1. This document discusses various topical fluoride treatments including professionally applied and self-applied options. Professionally applied treatments include sodium fluoride, stannous fluoride, acidulated phosphate fluoride, and varnishes. 2. Self-applied options include fluoride dentifrices, mouthwashes, and gels. Fluoride dentifrices and mouthwashes containing levels between 225-900 ppm fluoride have been shown to reduce caries by 20-35%. 3. Both acute and chronic fluoride toxicity are discussed. Acute toxicity results from ingestion of large amounts and can damage the gastrointestinal and neurological systems. Chronic ingestion of small amounts can result in dental or skeletal fluorosis characterized by staining

1. TOPICAL
FLUORIDE
1

2. Indications:
• Caries active
• In children immediately after tooth eruption
• Medications that decrease salivary flow
• After periodontal surgery, on exposed roots
• Patients with RPD, FPD, ortho appliances
• Mentally and physically challenged
2

3. 3
TOPICA
L
Professionally
Applied
Self
Applied
• NeutralNaF,
• SnF
• APF
• Varnish
• Highconcentration
• i.e.5000to19000ppm
• Dentifrices,
• Mouthrinses
• Gel
• Lowconcentrationi.e. from
200to1000 ppm

4. Professionally applied topical fluorides
1. Sodium fluoride
2. Stannous fluoride
3. Acidulated phosphate fluoride
4. Varnishes – Duraphat and Fluorprotector
4

5. Neutral Sodium Fluoride (2% NaF)
• First compound
• 30% caries reduction
• Powder and liquid form
• Neutral NaF – pH = 7
5

6. • Method of preparation of 2% NaF :
20 gms of NaF is dissolved in 1 litre distilled water
in a plastic container
6

7. • Treatment is given in a series of
• 4 appointments
• At 4 ages – 3, 7, 11, 13 years
• Total – 16 appointments
7
Knutson’s technique

8. 8
First appointment -
Prophylaxis and isolation
Thoroughly wetted with
solution
Allowed to dry for 3-4 min
3 further applications
With one week intervals
Recommended ages –
3,7,11 &13yrs

9. Mechanism of action of NaF
• NaF + hydroxyapatite = CaF2 end product
• Thick layer interferes with further F diffusion
• Sudden stop = CHOKING EFFECT
• CaF2 + HA = fluoridated HA
9

10. Advantages
1. Acceptable taste.
2. Stable if stored in plastic container and
refrigerated.
3. Non – irritating to gingiva
4. No discolouration of teeth
Disadvantages
1. Four visits in a short interval
10

11. Stannous Fluoride (SnF2) 8% and
10%
• Muhler – 1947
• Method of preparation of 8% SnF2 :
0.8 gms of SnF2 is dissolved in 10ml distilled water in a
plastic container
• pH = 2 – 3
• Biannual applications
11

12. 12
First appointment -
Prophylaxis and isolation
Thoroughly wetted with
solution
Allowed to dry for 3-4
min
Twice a year

13. Mechanism of action
• SnF2 + HA = tin hydroxyphosphate – dissolved –
metallic taste
• High conc –tin trifluorophosphate -- increases
caries resistance
• Calcium fluoride is the end product + HA = FHA
13

14. Advantages
1. Effective in caries prevention and arrest
2. Only two appointments each year
Disadvantages
1. Discolouration of teeth and restorations
2. Irritating to gingiva
3. Unstable, cannot be stored
4. Metallic taste
14

15. Acidulated Phosphate
Fluoride (APF)
• Brudevold – 1963
• To achieve greater amount of fluorapatite and
lesser amount of CaF2, they suggested that
1. Decrease the pH of the fluoride system
2. Use of phosphoric acid
15

16. Method of preparation of 1.23%APF
• 20 mg of NaF in 1 liter of 0.1M phosphoric
acid.
• To this is added 50% hydrofluoridic acid to
adjust to pH at 3 and F concentration to 1.23%
• For the preparation of APF gel, a gelling agent
methylcellulose or Hydroxyethyl cellulose is to
be added.
16

17. Method of Application - Video
• Selection of trays
17

18. Mechanism of action
• Initially - dehydration and shrinkage in the
volume of HAP crystals which further on
hydrolysis forms Dicalcium phosphate
dihydrate (DCPD).
• This leads to formation of FA.
18

19. Advantages
1. Only two appointments each year
2. Stable if stored in plastic containers
Disadvantages
1. Teeth should be kept wet for 4 min - increases
chair-side time.
2. Acidic, sour and bitter in taste.
3. Causes surface alterations of many restorative
materials – low pH
19

20. 20
NaF SnF2 APF
% F 2% 8% 1.23%
ppm F 9,200 19,500 12,300
Frequency of
application
4 weekly intervals
at 3,7,11,&13yrs
1or 2/yr 1 or 2/yr
pH 7 (Neutral) 2 – 3 3 – 4
Taste Bland Disagreeable Acidic
Stability Stable Unstable Stable in plastic
container
Pigmentation No Yes No
Gingival
irritation
No Occasional
transient
No
Average
effectiveness
29% 30% 28%

21. Fluoride varnish –
Duraphat and Fluorprotector
• Topical fluoride solutions have disadvantages –
1. Strict isolation, Washed away with saliva
2. Remain in contact for a short time
1. Varnishes set in the presence of saliva
2. Form a thick layer on the tooth following
application
21

22. Duraphat
• 1st Fluoride varnish in Germany
• Viscous yellow material containing 22,600 ppm F
• NaF : Neutral colophonium base (NaF varnish
containing 2.26% F in organic lacquer)
• Banana flavored
22

23. Fluorprotector
• Clear polyurethane based product containing 7000
ppm F
• an organic compound difluorosilane (silane
fluoride with 0.7% F in a polyurethane based
lacquer)
23

24. 24
First appointment - Prophylaxis
Isolation with cotton not
required
Thoroughly wetted with solution:
0.3-0.5 ml and Allowed to dry for 3-4 min
Patient asked not to eat or drink for 1hour
& not to eat hard food till next day
Twice a year
Application is done on lower arch & then
on upper arch

25. 25
Duraphat
(Heuser
and Schmidt,1968)
Fluor protector
(Sehann, Liech-
tenstein,1970s)
Fluoride
compound
5% Sodium fluoride 1% Difluorosilane
Fluoride
content
22,600 ppm (2.26%) 7000 ppm
(0.7%)
Application
frequency
Biannual Biannual
Effectivenes
s
30%-40% 1%-17%

26. SELF APPLIED
TOPICAL
FLUORIDES
26

27. FLUORIDE
DENTIFRICES
27

28. • The term ‘dentifrice’ derived from the Latin
word ‘dens’ = tooth ; ‘fricare’ = to rub
• 1955 – SnF2 dentifrices – 1st dentifrices
recognized by FDA
• 1st fluoride dentifrices was accepted by ADA in
1964
28

29. Types of fluoride dentifrices
1. NaF dentifrices
2. SnF2 dentifrices
3. Monofluorophosphate dentifrices
4. Amine fluoride dentifrices
29

30. 30
Below 4 yrs F toothpaste is not recommended
4-6 yrs Brushing once daily with F paste &
twice with out F paste
6-10 yrs Brushing twice daily with F paste &
once with out F paste
Above 10 yrs Brushing twice daily with F paste

31. 31

32. 32

33. 33

34. • Reduction: 20 – 35%
• Adult toothpaste?
• Paediatric toothpaste?
34

35. FLUORIDE
MOUTHRINSES
35

36. • First described by Bibby in 1946
• One of the most widely used caries preventive
public health methods
• ADA acceptance in 1975 for neutral NaF and
APF mouthrinses.
36

37. Sodium fluoride mouthrinses
• 0.2% NaF (900 ppm) for weekly use or
• 0.05% NaF (225 ppm) for daily use.
• Intended to use by forcefully swishing 10ml of
the liquid around the mouth for 60 sec before
expectorating it.
• Caries reduction - 25 %.
37

38. Rationale –
• Frequent use of low concentration of fluoride
is more cariostatic than less frequent use of high
concentration as in topical applications.
38

39. FLUORIDE GELS
• Neutral NaF and APF with a F conc of 5000ppm.
• Applied in trays or brushed on teeth.
• Patient should be cautioned to expectorate.
• Not recommended for children 6 years and
younger.

40. FLUORIDE
TOXICITY
40

41. 41
TYPES
ACUTE CHRONIC
• Long term
ingestion of small
amounts
• EFFECT:
mineralized tissues -
dental or skeletal
fluorosis
• Single ingestion of
a large amount
• EFFECT:
Gastrointestinal
symptoms to death

42. Causes –
1. Accidental exposures
2. Excess dietary supplements
3. Ingestion through dental products
42
ACUTE
TOXICITY

43. Acute Fluoride Toxicity
Sr
no
SYSTEM SYMPTOMS AND SIGNS
1 Gastrointestinal Nausea, Vomiting, Diarrhoea, Abdominal
pain and Cramps
2 Neurological Paresthesia, paresis, tetany, central
nervous system - depression and coma
3 Cardiovascular Weak pulse, hypotension, pallor, shock,
cardiac irregularities, ultimately failure
4 Blood chemistry Acidosis, hypocalcaemia and
hypomagnesaemia
43

44. 44

45. Certainly Lethal dose (CLD)– 32–64mg/kg body
wt
• 70 kg person was 5 -10 g when taken orally
Safety tolerated dose (STD) – 8–16mg/kg body wt
(1/4TH OF CLD)
45

46. THE TRIO OF MANAGEMENT
Reduce Fluoride
Absorption Increase
Fluoride
Excretion
Plasma potassium
and calcium
monitoring

47. Management of toxicity based on amount of
Fluoride Ingested
Dose Management
<5mg/kg F Milk, Induce Vomiting
>5mg/kgF Milk, Induce Vomiting, Hospitalization
5% Ca gluconate
>15mg/kgF Induce Vomiting, Hospitalization, Cardiac
monitoring, 10% Ca gluconate , Monitoring of K
and Ca levels, Urine output

48. • Long term ingestion of small amounts
• The most obvious early toxic effects of F
in humans are
1. Dental and
2. Skeletal fluorosis - endemic areas
48
CHRONIC
TOXICITY

49. 49
Fluoride
level
Effects
0.7-1.2 ppm Optimum level of fluoride;
prevents dental caries;
No dental/skeletal fluorosis.
1.5-3 ppm Consumption of water for 5-10 years;
Mild form of dental fluorosis.
3-8 ppm Consumption of water for15-20 years;
Severe form of dental fluorosis &
Milder form of skeletal fluorosis.
8ppm & more Consumption of water for 5-10 years/more;
Severe form of skeletal fluorosis.

50. • Hypoplasia or hypomineralization of tooth
enamel or dentin due to chronic ingestion of
excessive amounts of fluoride during the
period when teeth are developing.
50
DENTAL
FLUOROSIS

51. • The chronic effect of F on the skeletal
system was 1st observed in
India - Madras in 1937.
51
SKELETAL FLUOROSIS

52. • Severe pain in the back bone,
Joints, Hips
• Stiffness in joints & spine
• Outward bending of legs,
hands
(‘knock- knee’ syndrome)
52

53. • knock-knee syndrome,
• Kyphosis,
• Pokers back, - skeletal
fluorosis in advance stages
• Very Severe - “crippling
skeletal fluorosis.”
53

54. 54
India: among 23 nations in the world - F contaminated
groundwater is creating health problems

55. 55
•17 states -
affected
•F varies from
1ppm -48 ppm.

56. 56