Fluorides

S S Hiremath
Introduction

 Fluoride was introduced into

dentistry over 70 years ago, and it is
now recognized as the main factor
responsible for the dramatic decline
in caries prevalence that has been
observed worldwide.
 However, excessive fluoride intake
during the period of tooth
development can cause dental
fluorosis
Introduction

 In the 1980s, it was established that

fluoride controls caries mainly
through its topical effect.
 Fluoride present in low, sustained
concentrations (sub- ppm range) in
the oral fluids during an acidic
challenge is able to absorb to the
surface of the apatite crystals,
inhibiting demineralization.
History of water fluoridation

Colorado stain:
 1901,Dr Fredrick Mckay of Colorado, USA
accidentally discovered permanent brown
stains on his patient’s teeth, & called them
“ Colorado Stain”.
 In 1916, it was referred as “ mottled
enamel”.
 Dr Mckay along with Dr G V Black, after
detailed examination of mottled teeth from
different areas, published their findings in
1917 as “ endemic imperfections of enamel
of teeth”.
History of water fluoridation

Deans 21 sites study:

 Dean conducted a study on
7257 children of age group 12-
14 years from 21 cities of 4
states to find possible
association between increasing
fluoride concentration in drinking
water & degree of dental
fluorosis.
History of water fluoridation

Deans 21 sites study:

 Results :
1. With increase in fluoride
concentration from 0ppm, there is
decrease in caries experience.
2. Maximum reduction of caries
occurred at 1ppm.
3. Increase from 1ppm, there were
increased chances of fluorosis.
Dental caries prevalence in
artificially fluoridated areas
Grand Rapids, Michigan vs
Muskegon, Michigan
(control):
 Water was artificially fluoridated in
Grand Rapids & Muskegon was the
control population.
 After 6.5 years, study of caries
experience of children age 6 years in
grand Rapids showed half levels as
compared with Muskegon children.
Dental caries prevalence in
artificially fluoridated areas
 Later Muskegon was also
fluoridated & after 10-15 years,
result showed marked decrease
in caries prevalence.
 Result showed a reduction of
50% in caries prevalence.
Fluoride homeostasis

 The dynamic equilibrium

between fluoride uptake &
fluoride excretion is fluoride
homeostasis.
 It depends upon absorption,
deposition in different structures
of the body & excretion of
fluoride.
Fluoride homeostasis
Absorption of fluoride
 Main route of fluoride absorption is
through GIT.
 Maximum plasma concentration
0.15-0.25ppm reaches within 60
minutes.
 Inorganic fluoride is normally rapidly
absorbed by the stomach &
intestines.
 A small amount may also be
absorbed by oral tissues.
Excretion of fluoride

 The major route for removal of

fluoride from the body is by the
kidneys.
 The renal clearance of fluoride
in adults typically ranges from
30-50 ml/min.
 Individuals in active state of
bone growth, excrete less
fluoride than older individuals.
Physiology & chemistry of
fluoride
 Principal source of fluoride ingested
is by drinking water & diet.
 Ingested fluoride is rapidly absorbed
by stomach & intestines.
 The peak levels for fluoride in
plasma reaches in 30-60 mins.
 Fluoride levels in saliva are about
65% of the blood levels.
 Skeletal system is the major site for
fluoride accumulation followed by
dental tissues.
Physiology & chemistry of
fluoride
 Most enamel fluoride is acquired
before eruption of teeth, higher
concentration is found in outer most
layer of enamel (30-50microns).
 Permanent teeth have higher fluoride
levels
 Elimination of fluoride is rapidly done
by kidneys
 Fluoride in 2-3ppm causes dental
fluorosis.
Mechanism of action of
fluoride
Anticaries effects of fluoride:
1. Fluoride & hydroxyapetite
crystals
2. Fluoride & remineralisation of
teeth
3. Fluoride & oral Bacteria

4. Fluoride & morphology of teeth

5. Fluoride & enamel surface

Fluoride & hydroxyapetite
crystals

 Improving crystallinity:
hydroxiapatite crystals have voids &
contain several impurities, fluorine
ion in small concentrations can fill
these voids & increase crystallinity of
hydroxiapatite. This is based on
‘Void theory”.
Fluoride & remineralisation
of teeth
 fluoride depresses demineralization & it
enhances remineralization.
 Enamel is made up of packed Calcium
Hydroxyapatite(CAP) crystals organised in
enamel rods.
 Fluoride ions are capable of replacing
Calcium in these crystals to form a larger,
more acid resistant crystal –
fluorohydroxyapatite. (FAP)
Fluoride & hydroxyapetite
crystals
 Decreases solubility: tooth initially
are made up of carbonated apatite
crystals, which are soluble in acid,
which are later replaced by
hydroxiapatite crystals (less soluble).
 FAP is found to be more acid
resistant.
 Where the critical pH (the point
which demineralisation occurs) is 5.5
in CAP, FAP’s critical pH is below
4 (Featherstone et al 1990)
Fluoride & oral Bacteria

 At high concentrations, fluoride has

an effect on the bacterial flora in
the mouth.
 It does this by inhibiting the
enzyme enolase.
 Enolase inhibition affects glycolysis
and so acid production of the oral
bacterium, namely Streptococcus
Mutans, leading
to theoretical anticariogenic
properties
Fluoride & oral Bacteria

 Fluoride acts on “enolase”

enzyme & prevents conversion
of glucose to lactic acid
 It prevents entry of glucose into
bacterial cell.
 It prevents conversion of
glucose into glycogen.
Fluoride & enamel surface

 Desorbs bacteria & proteins: this is

true when topical fluoride has higher
conc. of fluoride. Thus bacterial colonies
& plaque formation is minimized.
Fluoride & morphology of
teeth

 Studies have shown that

children living in fluoridated
areas, have shallow occlusal
grooves, low cuspal heights, &
hence lesser chances of
plaque formation & caries.
Methods of fluoride delivery

 Water fluoridation
 Fluoride tablets & drops
 Fluoride salt
 Fluoride milk
 Fluoride in fruit juice
 Topical fluoride
 Fluoride toothpaste
Methods of fluoride delivery

Water fluoridation
 Life-long residency produces the
greatest Cario-protective effect.
 Results in 20-40% reductions in
caries over a lifetime.
 Caries increases after
fluoridation cessation.
Methods of fluoride delivery

Water fluoridation contd.,

Advantages
1. Safe
2. Cost effective
3. Good population coverage
4. Low risk of overdose
Methods of fluoride delivery

Water fluoridation Contd.,

Disadvantages
1. Freedom of choice removed
2. Requires complex
infrastructure & initial capital
outlay.
Methods of fluoride delivery

Fluoride tablets & drops

 40-50% reduction in caries
experience in both adults &
Children.
 NaF is compound of choice.
Advantages
1. Effective
2. Freedom of choice
Methods of fluoride delivery

Fluoride tablets & drops

Disadvantages
1. Consistency of delivery
needed
2. Risk of overdose
Methods of fluoride delivery

Fluoride salt
 Effective method
 Caries protective effect as good as
fluoridation
Advantages
1. Effective.

2. Freedom of choice.

3. Consistent & regular.

Methods of fluoride delivery

Fluoride salt
Disadvantages
1. Conflict with general health
messages (Reduction of salt
intake & heart diseases
prevention)
Methods of fluoride delivery

Fluoride milk
 Well absorbed, calcium diminishes
topical effect
Advantages
1. Safe
2. Smaller risk of overdose
3. Regular , consistent supply
4. Effective
5. Freedom of choice
Methods of fluoride delivery

Fluoride milk
Disadvantages
1. Untested in community
settings.
Methods of fluoride delivery

Topical fluoride
 Aqueous solutions of NaF &
stannous fluoride are examples
 Results in 20-30% of caries
reduction.
 Used in school-based mouth
rinsing programmes.
Methods of fluoride delivery

Topical fluoride
Advantages
1. Effective

2. Useful in high caries risk

individuals
3. Freedom of choice
Methods of fluoride delivery

Topical fluoride
Disadvantages
1. Need personnel

2. Time consuming

3. Access to service
Methods of fluoride delivery

Fluoride toothpaste
 Simplest method of fluoride
delivery.
 World-wide decline in caries
attributed to toothpaste.
Methods of fluoride delivery

Fluoride toothpaste
Advantages
1. Easy
2. Effective
3. Freedom of choice
Disadvantages
1. Expensive
2. Risk of over dosage.
 Classification of fluoride therapy

Systemic fluorides Topical fluorides

Community water fluoridation Professionally applied
Salt fluoridation Sodium fluoride preparation
School water fluoridation Stannous fluoride preparation
Milk fluoridation Acidulated phosphate fluoride (APF)
Fluoride supplements Fluoride varnish
Fluoride impregnated floss and
prophylactic paste
Fluoride containing dental materials
and devices
Self-applied
Fluoridated dentifrice
Fluoride mouth rinse
Dosage of supplemental
fluoride
Recommendations on fluoride use
Fluorosis

 Dental fluorosis is a hypoplasia

or hypomineralisation of tooth
enamel or dentine, produced by
chronic ingestion of excessive
amounts of fluoride during the
period when teeth are
developing.
 Dental fluorosis is clinically
manifested as dull, opaque,
white areas in the enamel,
which may become mottled,
discolored or pitted.
 The mottled areas may be
yellow or brown in color.
 Dental fluorosis results from
ingestion of water, containing high
levels of fluoride, during the
development stage of teeth in infants
and children [ during the first 5 years
of life (0-5 years is the window
period for fluorosis)].
 Fluorosis in primary dentition could be a
possible predictor of fluorosis in permanent
dentition according to the recent studies.
 The primary second molar is the most
affected tooth among the deciduous teeth
Dental fluororsis
Dean’s Fluorosis index

 The classification of mottled enamel

developed by Dean in 1934 and later
index of dental fluorosis in 1942
gained significant acceptance.
 Dean's fluorosis index has been in
use throughout the world and still
being used in many epidemiological
studies since 1942.
Objective
 To assess the prevalence of dental
fluorosis (mottled enamel), the following
classification was used:
0. Normal
1. Questionable fluorosis
2. Very mild fluorosis
3. Mild fluorosis
4. Moderate fluorosis
5. Severe fluorosis.
Scoring Criteria Normal - (0)
 The enamel
represents usual
translucent semi-
vitriform type of
structure (Fig.
17.28).
 The surface is
smooth, glossy
and usually of a
pale creamy white
colour.
Questionable Fluorosis - (1)
 The enamel discloses a slight aberration
from the translucency of normal enamel
ranging from a few white flecks to
occasional white spots.
 This classification is used in those
instances where a definite diagnosis of the
mildest form of fluorosis is not warranted
and classification of 'normal' not justified.
Very Mild Fluorosis - (2)

 Opaque, paper-
white areas are
scattered
irregularly over
the tooth but
involving less
than 25% of the
labial tooth
surface.
Mild Fluorosis - (3)

 The white
opacity of the
enamel of the
teeth is more
extensive than
for code 3, but
covers less than
50% of the tooth
surface (Figs
17.30A, B).
Moderate Fluorosis - (4)
 Moderate
Fluorosis - (4) The
enamel surfaces of
the teeth show
marked wear, and
brown stain is
frequently a
disfiguring feature
(Figs 17.31A, B).
Severe Fluorosis - (5)
 The enamel surfaces
are badly affected and
hypoplasia is so
marked that the
general form of the
tooth maybe affected.
 There are pitted or
worn areas, and brown
stains are widespread;
the teeth often have a
corroded appearance
(Fig. 17.32)
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