practice of this method are:
¡ Children under 6 years of age
¡ Those of any age who cannot
rinse because of disability.
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Rinse
daily with 1 tsp (5ml) after brushing
before going to bed.
Swishbetween teeth with lips tightly closed
for 60 sec; expectorate
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Advantages
30-40% average reduction in dental
caries incidence.
Disadvantages
Requires community participation.
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Controlledrelease fluoride:
Sustained release from an intra oral
device- may control caries in special
groups.
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Full series of four treatments is recommended
at ages 3, 7, 11 and 13
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Sodium fluoride is applied topically ® it
reacts with hydroxyapatite crystals to
form calcium fluoride
A phenomenon called ‘choking off’ takes
place at a later stage
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Solution is applied on teeth with cotton.
It is left to dry for 4 minutes.
Repeated at weekly intervals.
Instruct patient to avoid intake of food or
liquids for 30 minutes.
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1 Acceptable taste
2 Stable if stored in plastic containers.
3 Non-irritating to gingiva and does not cause
discolouration of tooth structures.
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1. Four visits relatively at short period of
time.
2. Only 20-25% caries reduction.
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Dr. Khulood
Therecommended frequency of 8% SnF2
applications is once per year.
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When stannous fluoride reacts with
hydroxyapatite, in addition to fluoride, the
tin of stannous fluoride also reacts with
enamel and new crystalline product
stannous tri-fluorophosphate which is more
resistant to decay than enamel is formed.
Dr. Khulood
Stannous
fluoride with hydroxyapatite
shows mainly four end products:
1. Tin hydroxyphosphate
2. Tin-tri fluoro phosphate
3. Calcium-tri fluorostannate
4. Calcium fluoride
Dr. Khulood
Calcium fluoride further reacts with
hydroxyapatite
Tin
hydroxyphosphate gets dissolved in oral fluids
and is responsible for the metallic taste
Themain end product tin tri-fluorophosphate is
responsible for making the tooth structure more
stable and less susceptible to decay.
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Applicationrequired once or twice per year.
Expected caries reduction -> 25-35%
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1. Has to be prepared freshly each time
before use.
2. Metallic taste
3. Chemically more unstable
4. Pigmentation of teeth after application.
5. Astringent property
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Twice a year (APF topical application)
Solution and gel form
Dr. Khulood
When APF is applied on the teeth, it
eventually leads to tooth dehydration and
shrinkage in the volume of hydroxyapatite
crystals ® hydrolysis ® DCPD (Dicalcium
phosphate dihydrate)- an intermediate
product.
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DCPD--- starts forming immediately when
APF is applied and fluoride penetrate into
the crystals more deeply- through the
openings produced by shrinkage and leads
to formation of fluorapatite
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No staining of tooth structure
Stable when kept in polyethylene bottle
Caries reduction -> 30-40%
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Repeated applications necessitates the
use of suction thereby minimizing its use
in the field.
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Adheres to enamel for longer period
Provides prolonged release of fluoride
Results in 50-60% caries reduction
Types:
Fluorprotector
Durafluor
Cavity Shield
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Fluorprotector:
Isa colourless, polyurethane lacquer.
The fluoride compound difluorosilane-
ethyl difluorohydroxy silane.
The active fluoride available is 7000ppm.
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1. Oral prophylaxis.
2. Teeth are dried.
3. Teeth are not isolated with cotton rolls as
varnish being sticky has a tendency to
stick to cotton.
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5. Application of varnish is done with single
tufted small brush.
6. After application patient is made to sit with
mouth open for 4 mins.
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7. Patient is instructed not to rinse or drink
anything at all for 1 hour and not to eat
anything solid
8. Contact between varnish and tooth surface
are needed to be maintained for 18 hours for
prolonged interaction between fluoride and
enamel.
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When varnish is applied topically, a
reservoir of fluoride ions gets build up
Fluoridekeeps on slowly releasing and
reacting with the hydroxyapatite crystals .
Dr. Khulood
0.5ml of duraphat - contains 11.3mg F
0.5ml of fluorprotector - contains 3.1 mg
F
Dr. Khulood
Symptoms manifested as a result of over
dosage or excessive administration
Types: Acute & Chronic
Acute : Due to single ingestion of large amount
of fluoride
Chronic: Due to long term ingestion of smaller
amounts
Dr. Khulood
Concentration Medium Effect
1ppm Water Dental caries reduction
2ppm or more Water Mottled enamel
8ppm Water 10% Osteosclerosis
20-80 mg/day or more Water /Air Crippling fluorosis
50ppm Food /Water Thyroid changes
100ppm Food /Water Growth retardation
< 125 ppm Food /Water Kidney changes
2.5-5.0 gms Acute dose Death
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Acute lethal dose ® different in adults
and children
Probable range ® 2.5-10 gms
Acute fluoride intoxication is rare
Acutefluoride poisioning:
Ø As a result of accidents
ØDeliberate attempts to suicide
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Toxicity depends upon:
Mode of entry
Physical properties
Chemical properties
Solubility
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Vomiting, nausea , diarrhoea
Pain
Ø Abdomen
Ø Extremities
Difficulty in speech
Thirst
Perspiration
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Weak pulse
Coma
Convulsions
Cardiac arrhythmia’s ® Death
* Death will occur within 4 hours. If the patient
survives for 24hrs, the prognosis is GOOD!
Dr. Khulood
Four major functional derangements
Enzyme inhibition (blocks cellular metabolism)
Calcium complex formation
Shock
Specific organ injury
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<5mg Fl’/ Kg body wt large volume of
milk
> 5 mg Fl’/ Kg body wt
Immediate: Hospitalization for gastric lavage
Delay: I/V calcium gluconate & emetic
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1. Milk or egg
2. Lime water
3. Aluminium hydroxide gels
4. Vomitting
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In a hospital:
1. Cardiac monitoring
2. Gastric lavage
3. Oral or IV calcium gluconate(10ml of
10%)
4. Urine output to be maintained
5. General supportive measures
Dr. Khulood
On Enamel
The
influence of is on the structure of
enamel in the development of mottled
enamel.
“Characterised by minute white flecks,
yellow or brown spot areas, scattered
irregularly over the tooth surface”
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Fluorosis
occurs symmetrically within
dental arches.
Permanent teeth are particularly affected
although occasional mottling of primary
teeth may also be seen.
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Downward adjustment of level of fluoride in
drinking water to optimal level of 1 ppm.
Defluoridation
of water is more than 10
times as expensive as fluoridation.
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The ideal method to defluoridate an area is
to blend the water from the well with the
excess amount of fluoride with another
water supply deficient in fluoride.
This
method is being used at myrtle beach,
South carolina.
Dr. Khulood
The expenditure is associated with the
connecting of pipes.
DISADVANTAGES
It can be used only in areas where extremes in
concentration exists ® Hence alternative
chemical methods need to be used.
Dr. Khulood
Thewater rich in fluoride is run over contact
beds, where the fluoride is removed by ion
exchange.
Chemicals used
1 Synthetic hydroxyapatite
2 Ion exchange resin
3 Activated alumina
4 Magnesia
Dr. Khulood
NALGONDA TECHNIQUE
Addition of aluminium salt, lime, and
bleaching powder to water
Water then goes through flocculation,
sedimentation and filtration.
Best for coummunity / domestic purposes.
Can be done in a bucket or container
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20-50 ltr water used
Lime water(30 mg/ltr) and bleaching powder
are added and mixed.
Alum solution (500 mg/ltr) is added and
stirred for 10 mins.
Contents then stirred for an hour followed by
flocculation, sedimentation and filtration.
Clear water is then filtered.
Dr. Khulood
Read recommended books for detailed study
Dr. Khulood
