This presentation is all about the systemic administration of fluorides ,as it is an easier way for the administration of fluorides to prevent dental caries and tooth decay.the aim is to explain the advantages of systemic fluoride ,their present status in India and in other countries and to create awareness among population.Also raising an issue that how these methods of systemic fluoride administration can be improved so that there is better prevention of decay problems

1. GUIDED BY : MADE BY :
DR. ARCHANA AGGARWAL (HOD) SURBHI MISHRA
DR. NATASHA GAMBHIR BDS- FINAL YEAR
DR. VARUN GUPTA ROLL NO. – 49 ( 10-11)

2. CONTENTS
1. Introduction
2. How do systemic fluorides work
3. Types of systemic fluoride
4. Fluoride compounds and their concentration.
5. Water fluoridation
• Definition
• History of water fluoridation.
• Grand rapid –Muskegon study
• Newburgh – Kingston study

3. • Evanston Oak Park study
• Brantford – Sarnia – Stratford fluoridation caries study
• Tiel – Culemborg fluoridation
• Optimal water fluoride concentration.
• Pre - requirements in water fluoridation
• Equipments used in water fluoridation
• Advantages and disadvantages.
• Feasibility in India (water fluoridation)
6. School water fluoridation. (Advantages and disadvantages).
7. Salt fluoridation
• Introduction
• Production and preparation
• Advantages and disadvantages
• Feasibility in India
• Limitations

4. 8. Milk fluoridation
• Introduction
• Rationale of milk fluoridation.
• Planning a milk fluoridation programme.
a) Dental health status
b) Other fluoride sources
c) Urine analysis
d) Milk distribution
e) Fluoridating the milk
f) Feasibility in India
9. Fluoride supplements and tablets
a) Introduction
b) Fluorides compounds used
c) Frequency of use and dosage
d) Indications
e) Benefits
f) Precautions

5. INTRODUCTION
• Systemic fluorides provides a low concentration
of fluoride to the teeth over a long period of time.
• It circulates through the blood stream and is
incorporated into developing teeth.
• After teeth erupt, fluoride contacts teeth directly
through salivary secretions.
• Most systemic fluorides have a topical effect but
their primary effect is systemic.

6. HOW DO SYSTEMIC FLUORIDES WORK
• Systemic fluorides are those that are ingested into the body
and become incorporated into forming tooth structures.
• Systemic fluorides when ingested during tooth development
are deposited to some extent throughout the tooth surface.
• However, the actual mechanism of action of systemic
fluorides is from the topical protection as the fluoride present
in saliva, which continually bathes the teeth, provides a
constant source that is also incorporated into plaque and
facilitates remineralisation.

7. TYPES OF SYSTEMIC FLUORIDES
1. WATER FLUORIDATION
• COMMUNITY WATER FLUORIDATION
• SCHOOL WATER FLUORIDATION
2. SALT FLUORIDATION
3. MILK FLUORIDATION
4. FLUORIDES TABLETS

8. FLUORIDES COMPOUNDS AND CONCENTRATIONS THAT ARE
USUALLY USED IN DIFFERENT SYSTEMIC FLUORIDES METHODS
FLUORIDES
METHODS
FLUORIDES
COMPOUNDS
CONCENTRATION
S
WATER FLUORIDATION hydro fluorosilicate (FSA),
sodium
fluorosilicate, sodium fluoride
0.7 - 1.2 mg/L
SALT FLUORIDATION potassium fluoride , sodium
fluoride
250-300 mg/kg
MILK FLUORIDATION Sodium fluoride or disodium
monofluorophosphate
5 mg/L
DIETRY FLUORIDES
SUPPLEMENTATION
sodium fluoride, acidulated
phosphate fluoride, potassium
fluoride, calcium fluoride
0.25 – 1.0 mg/day
Table

9. WATER FLUORIDATION
• Water fluoridation is defined as “
controlled adjustment of the
concentration of fluoride in a communal
water supply so as to achieve maximum
caries reduction and clinically
insignificant level of fluorosis”.
• It can also be defined as “the upward
adjustment of the concentration of
fluoride in public water supply in such a
way that the concentration of fluoride ion
in the water may be consistently
maintained at 1 parts per million(ppm) by
weight to prevent dental caries with
minimal possibility of causing dental
fluorosis .”

10. • The water fluoridation is one of the most common delivery
methods of fluoride.
• It presents a lower cost and long range.
• However for water fluoridation to be effective it has to be a
continuous process and the concentration of fluoride has to be
well controlled.
• The recommended concentration varies between 0.7 and 1.2
ppm, depending on the average regional temperature. a
• The lower levels of fluoride are recommended for warmer
regions. In these locations the intake of water tends to be
higher

11. • The optimal level of fluoride in water for
protection against dental caries is
approximately 1 part per million. (ppm)
• Fluoridation is the adjustment of water supply
to a fluoride content such that reductions of 50
to 70 % in dental caries would occur without
damage to teeth or other structures.

12. HISTORY OF WATER FLUORIDATION.
The first water
fluoridation
programme was
started in the year
1945 in the four
cities in USA.
GRANDS
RAPIDS-
MUSKEGON
STUDY
NEWBURGH-
KINGSTON
STUDY
EVANSTON-
OAK PARK
STUDY
BRANTFORD-
SARNIA-
STARTFORD
STUDY
TIEL – CULEMBORG STUDY

13. GRAND RAPID- MUSKEGON STUDY
• On January 25 th ,1945 ,sodium fluoride was
added to GRAND RAPIDS water supply. Muskegon
town was kept as a control.
• After 6 ½ years in July ,1951 the caries experience
of 6 and 15 years old children residents of Grand
Rapids was half that of Muskegon . ( reported by -
Arnold et al,1953).
• So impressive was the efficacy of fluoridation that
the city officials of Muskegon also decided to
fluoridate their own water supply also.

14. NEWBURGH –KINGSTON STUDY
• On may 2 nd 1945 , sodium fluoride was
added to drinking water of Newburgh on the
Hudson river .
• Kingston town was kept as a control.
• After 10 years of fluoridation Et Al (1956)
reported that the DMF rate had fallen from
23.5 % to 13.9 %, confirming the caries
inhibitory property of 1 ppm fluoride in
drinking water.

15. EVANSTON- OAK PARK STUDY
• In January 1946, a fluoridation experiment
began in Evanston ,Illinois and the nearby
community of oak park acted as the control
town.
• After 14 years of fluoridation in Evanston,
there was a reduction of 49 % in DMF values.
• The Evanston-Oak park study presented the
most detailed data of all the fluoridation
studies.

16. THE BRANTFORD- SARNIA-STARTFORD
FLUORIDATION CARIES STUDY
• In Canada, a project was undertaken in Brantford, Ontario,
where fluoride was added to water supply in June 1945.
• The community of Sarnia was established as the control
town.
• In addition ,the community of Stratford, where fluoride
was naturally present in drinking water at level of 1.3 ppm
was used as an auxiliary control.
• After 17 years of fluoridation in Brantford, caries
experience was similar to that occurring in the natural
fluoride area of Stratford and was 55 % lower than in the
control town of Sarnia ( REPORTED BY – ET OL-1951 ;
BROWN AND POPLOVE,1965)

17. TIEL – CULEMBORG STUDY
• In March 1953 the drinking water in Tiel was
fluoridated to a level of 1.1 ppm.
• Culemborg with water fluoride level of 0.1 ppm was
the control.
• After 13 years of fluoridation, the number of
anatomical sites of teeth affected by dental caries was
58 % lower in Tiel than in Culemborg.

18. OPTIMAL WATER FLUORIDE
CONCENTRATION
• The optimum recommended fluoride levels varies
with climate because the average consumption of
water increases in warmer climates
• In cold climates the recommended fluoride level may
be as high as 1.2 ppm while in extremely hot climate a
level of about 0.7 ppm is recommended
• In moderate climates this optimum fluorides level has
been shown to be 1 ppm.
• The optimum fluoride concentration for particular
community can be calculated by following equation:
• Ppm fluoride (concentration) = 0.34/E
• Where E = -0.038+0.0062 x temperature of the area
in degree farhenite.

19. PRE REQUIREMENTS OF WATER
FLUORIDATION
1. Presence of caries in the community/public
2. Level of fluoride concentrations in their
drinking water .
3. Centralized water supply to the community
4. Community acceptance/approval.
5. Installation and maintenance cost.

20. MATERIALS USED IN WATER
FLUORIDATION
• Three types of fluoride equipments
1. Dry feeder
2. Solution feeder
3. Saturation methods
• Dry compound such as ammonium silico fluoride, fluorspar,
sodium silico fluoride.
• Solution of hydrofluoro sillicic acid.
Fluoride is added to water , after it is purified and before it is
ready for consumption, with the help of fluoride equipment.
Constant monitoring is required once the water is fluoridated
to maintain the constant level of fluoride i.e., 0.8 to 1.2 ppm.

21. SYSTEM PROCEDURE FACTORS LIMITING
USAGE
RECOMMENDATION
SATURATOR SYSTEM 4 % saturated
solution of NaF is
produced and
injected at the
desired concentration
in the water
distribution source
with aid of a pump.
Need to clean gravel
bed used for
filtration.
Suitable for medium
sized towns requiring
less than 3.8 million
lit/day
DRY FEEDER NaF or silicofluoride
in the form of powder
is introduced into a
dissolving basin.
Care in handling
fluoride, obstruction
of pipes and
compacting of
fluoride while
storage.
Suitable for medium
sized towns requiring
3.8 million lit/day to
19 million lit/day.

22. SOLUTION FEEDER Volumetric pump
permitting the
addition of a given
quantity of
hydrofluosilicic acid
in proportion to
the amount of
water treat
the equipment
must be resistant
to attack by
hydrofluosilicic
acid, necessitating
construction in
polyvinyl chlorides
or another plastic.
Suitable for
medium sized and
large towns with a
capacity of more
than 7.6 million
lit/day

23. ADVANTAGES OF WATER FLUORIDATION
• LARGE NUMBER OF PEOPLE ARE BENEFITED.
• CONSUMPTION IS REGULAR
• FLUORIDATED DRINKING WATER NOT ONLY ACTS
SYSTEMICALLY
• DURING TOOTH FORMATION TO MAKE DENTAL ENAMEL MORE
RESISTANT TO DENTAL DECAY,BUT ALSO HAS TOPICAL EFFECT
THROUGH THE RELEASE IN SALIVA AFTER INGESTION.
• FLUORIDATION OF COMMUNITY WATER IS THE LEAST
EXPENSIVE WAY TO PROVIDE FLUORIDE TO A LARGE GROUP OF
PEOPLE.

24. DISADVANTAGES OF WATER FLUORIDATION
• INTERFERE WITH HUMAN RIGHTS
• OTHER MODES ARE NOT CONSIDERED
• COMMON SOURCE OF WATER SUPPLY MAY NOT BE
PRESENT.

25. FEASIBILILITY IN INDIA
• Based on the current knowledge of increasing
prevalence of dental caries, developing economy
of our country, dentist population ratio of
1:80,000 and lack of preventive awareness of oral
diseases , communal water fluoridation appears to
be the most effective, practical and economical
public health measure for prevention of dental
caries as this method extends its benefits to all the
residents of the community without necessitating
any conscious effort on the part of the residents.

26. • But the only short coming in hat it can be
implemented only in the areas which have
central pipe water supply system.
• Currently, most of the cities and towns in India
covering 30% of the population have piped
water supply.
• An effort should be made with the concerned
authorities to institute water fluoridation at
least in these areas ( hope I.D.A.takes it up).

27. SCHOOL WATER FLUORIDATION
• School water fluoridation is one of the possible areas to be
explored. This programme helps in limiting caries in school
children who are the prime concern.
• It is the suitable alternative where water fluoridation is not
feasible.
• The amount of fluoride added In school drinking water
should be greater than normal because children have to stay
in the school for a short period of time and to compensate
for holidays and vacations.
HISTORY
• This procedure was first started in 1954 in St. Thomas V.S
Virgin islands by US public health service division. .

28. s
• The current recommended regimen for school
water fluoridation is adding 4.5 times more
fluoride .
• There has been around 25 to 40 % decrease in
dental caries with this program.
• Simple fluoridators particularly that employ the
venturi system are most suitable ,because they
require almost no maintenance and can be utilized
effectively in small instalments of small or
medium sized schools.
ADVANTAGES
• good results in reducing caries.
• Minimal equipment .
• Not expensive.

29. DISADVANTAGES
• Children do not receive the benefit until they
go to school.
• Not all children go to the school go the school
in poor countries and towns and villages.
• Amount of amount water drunk can’t be
regulated.

30. SALT FLUORIDATION

31. INTRODUTION
• Salt fluoridation is a controlled addition of
fluoride ,usually sodium or potassium fluoride
,during the manufacture of salt for human
consumption.
HISTORY
• First fluoridated salt was introduced by WESPI in
Switzerland 1948.it has been on sale in
Switzerland since 1955.
• Experiments have been conducted with
concentration of fluoride in salt ranging from 90
mg of fluoride per kg. salt to 200 -350 mg/kg .

32. • Initial clinical clinical trial of 90 mg/kg
fluoride salt showed 20- 25 % of reduction of
dental caries.
• In 1967 Muhleman showed the safe dose of
fluoridated salt, that 300 mg/kg yields 1.5 mg
fluoride/5 gm of salt. Tooth from Hungary,
after 8 years of salt fluoridates at the level of
250 mg fluoride /kg reported 35-58% of caries
reduction

33. PRODUCTION AND PREPARATION OF
FLUORIDATED SALT
• For effective caries prevention, fluoride must be
present in ionic form when salt( sodium chloride)
is dissolved in water . There are essentially two
different salt production processes:
1. Batch processing
2. Continuous processing
• Fluoride is added to salt by spraying concentrated
solutions of sodium fluoride or potassium
fluoride.
• Premixed granules of NaF and CaF2 with PO4 are
added to common salt.

34. ADVANTAGES AND DISADVANTAGES
ADVANTAGES
• Fluoridated salt is safe.
• Theoretically fluoridated salt prevents dental caries
by both systemic as well topical action.
• It does not require community water supply as in case
of water fluoridation.
• It permits individual to accept it or reject it.
• Low cost
• Fluoridated salt and iodized salt can be made
available to the population.

35. DISADVANTAGES
• No precise control over indicated
consumption, since salt intake varies greatly
among people.
• International efforts to reduce sodium uptake.
• Less sodium (Na) intake to help control
hypertension.

36. FEASIBILITY IN INDIA
• Salt fluoridation appears to be a viable and feasible
method of fluoride ingestion systemically because its
distribution can be easily monitored as the supply can
be effectively controlled especially for those areas
which do not need supplemental fluorides i.e.,
endemic fluoride belts.
• Moreover ,individual monitoring is not required as
the levels are so adjusted so as to provide optimum
levels of fluoride keeping in view the fact that on an
average an individual consumes 5-8 gms of salt per
day.

37. • Also salt is freely available and is used on a
large scale all over the country by majority of
the population of various ethnic and regional
groups.
• Regarding the acceptability of the population it
shall be readily accepted as the addition of
fluoride to salt does not alter its colour as in
case of salt iodization.

38. LIMITATIONS
1. There may be large variations in salt intake in
different groups of people .fluoridated salt
consumption is lowest when the need for
fluorides is greatest – in early years of life.
2. The amount of fluoridated salt ingested may
decrease with increasing consumption of
processed foods .if the processors do not use
fluoridated salt.
3. Difficulties arise when there are multiple
drinking water sources which have a naturally
optimal or excessive fluoride concentration.

39. 4. It requires refined salt produced with modern
technology and a high level of technical
expertise.
5. The current view data high salt intake may
contribute to hypertension.

40. MILK FLUORIDATION

41. INTRODUCTION
• Milk fluoridation is the addition of a measured quantity of
fluoride to bottled or packaged milk to be drunk by
children.
HISTORY
• It was introduced by Zeigler ,a paediatrician, who started
the first project with fluoridated milk in Swiss city of
Winterthur in 1953.
• In 1971, Dr. Edgar borrow established the Borrow
foundation (formally the Borrow dental milk foundation) in
England, with the aim of promoting the use of milk as a
vehicle for fluoride for the benefit of children’s oral health.
• The first community based milk fluoridation scheme was
introduced in 1988, in Bulgaria, under the international milk
fluoridation program.

42. RATIONALE OF MILK FLUORIDATION
• The nutritional value of milk has been well
documented .
• Milk is often available to children through school
and nutritional programs and the use of such
distribution systems can provide a convenient
and cost efficient vehicle.
• Virtually all forms of milk products are suitable
for fluoridation and the process is relatively
simple.
• Milk fluoridation can be targeted at those
communities in greatest need.

43. • Research has been demonstrated the effectiveness
of fluoridated milk in preventing dental disease .
• The bioavailability of fluoride is not reduced by milk.
• Fluoridated milk keeps a permanently low level of
ionized fluoride within the oral cavity ,promoting
remineralisation. This topical mechanism contributes
to the caries preventive effect of fluoridated milk.

44. PLANNING A MILK FLUORIDATION
PROGRAMME
• There are a number of points, which have to be
considered when deciding whether milk fluoridation is
necessary for any given community.
DENTAL HEALH STATUS:
• The oral health status within the community especially
that of the children must be determined properly. If the
DMFT among the children is moderate to very high,
then there is a clear indication for caries preventive
programs.

45. OTHER FLUORIDE SOURCES:
• The levels of fluoride in the drinking water of the
community and whether fluoride tooth pastes are being
used should be considered before the fluoride dose to be
delivered in the milk estimated.
 URINE ANALYSIS
• When a decision has been taken to implement milk
fluoridation scheme, urinary fluoride monitoring
procedure is mandatory with respect to safely and
compliance of the program.

46.  MILK DISTRIBUTION
• Fluoridated milk distribution to children is best done through
an established or existing system, like school milk or milk for
kindergartens and nursery schools.
• Persons at the schools who would supervise milk distribution
and consumption should be identified.
 FLUORIDATING THE MILK
• Fluoridated milk can be produced in number of forms,
• Liquid (pasteurized and sterilized) and
• Powder
• Each containing a variety of fluoridating agents so as to
provide them with the optimum amount in line with
recommendations of WHO Expert Committee (1994), i.e.
ranging from zero to 1.0 mg fluoride per day according to the
age of the child and the fluoride concentration in the local
water supply.

47. • MILK DISTRIBUTION
PROGRA PROGRAME

48. COMPOUNDS USED FOR MILK FLUORIDATION
• Calcium fluoride
• Sodium fluoride
• Disodium monofluorophosphate
• Disodium silicofluoride

49. FEASIBILITY IN INDIA
In spite of the controversy concerning the binding and
complexing of fluoride with calcium and protein of the milk and
thus making it unavailable for its anti cariogenic action,
 Though theoretically milk fluoridation is advantageous, in
addition being the staple food for children and its consumption
can be confined to groups who need it most, that practically
speaking that this scheme /method does not seem to be viable
and feasible because of :

50. a)In INDIA, majority of children population living
in rural and urban areas cannot afford milk daily.
a)Central milk supply system does not exist in India
a)Variation of intake and quantity of milk is another
which cannot be controlled since it depends upon
the socio-economic religious and ethnic factors.

51. FLUORIDE SUPPLEMENTS
• Fluoride supplements are available in different
forms such as fluoride tablets ,drops ,
lozenges.
• Fluoride tablets, drops and lozenges are not
available over the counter but prescribed by
the dentist or paediatrician to individual
patients or as a part of school or home based
preventive dentistry program.

52. FLUORIDE COMPOUND USED
• Most commonly used is sodium fluoride .
• Other compounds used are acidulated phosphate fluoride,
potassium fluoride or calcium fluoride.
• Supplements contain measured amount of fluorides, 0.25
mg , 0.5 mg, 1.0 mg.
• They should be taken on daily basis according to the
prescribed dosage schedule.
• The council of DENTAL THERAPRUTICS OF
AMERICAN DENTAL ASSOCIATION recommends the
dosage schedule for dietry fluoride supplements as shown in
the table :

53. AGE Fluoride concentration of drinking water (ppm)
(ADA 1994)
< 0.3 > 0.3 < 0.6 > 0.6
0-6 MONTHS - - -
6 MON TO 3
YRS
0.25 gm - -
3 TO 6 YRS 0.5 gm 0.25 gm -
6 TO 16 YRS 1 gm 0.5 gm -

54. • Correct dosage is based on the concentration
of fluoride in drinking water, age and weight
of the child and other available fluoride.
• Not more than 1 milligram of fluoride should
be ingested each day from all available
systemic sources.

55. INDICATIONS FOR USE
• In areas where there are no central supplies, where the fluoride
concentration of well-water is low and where parental motivation is
very high.
• As an interim measure in these communities with a central water
system that have not yet implemented community water
fluoridation.
• In areas where water fluoridation or salt fluoridation schemes cannot
be implemented.
• In families where there is high degree of mobility involving frequent
changes in the place of work and residence and where parents wish
to ensure daily fluoride supplementation themselves.

56. BENEFITS
• The use of dietary fluoride supplements from
birth to age 13 or 16 years provides caries
reduction from 16-65%.
• Supplements provide systemic and topical
benefits for primary and permanent teeth.

57. PRECAUTIONS
• Accidental ingestion of fluoride supplements can cause
stomach upset.
• No more than 120, 2.2 mg sodium fluoride tablet
should be dispensed at one time.
• There is no risk of dental fluorosis if the proper regime
is followed.
• However, fluoride supplements when ingested prior to
tooth eruption are a risk factor for dental fluorosis.

58. CONCLUSION
• When used appropriately, fluoride is a safe and effective
agent that can be used to prevent dental caries.Fluorides has
contributed profoundly to the improved dental health of
persons all over the world. Fluoride is needed throughout the
life to protect teeth against tooth decay. To ensure additional
gains in oral health systemic fluorides has been introduced.
They provide a low concentration of fluoride to the teeth over
a long period of time.it is easy to administer through various
mediums like water, milk, salt. Systemic fluorides help in
circulating fluorides in the blood stream and is incorporated
into developing teeth. But still systemic fluorides are yet not
widespread in India, therefore to ensure additional gains in
oral health practices water fluoridation should be extended to
additional communities and fluoride toothpastes should be
used widely.

59. REFERENCES
1. Essentials of Public Health Dentistry,
4thedition; SOBEN PETER; Pg. no. 265-280.
2. Textbook of pedodontics , 3rd edition, NIKHIL
MARWAH ; Pg. no. 257-265