Professional fluoride-Class.pptx

PROFESSIONALLY
APPLIED
FLUORIDE
4

Content
◦ Introduction
◦ Mechanism of action Fluoride in caries prevention
◦ Fluoride delivery methods
◦ Professionally applied fluorides
◦ Fluoride Solutions & gels
◦ Fluoride Varnishes
◦ Fluoride Prophylactic pastes
5

◦ Silver-diamine fluoride
◦ Newer advances in fluoride delivery methods
◦ Conclusion
◦ References
6

Introduction
◦ Incipient carious lesions (White spot lesions) can be managed using
remineralisation therapies involving behavioral changes (reviewing
dietary habits and plaque control) and using fluoride-containing
products.
◦ Fluoride can be delivered topically and systemically.
◦ Topically applied modalities can be divided into self-applied and
professionally applied topical fluorides.
◦ Professionally applied topical fluorides are used in different form by a
dental professional in the dental office.
7
Amaechi BT. Remineralization therapies for initial caries lesions. Curr Oral Health Rep. 2015;2(2):95-101. https://doi.org/10.1007/s40496-015-0048-9
American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride: Evidence-based clinical recommendations. JADA 2006, 137,
1151–1159.

Mechanism of action of fluoride
in caries prevention
A number of proposed mechanisms have been identified which are
assumed to work simultaneously, those are:
a) Increase enamel resistance or reduction of enamel solubility
b) Increased rate of post-eruptive maturation
c) Remineralization of incipient lesions
d) Interference with microorganisms
e) Modification of tooth morphology
8

Fluoride delivery methods
Can be delivered either as
1. Topical Fluorides: Placed directly on the teeth, some in high
concentration and some in low concentration
2. Systemic Fluorides: Circulate through the blood stream and
incorporated into developing teeth. Different types are:
a) Community Water Fluoridation
b) Salt Fluoridation
c) Milk Fluoridation
d) Fluoride tablets/drops/lozenges
9
Peter S. Essentials of preventive and community dentistry. 7th ed. Arya publication; New Delhi. 2021

Topical fluorides delivered by 2 methods
1) PROFESSIONALLY ADMINISTERED
◦ Professionally applied fluoride are medications dispensed by dentists in
the dental office settings and involve use of high fluoride concentration
products that is from 5000 to 22,600 ppm Fluoride.
◦ FLUORIDE SOLUTIONS: Sodium Fluoride – 2 %, Stannous Fluoride – 8 %
◦ FLUORIDE GELS: Acidulated Phosphate Fluoride – 1.23 %
◦ FLUORIDE VARNISHES: Duraphat, Fluorprotector, Cavity shield etc.
10

2) SELF ADMINISTERED
 Self-applied fluoride products are usually bought and dispensed by the
individual patient but at the recommendation of dental personnel.
 These products typically are low fluoride concentration 200 to 1000
ppm.
 It includes: Fluoride Dentifrices, Fluoride Mouthwashes, etc
11

SODIUM FLUORIDE
◦ Sodium fluoride was the first topically applied fluoride compound.
◦ For the first time in 1941, the first clinical study of NaF was carried out
by Bibby using 0.1% NaF solution.
◦ In 1942, Knutson used 2% solution for 3-4 minutes.
12
Jalili VP,Tewari A.Fluorides and dental caries : A Compendium. 1st ed.Indore: J Indian Dent Assoc ;1986.

METHOD OF PREPARATION
◦ 2% Neutral NaF solution can be prepared by dissolving 20 grams of NaF
powder in 1 liter of distilled water in plastic bottle and it has a pH of 7.
◦ 9200 ppm concentration is achieved.
◦ Stored in plastic bottles because if stored in glass containers, the
fluoride ion, of the solution can react with silica of glass, forming Silicon
Fluoride, thus reducing the availability of free active fluoride for anti-
caries action.
13

KNUTSON’s TECHNIQUE
14
The teeth are cleaned with pumice slurry and dried with
compressed air and are isolated either by quadrant or by
half mouth
2% NaF solution is painted on all the surfaces of teeth till
they are visibly wet allow to dry for 3-4 minutes and repeat
process for all quadrants
2nd, 3rd and 4th NaF application at intervals of at least 1
week

◦ The 4 visit procedure is recommended for ages 3,7,11 and 13 years,
coinciding with the eruption of different age groups of primary and
permanent teeth.
15
Murray JJ, Rugg-Gunn AJ, Jenkins GN. Fluorides in caries prevention. 3rd ed. Butterworth-Heinemann Ltd. 1991,
Cambridge.

MECHANISM OF ACTION
◦ When NaF is applied topically, it reacts with hydroxyapatite crystals to
form CaF2 which is the dominant product of the reaction.
◦ This deposited CaF2 on tooth surface react with hydroxyapatite to form
fluoridated hydroxyapatite.
16
10

◦ With higher conc. of F in 2%NaF the solubility of CaF2 gets exceeded
fast and a thick layer of CaF2 gets formed which interferes with further
diffusion of F to react with hydroxiapatite, the phenomenon is called
chocking off effect.
17

ADVANTAGES Of Neutral NaF Solution
◦ Relatively stable so there is no need to prepare a fresh solution for each
patient.
◦ The taste is well accepted by patients and does not cause discoloration
of tooth structure.
◦ Once applied to the teeth, the solution is allowed to dry for 4 minutes,
thus the clinician in public health programs can pursue a multiple chair
procedure.
◦ It is non-irritating to hard and soft tissues.
18

DISADVANTAGES
◦ Four visits to the dentist within a relatively short time.
◦ Very limited effectiveness as a professionally applied topical fluoride.
19

STANNOUS FLUORIDE (SnF2)
◦ The basis for the introduction of SnF, was the finding that powdered
enamel treated with SnF₂ had a greater reduction in rate of dissolution
in acids than with other fluorides.
◦ Stannous fluoride available in 2 concentrations 8% and 10% solution of
stannous fluoride (SnF2) pH 2.1.
20
Nikiforuk G. Understanding dental caries. Vol 2. prevention, basic and clinical aspects. 1985. Karger publishers,
New York.

METHOD OF PREPARATION:
◦ To prepare 8% stannous fluoride solution, The content of one capsule
which is 0.8 gms is dissolved in 10 ml of distilled water in a plastic
container and the solution is shaken briefly and applied immediately to
the teeth.
◦ The 10ml of the solution should be sufficient to treat the whole mouth
of a single patient.
◦ Solutions of stannous fluoride are not stable. Soon after mixing, they
become cloudy due to the formation of tin hydroxide.
21

Application of SnF2 ( Muhler’s technique)
22
Clean the teeth with aqueous pumice slurry
unwaxed floss is passed between the interproximal areas
repeat applications are done every 6 months or more frequently if the
patient is at high risk of caries
SnF2 is applied using the paint on technique and the
solution is kept for 4 minutes

MECHANISM OF ACTION
◦ When SnF2 reacts with hydroxyapetite in addition of F the tin of SnF2 also
react with enamel tin trifluoro phosphate (Sn3F3Po4) gets formed which
is more resistant to decay than enamel.
◦ At very high concentrations calcium trifluorostanate (CaF2 (Snf3)2) gets
formed along with Sn3F3PO4(Tin Tri-Fluorophosphate), which also had
similar property.
23

◦ When applied at low concentration tin hydroxy phosphate
(Sn2(OH)PO4 )is formed which is responsible for the metallic taste.
◦ CaF2 so formed further reacts with HA and small fractions of Flour-
hydroxyapetite also get formed.
24

ADVANTAGES
◦ 8% SnF2 solution is generally accepted as highly effective when applied
to teeth on a semiannual application.
◦ Rapid penetration of the tin and fluoride ions, resulting in the formation
of highly insoluble ions, and amorphous layer of tin phosphate complex
on the enamel surface.
◦ Stannous fluoride gel has been shown to be effective against radiation
caries as well as for patients undergoing orthodontic treatment.
25

DISADVANTAGES:
◦ It is highly unstable solution and should ideally be prepared fresh.
◦ It has a very low pH of 2.1 to 2.3. It causes gingival tissue irritation.
◦ It has a metallic and astringent taste.
◦ It produces a light or dark brown discoloration.(probably due to tin
sulfide)
◦ It produces a grayish discoloration of margins of restorations,
particularly, composite restorations.
26

ACIDULATED PHOSPHATE
FLUORIDE (APF)
INTRODUCTION
◦ Brudevold et al. (that1963) found that the fluoride concentration in
enamel increased with decrease in the pH of the solution.
◦ The pH of APF solution is 3 and APF gel is 4 to 5.
◦ The fluoride concentration is 12,300 ppm.
27
Murray JJ, Rugg-Gunn AJ, Jenkins GN. Fluorides in caries prevention. 3rd ed. Butterworth-Heinemann Ltd. 1991,
Cambridge.

METHOD OF PREPARATION
◦ APF usually contains 1.23% of fluoride in 0.1M phosphoric acid at a pH
of 3 and is stable with long shelf life when stored in opaque plastic
bottles.
◦ It is prepared by dissolving 20 grams of NaF in 1 liter of 0.1M
phosphoric acid.
◦ To this is added 50% hydrofluoric acid to adjust pH at 3 and Fluoride
concentration to 1.23%.
◦ For the preparation of APF gel, a gelling agent methyl cellulose or
hydroxy ethyl cellulose is to be added to the solution and the pH be
between 4-5.
28

APPLICATION OF APF Gel and Solution
29
The patient is seated upright in chair and oral prophylaxis is done.
For paint on technique APF solution
is dispensed on to an applicator
brush and all the teeth surfaces are
painted
Saliva ejector is used for suctioning out excess saliva and fluoride
For tray technique the gel is
dispensed on the foam tray and
inserted in the mouth. (<5ml)
Teeth are isolated and dried thoroughly with air
The patient is instructed to apply light
pressure on the tray and kept for 4
minutes so that the gel can flow
interproximally, and the excess should be
expectorated
The APF solution needs to be reapplied
after every 15-30 seconds until 4 mins

◦ The patient is asked not to eat, drink or rinse for at least next 30 mins.
◦ Recommended application at 6-12 months interval.

MECHANISM OF ACTION
◦ Larger amount of F acquired with deeper penetration when pretreated
with dilute phosphoric acid before being exposed to F solution.
◦ When APF is applied on the teeth it initially leads to dehydration and
shrinkage in the volume of Hydroxyapatite crystal which further on
hydrolysis form intermediate products called Dicalcium phosphate
dihydrate(DCPD) and calcium fluoride.
31

◦ With this F penetrates deep into the crystal through the opening
produced by shrinkage and leads to formation of fluorapatite.
32

ADVANTAGES
◦ Requires only 2 applications in a year.
◦ It is stable so no need to prepare fresh for each patient.
◦ Gel form can be self-applied.
◦ Deposit fluoride to deeper depth.
◦ Full mouth can be treated simultaneously, resulting in a substantial
reduction in the time of total treatment.
33

DISADVANTAGES
◦ Since the teeth should be kept wet for 4 minutes use of suction is
necessary thereby minimizing its use in the field.
◦ Sour and bitter in taste.
◦ It cannot be stored in glass containers.
◦ loss of materials and possible cosmetic of porcelain or composite
restorations.
◦ Over-ingestion manifested by nausea, vomiting, headache and
abdominal pain.
34

Amine Fluoride
◦ First studied by Muhlemann in 1957, at University of Zurich.
◦ It had combined effect of chemical protection by the fluoride and
physicochemical protection due to the organic portion of the molecule.
◦ Reduce enamel solubility.
◦ Due to an affinity for enamel and will hold the fluoride for a longer time
against the tooth.
35
Nikiforuk G. Understanding dental caries. Vol 2. prevention, basic and clinical aspects. 1985. Karger publishers, New York.

FLUORIDE VARNISH
◦ First developed in Europe by Schimdt in 1964.
◦ This was developed to increase the time of contact between topical
fluoride agent and enamel there by enhancing the deposition of
permanently bound fluorapatite and hydroxy fluorapatite.
36
Azarpazhooh A.Fluoride Varnish in the Prevention of Dental Caries in Children and Adolescents: A
Systematic Review. J Can Dent Assoc.2008;74(1):73-79.

◦ Fluoride varnish is a concentrated topical fluoride that is applied to the
teeth by using a small brush and sets on contact with saliva.
◦ As a very small quantity (0.3–0.6 mL containing 6.6–13.2 mg F) is applied
by trained professionals.
◦ The ingested amount is generally considered to be too little to induce
any toxic or unwanted effects.
37
Clark M B, Slayton R L. Fluoride Use in Caries Prevention in the Primary Care Setting. J. Pediatr.2014;134(3):626-633

Fluoride Varnish Products
Products Name Composition Manufacturer
Duraphat 5% NaF; containing 2.26% F Colgate-Palmolive,
Canton, MA, USA
Fluor protector Silane fluoride with O.7% F Ivoclar/Vivadent,
Amherst, NY, USA
Cavity shield 5% NaF in a neutral resin OMNII Oral
Pharmaceuticals,West
Palm Beach, FL, USA
Duraflor 5% NaF Pharma Science,
Montreal, Canada
Bifluorid 12 NaF (2.7% F-) and CaF2 (2.9%
F-)
Voco, Germany
Mirafluorid 0.15 % NaF Hager and Werken,
Germany
38
Dhama K, Patthi B, Singla A. Topical Fluorides: A Literature Review. Hamburg: Anchor Academic Publishing; 2017

DURAPHAT:
◦ First fluoride varnish containing 22,600ppm fluoride as sodium fluoride.
◦ It should be applied to dry, clean teeth.
◦ The resinous base is an alcoholic suspension which when applied to the
tooth surface, evaporates, leaving a layer of fluoride rich varnish
attached to the tooth surface.
◦ It hardens into yellowish brown coating in the presence of saliva
39
Jalili VP,Tewari A.Fluorides and dental caries : A Compendium. 1st ed. Indore: J Indian Dent Assoc ;1986.

FLUOR PROTECTOR
◦ Fluoroprotector is a clear polyurethane product containing fluoride, in
the form of difluorosilane.
◦ Silane fluoride with 0.7% F in a polyurethane based lacquer (7000 ppm)
◦ It is dispensed in 1 ml ampules each ampule containing about 6.21 mg
of fluoride.
◦ Fluor protector has a lower pH and less viscosity than duraphat thus
spreads easily and readily flows into complex surface structures.
◦ It dries quickly and shows excellent adhesion to teeth.
40

DURAFLOR
◦ It is similar to duraphat in formulation contains 5% NaF varnish in an
alcoholic suspension of natural resins.
◦ The one additional ingredient is the artificial sweetening agent Xylitol
that as per manufacturer improves taste & patient acceptability.
◦ It is less viscous in nature than duraphat & is supplied as 10 ml tube.
◦ It should be allowed to dry for 10 seconds before the patient is allowed
to close his/her mouth.
41

◦ The setting time is very quick after the varnish comes in contact with
moisture.
◦ It is colorless after it sets, but some of the excess will appear spotty.
42

CAVITY SHIELD:
◦ It is a 5% NaF varnish in a resinous base 50mg NaF/ml
◦ The difference between cavity shield & other varnishes is that it is a
unit – dosed fluoride varnish.
◦ Each individual package contains either 0.25 ml (12.5 mg NaF) or
0.4 ml (20 mg NaF) depending on the number of teeth to be
treated.
◦ Color-coded brushes to quickly identify 0.25 ml and 0.40 ml doses
43

◦ ADVANTAGES: Avoids wastage, cost-effective, reduced chance of over
ingestion & fluoride toxicity.
◦ The cavity shield varnishes are supplied in individual pouches that are
light resistant to avoid congealing of the varnish.
44

FLUORITOP
◦ It is the first fluoride varnish manufactured in India by ICPA Health
Products Ltd, Mumbai.
◦ It contains 50 mg Sodium Fluoride per ml equivalent to 22.6 mg of
fluoride in slow release form.
45

Bifluorid 12
◦ Contains both NaF (2.7% F-) and CaF2 (2.9% F-).
46

Mirafluorid
◦ Can be applied under moist conditions.
47

VARNISH APPLICATION TECHNIQUE
◦ Frequency of varnish- based on individual's caries risk but semi annual
application frequency however is the optimum.
◦ Perform prophylaxis and dry the teeth.
◦ Varnish being sticky has a tendency to stick to cotton so suction can be
used.
◦ A total of 0.3-0.5 ml equivalent to 6.9-11.5 mg F can cover the full
dentition.
48

◦ Applied first on lower arch- upper arch using single tufted small brush
starting with the proximal surfaces.
◦ The patient is made to sit with mouth open for 4 minutes before
spitting.
◦ The patients should be instructed not to rinse or drink anything for 1
hour and not to eat anything solid but liquids and semisolids only till
next morning.
◦ This is to maintain the contact between varnish and tooth surfaces for
about 18 hours for prolonged interaction between F and enamel.
49

PROPHYLACTIC PASTES
CONTAINING FLUORIDE
◦ Provides both the cleaning and the fluoride application in one step.
◦ If prophylaxis pastes containing fluoride are used, the lost fluoride is
replenished and there is small but significant, net gain in the
concentration of fluoride.
◦ 1st marked prophylaxis paste contained SnF2 as active ingredient and
Zirconium silicate as the abrasive.
50

SILVER DIAMINE FLUORIDE
◦ It has both the antibacterial effects of silver and the remineralizing
effects of fluoride.
◦ First approved SDF product, Saforide (38% SDF, Bee Brand Medico
Dental Co, Ltd, Osaka, Japan) in 1970.
◦ in 2015, the first commercial product became available in the United
States: Advantage Arrest.(38% SDF solution)
◦ Thirty-eight percent SDF contains a high concentration of fluoride ions;
44,800 ppm
51
Crystal YO, Niederman R. Evidence-based dentistry update on silver diamine fluoride. Dental Clinics. 2019 Jan 1;63(1):45-68.

INDICATIONS
◦ Lesions that are, or can be made, cleansable
◦ Several carious lesions that may not all be treated in one visit
◦ Root surface carious lesions (primary and permanent teeth)
◦ Non-carious cervical lesions giving sensitivity
◦ Molar incisor hypomineralisation to reduce sensitivity
◦ High caries risk patients with medical or psychological conditions
52
Seifo N, Cassie H, Radford JR, Innes N. Silver diamine fluoride for managing carious lesions: an umbrella review. BMC Oral health.
2019 Dec;19(1):1-0.

CONTRAINDICATIONS
◦ Silver allergy
◦ Clinical signs or symptoms of irreversible pulpitis, or dental
abscess/fistula
◦ Presence of stomatitis or ulcerative gingival conditions
53
2019 Dec;19(1):1-0.

Clinical application
1. Remove gross debris from cavitation to ensure SDF reaches the carious
tooth tissue or area of the tooth it is being applied to.
2. Apply petroleum jelly to the lips to reduce the chance of temporary
staining if inadvertent contact with SDF.
3. Isolate the area with cotton roll and apply gingival barrier if the lesion is
close to the gingiva. Alternatively, rubber dam can be used.
4. Dry the carious lesion or tooth tissue with a gentle flow of compressed
air or a cotton wool roll.
54
2019 Dec;19(1):1-0.

5. Apply the SDF with a micro-brush directly onto the lesion or area of
tooth being treated.
6. Allow the SDF to absorb into the tooth via capillary action for at least 1
minute. Try to keep isolated for up to 3 minutes.
7. Blot excess solution to reduce the chance of it contacting the patient’s
tongue.
8. Consider placing a dab of toothpaste on the patient’s tongue if they
notice a metallic taste
55
2019 Dec;19(1):1-0.

Limitations
◦ Main side effect is black staining of almost everything it comes into
contact with.
◦ Regarding suspected adverse reactions, reversible, small, mildly painful
white lesions in oral mucosa, due to inadvertent contact with SDF, were
reported; these healed uneventfully within 48 h.
56
Crystal YO, Niederman R. Evidence-based dentistry update on silver diamine fluoride. Dental Clinics. 2019 Jan 1;63(1):45-68.

ADVANCES IN PROFESSIONALLY
APPLIED TOPICAL FLUORIDE
INTRAORAL FLUORIDE RELEASING DEVICE
◦ These devices are developed to release fluoride at a
predetermined rate when placed in an oral aqueous environment.
◦ Mainly two types of slow-release F devices:
◦ Copolymer membrane type - developed in the United States
◦ Glass bead - developed in the United Kingdom.
57
Pessan JP, Al-Ibrahim NS, Buzalaf MA, Toumba KJ. Slow-release fluoride devices: a literature review. Journal of Applied Oral
Science. 2008;16:238-44.

LIMITATIONS OF PROFESSIONALLY
APPLIED TOPICAL FLUORIDES
◦ Soon after application much of the acquired fluoride leaches away. Most
of the loss occurring in the first 24 hours.
◦ Operator applied topical fluorides for community programs has serious
limitations primarily because of the personnel costs associated with this
one to-one method of fluoride delivery.
58

Conclusion
◦ The primary caries-preventive effects of fluoride result from its topical
contact with enamel and through its antibacterial actions.
◦ Fluoride products should be used in proven, approved regimens, and
steps should be taken to reduce the unnecessary ingestion of fluoride by
young children.
◦ Hence, to reduce dental decay fluoride should be used in conjunction
with other preventive methods
59

References
◦ Peter S. Essentials of preventive and community dentistry. 7th ed. Arya
publication; New Delhi. 2021
◦ Fejerskov O, Erkstrand J, Burt BA. Fluoride in dentistry.2nd ed. Wiley–
Blackwell; UK. 1996
◦ Nikiforuk G. Understanding dental caries. Vol 2. prevention, basic and
clinical aspects. 1985. Karger publishers, New York.
◦ Murray JJ, Rugg-Gunn AJ, Jenkins GN. Fluorides in caries prevention. 3rd
ed. Butterworth-Heinemann Ltd. 1991, Cambridge.
◦ Jalili VP,Tewari A.Fluorides and dental caries : A Compendium. 1st
ed.Indore: J Indian Dent Assoc ;1986.
◦ Dhama K, Patthi B, Singla A. Topical Fluorides: A Literature Review.
Hamburg: Anchor Academic Publishing; 2017
60

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