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Topical fluorides in dentistry


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topical fluorides - pedodontics

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Topical fluorides in dentistry

  1. 1. TOPICAL FLUORIDES IN DENTISTRY INTRODUCTION  Fluorine is a member of the halogen family and is the most electronegative and reactive of all the elements.  The word fluorine is derived from the latin term ‘Fluore’ meaning to flow.  Its selective action on the hard tissues of the body attributes significantly to prevention and control of dental caries.
  2. 2. FLUORIDE DELIVERY METHODS Fluoride can be delivered as… (A) Topical Fluorides (B) Systemic Fluorides
  3. 3. TOPICAL FLUORIDES SYSTEMIC FLUORIDES  These are placed directly on the teeth  Some preparations provide high or low concentrations of fluoride over a short period of time  These circulate through the blood stream and are incorporated into developing teeth  They provide a low concentration of fluoride over a long period of time
  4. 4. INDICATIONS  Caries active individuals  Children shortly after period of tooth eruption  Those who take medication that decrease salivary flow or have received radiation to head and neck  After periodontal surgery when roots of teeth have been exposed  Patients with fixed or removable prosthesis and after placement or replacement of restorations  Patients with an eating disorder or who are undergoing a change in lifestyle which may affect eating or oral hygiene habits conductive to good oral health  Mentally and physically challenged individuals
  5. 5. TOPICAL FLUORIDE PRODUCTS ARE DIVIDED INTO 2 CATEGORIES (A) Professionally applied  Introduced by Bibby in 1942  Dispensed by dental professionals in the dental office and usually involve the use of high fluoride concentration products ranging from 5000-19000 ppm which is equivalent to 5-9 mg F/ml (B) Self applied  Include fluoride dentifrices, mouth rinses & gels  Are low fluoride concentration products ranging from 200-1000ppm or 0.2-1 mgF/ml.
  6. 6. RATIONALE FOR USING TOPICAL FLUORIDE AGENTS  To speed up the rate and increase the concentration of fluoride acquisition above the level which occurs naturally  The initial caries lesion characterized by a white spot is porous and accumulates fluoride at a much higher concentration than adjacent sound enamel
  7. 7. PROFESSIONALLY APPLIED FLUORIDES FLUORIDE VEHICLES  AQUEOUS SOLUTIONS AND GELS  Gel adheres to the tooth surface for a considerable amount of time and eliminates the continuous wetting of enamel surfaces when solutions are used  2 or 4 quadrants can be treated simultaneously when trays are used for gel application which results in substantial saving of time  Thyxotrophic solutions are not gels but have high viscosity under storage conditions and become fluid under high stress  Thyxotrophic solutions are more stable at lower ph and don not run off the tray as readily as conventional gels
  8. 8. GELS
  9. 9. FLUORIDATED PROPHYLACTIC PASTES  If prophylaxis pastes containing fluoride are used, the lost fluoride is replenished & there is a significant gain in the concentration of fluoride.
  10. 10. FOAM  Developed to minimize the risk of fluoride over dosage as well as to maintain the efficacy of topical fluoride treatment.  ADVANTAGES:  Its lighter than a conventional gel & therefore only a small amount of agent is needed for topical application  The surfactant has cleansing action by lowering surface tension, this facilitates the penetration of material into interproximal surfaces.  It doesn’t require suctioning so it offers advantages for home use
  11. 11. FOAM
  12. 12. FLUORIDE VARNISH  It was first developed by Schimdt in Europe in 1964  Increasing the time of contact between enamel surface & topical fluoride agents favors the deposition of fluorapatite & fluorhydroxyapatite. Technique:  After prophylaxis teeth are dried but not isolated with cotton rolls since varnish sticks to cotton  Total of 0.3-0.5 ml of varnish is required to cover full dentition  Application is done first done on lower arch then upper, using single tufted small brush, starting with proximal surfaces  Patient is asked to sit with mouth open for 4 min to let Duraphat set on teeth
  14. 14.  Patient is asked to not rinse or drink anything for one hour and advised liquid diet till next morning  DURAPHAT: It s a viscous yellow material, containing 22,600 ppm fluoride as sodium fluoride in a neutral colophonium base.  FLUORPROTECTOR: Its a clear polyurethane based product containing 7000 ppm fluoride from difluorosilane. It is dispensed in 1ml ampules each ampule containing 6.21mg of fluoride.  CAREX: It has low fluoride concentration than duraphat & has equal efficacy to that of duraphat as caries preventive agent
  15. 15. TOPICAL FLUORIDES USED IN PREVENTIVE DENTISTRY:  1.SODIUM FLUORIDE:  2.STANNOUS FLUORIDE  3.ACIDULATED PHOSPHATE FLUORIDE  4.AMINE FLUORIDE 1) NEUTRAL SODIUM FLUORIDE  Fluoride concentration - 9200ppm  A minimum of four applications with a 2% NaF solution gives a caries reduction of about 30%  METHOD OF PREPARATION  It is prepared by dissolving 20 gms of NaF powder in 1L of distilled water in a plastic bottle
  16. 16.  TECHNIQUE - KNUTSON’S TECHNIQUE  At the initial appointment teeth are cleaned with pumice slurry & then isolated with cotton rolls & dried with compressed air.  Using cotton-tipped applicator sticks ,the 2% NaF is painted on air dried teeth so that all tooth surfaces are visibly wet. The solution is allowed to dry for 3-4 min.  This procedure is repeated for each of the isolated segments until all the teeth are treated.  A 2nd, 3rd and 4th fluoride application, each not preceded by a prophylaxis, is scheduled at intervals of approximately one week;  The four-visit procedure is recommended for ages 3, 7, 11 and 13 years, coinciding with the eruption of different
  17. 17.  MECHANISM OF ACTION :  When NaF is applied on tooth surface it reacts with hydroxyapatite crystals in enamel to form CaF2 which is the dominant product of the reaction  As thick layer of Caf2 forms, it interferes with further diffusion of fluoride from the topical fluoride solution to react with hydroxyapatite and blocks further entry of fluoride ions. This sudden stop of the entry of fluoride is termed as ‘chocking off effect’  CaF2 acts as a reservoir and fluoride slowly leeches out of it  The CaF2 formed reacts with hydroxyapatite fluoridated hydroxyapatite increases the concentration of fluoride on enamel surface prevents caries
  18. 18.  ADVANTAGES :  It is relatively stable when kept in a plastic container;  The taste is well accepted by patients;  The solution is non-irritating to the gingiva;  It does not cause discoloration of tooth structure;  The series of treatments must be repeated only 4 times in the general age range of 3 to 13, rather than at annual or semiannual intervals.  DISADVANTAGES:  The major disadvantage of the use of sodium fluoride is that the patient must make 4 visits to the dentist within a relatively short period of time.
  19. 19. 2) STANNOUS FLUORIDE (SnF2)  Fluoride concentration-19500ppm  Stannous fluoride has been used at 8% and 10% concentrations  METHOD OF PREPARATION:  Solutions of stannous fluoride are not stable. Soon after mixing they become cloudy due to the formation of tin hydroxide.  A fresh solution of stannous fluoride be prepared for each patient.  To prepare 8% stannous fluoride solution, the content of one capsule which is 0.8 grams (‘0’ No. of gelation capsule) is dissolved in 10 ml of distilled water in a plastic container.
  20. 20.  TECHNIQUE - MUHLER’S TECHNIQUE  Each tooth surface is cleaned with pumice or other dental cleaning agent for 5 to 10 seconds;  Unwaxed dental floss is passed between the interproximal areas;  Teeth are isolated and dried with air;  Stannous fluoride is applied using the paint-on technique and the solution is kept for 4 minutes. Repeat applications are made every 6 months or more frequently if the patient is susceptible to caries.
  21. 21.  MECHANISM OF ACTION:  When SnF2 is applied in low concentration tinhydroxyapatite, which gets dissolved in oral tissues  At very high concentration Ca trifluorostannate forms along with tin tri-fluorophosphate  Tin trifluorophosphate is responsible for making the tooth structure more stable and less susceptible to decay  CaF2 is the end product both at low and high concentration which reacts with hydroxyapatite and a small fraction of fluorhydroxyapatite also gets formed
  22. 22.  ADVANTAGES :  Using an 8% stannous fluoride solution at 6 to 12 months intervals conforms to the practicing dentist’s usual patient – recall system;  Administrative difficulties are avoided.  DISADVANTAGES :  In aqueous solution the material is not stable;  8% solution is quite astringent and disagreeable in taste, its application is unpleasant;  The solution occasionally causes a reversible tissue irritation manifested by gingival blanching;  Causes pigmentation of teeth which has a characteristic light brown colour
  23. 23. 3) ACIDULATED PHOSPHATE FLUORIDE (APF)  Fluoride concentration-12300 ppm  METHOD OF PREPARATION  An aqueous solution is acidulated phosphate fluoride is prepared by dissolving 20 grams of sodium fluoride in 1 liter of 0.1 M phosphoric acid and to this is added 50% hydrofluoric acid to adjust the pH at 3.0 and fluoride ion concentration at 1.23%. It is also called as Brudevold’s solution  For the preparation of acidulated phosphate fluoride gel, a gelling agent methylcellulose or hydroxyethyl cellulose is added to the solution.
  24. 24.  TECHNIQUE  APF is recommended for application at 6 or 12 months interval  Oral prophylaxis is done  Teeth to be treated are completely isolated and thoroughly dried with air  Application of gel is done using trays; disposable foam lined trays are preferred  It is reapplied every 15-30sec so as to keep the teeth moist with the fluoride solution throughout the four min period  The patient is instructed to eat, drink or rinse his mouth for atleast 30 min
  26. 26.  MECHANISM OF ACTION  When APF is applied to teeth it initially leads to dehydration and shrinkage in the vol of hydroxyapatite crystals which on hydrolysis forms an intermediate product called Dicalcium phosphate dihydrate(DCPD)  DCPD is highly reactive and starts forming immediately after APF is applied  Fluoride penetrates into the crystals more deeply through the openings produced by shrinkage and forms fluorapatite  For the conversion of whole DCPD formed into fluorapatite, a deeper penetration and continuous supply of fluoride is required. Because of this reason APF is applied every 30 sec and the teeth have to be kept wet for 4 min
  27. 27.  ADVANTAGES  Requires only 2 application in a year;  The gel preparation can be self applied and thus the cost of application also gets reduced;  It has the ability to deposit fluoride in enamel to a deeper depth;  DISADVANTAGES :  Practical difficulties like the teeth should be kept wet for for 4 minutes;  It is acidic, sour and bitter in taste;  It cannot be stored in glass containers.
  28. 28. 4) AMINE FLUORIDE  They are cariostatic agents  Some of them are surface active agents i.e. they have an affinity for enamel and thus will hold the fluoride for a longer time against the tooth  They also have anti bacterial properties. Reduced plaque formation and anti glycolytic activity is also reported with these compounds  Amine fluorides have been tested in dentifrices, mouthrinses and topical gels where they are either brushed on teeth or applied with a tray but it is not known if they are superior to the other currently available fluoride agents
  29. 29. Characteristics Sodium fluoride Stannous fluoride Apf Percentage 2% 8% 1.23% Fluoride concentration (ppm) 9200 19500 12300 ph neutral 2.4-2.8 3.0 Frequency of application 4 at weekly intervals 3,7,11 & 13 yrs biannually biannually Adverse effects no Tooth pigmentation Gingival irritation no Caries reduction 30% 32% 28%
  30. 30. RECOMMENDATIONS FOR TOPICAL APPLICATION  No more than 2 g of gel per tray or approximately capacity
  31. 31. SELF APPLIED TOPICAL FLUORIDES  Dentifrices  Mouth rinses  Gels  DENTIFRICES  The first clinical trial of fluoride dentifrice was initiated by Bibby in1942  The various compounds used in dentifrice are sodium fluoride, stannous fluoride, monofluorophosphate and amine fluoride  A 200g tube of Colgate contains 1000ppm of fluoride with the fluoride compound as Monofluorophosphate
  32. 32.  A single brushing with a full ribbon of paste on a brush head provides about one gram of toothpaste and will expose the individual to approximately 1mgF  For young children non fluoridated and non abrasive toothpaste is recommended till the child is 4 years of age  After 6 years of age fluoridated toothpaste should be used  The amount should be pea sized and the paste should be pressed into the bristles and not on top of the brush
  33. 33.  MOUTHRINSES  Fluoride mouthrinsing is one of the most widely used caries preventive public health methods  Caries preventive agents used are Neutral sodium fluoride, Acidulated phosphate fluoride and Stannous fluoride
  34. 34.  Sodium fluoride mouthrinses  Formulated at concentrations of 0.2%(900 ppm F) for weekly use 0.05%(225 ppm F) for daily use  These are used by forcefully swishing 10ml of the liquid around the mouth for 60 sec before expectorating it  Recommendations for fluoride mouthrinses  Rinse and expectorate technique used for patients in fluoride deficient communities  In patients with increased caries risk e.g. those undergoing orthodontic treatment or radiotherapy
  35. 35.  FLUORIDE GELS  Fluoride gel products include neutral sodium fluoride and acidulated phosphate fluoride with a fluoride concentration of 5000 ppm and stannous fluoride with a concentration of 1000 ppm  The gels are either applied in trays or brushed on teeth  Professionally applied – given twice a year  Self applied – once a day or more  Home fluoride gels are not recommended for children below 6 yrs and younger
  36. 36. Limitations of fluoride gels  They violate the principle of delivering low concentration of fluoride at regular intervals  Toxicity hazard  Tedious to use on daily basis
  37. 37. TABLETS AND LOZENGES  These are prescribed by the dentist or pediatrician and are not available over the counter  These provide a topical as well as systemic benefit for both primary and permanent teeth  The amount of fluoride is 0.25mg, 0.5mg or 1mg. These are chewed, swished and swallowed  Correct dosage is based on the conc of fluoride in drinking water, age and weight of the child.  Not more than 1 milligram of fluoride should be ingested from all available systemic sources  Use of these supplements from birth to age 13 or 16 yrs provides caries reduction from 60% to 65%
  38. 38. Conclusion  Fluoridation is universally accepted by the dentists and other medical professionals as being useful in preventing tooth decay  They can be used in areas where there are no central water supplies, where the fluoride conc of well water is low(tablets and lozenges)
  39. 39. REFERENCES Essentials of public health dentistry-Soben Peter Topical fluorides – Amrit Tiwari Dental care for children – Anil Kohli