Systemic flourides / dental implant courses

Systemic fluorides
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

Contents
Introduction
water fluoridation
School water fluoridation
Salt fluoridation
Milk fluoridation
Fluoride tablets and drops
Prenatal supplementation
Defluoridation
Conclusion
references

Water fluoridation
Definition – upward adjustment of the concentration
of fluoride ion in public water supply in such a way
that the concentration of f ion in the water may be
consistently maintained at 1 ppm.

Optimal level of fluoride
Optimum fluoride concentration
WHO 1971 – 0.7-1.2ppm
Cold climate -1.2 ppm
Hot climate – 0.7 ppm
Moderate climate – 1ppm
WHO 1994- 0.5-1ppm
Galagon and vermillion 1957 – based on body wt & climatic
conditions = ppm F (conc.) = 0.34/E
Where E = -0.038+0.0062 x temperature of the area in 0
F

Choice of equipment and chemicals used
Fluoride compounds
Fluorspar- caf
hydrofluosilicic acid
Sodium fluoride – from hydrofluosilicic acid
(expensive)
Silicofluorides – purification of phosphate rocks
Sodium silicofluoride (low cost but corrosive)
ammonium silicofluoride

Equipment
Characteristics of system
Equipment should be adapted to local conditions
Safe and efficacious, precise
Standard type
Well defined precision limits
Antisiphon mechanism
Types of equipment for water F
Saturator – granular Na F
Dry Distributor– silicofluoride or Na F
Liquid distributor – hydrofluosilicic acid

equipment principle Factors
limiting
utilisation
recommenda
tion
Saturator
system
4% saturated
solution of NaF
(pump)
High hard
water level
Small towns
<3.8millions
lt/day
Dry feeder NaF or
silicofluoride
(Automated)
Care in
handling
Medium sized
town
3.8millions
lt/day
Solution
feeder
hydrofluosilicic
acid
(volumetric
pump)
Equipment-
polyvinyl
chloride
Medium ,
large sized
towns
7.6million/day
Types of equipment

Volumetric feeder
Saturator system
Solution feeder

Two other systems
Venturi fluoridator system – J.N.Leo
Non-electrical system
Activated by the flow of water in the main water
line
Adv- Simple to install, low cost
Saturation – suspension cone- brazil
Upside down cone charged with a bag of
silicofluoride- collected at the top

Venturi fluoridator
Saturated- suspension cone

Method of estimation of fluoride concentration in
drinking water
fluoride electrode coupled with ph meter
(orion, radiometer)
Scot- sanchis method
Zirconium alizarin reagent

Study year place Ppm
F
result
Dean et al 1939 Galesburg,mon
mouth
1.7 dmft
weaver 1944 South& north
shields
1.4
0.4
41% dmft
Tan&
storvick
1964 Corvalis albarny 1 56% dmft
Murray 1969 Hartepool,york 1.5-2 64% dmft
Murray &
Atkinson
Backer
dirkis
1971
1974
London
Holland & new
zealand
0.2 93% dmft
Prox& gingival
caries
Whittle &
downer
1979 Birmingham
salford
F/NO
N-f
54% dmft
Water fluoridation studies

Benefits of water fluoridation
Smooth surfaces receive maximal protection
Has both pre and post eruptive effects
Systemic and topical effect
Fluoride in saliva – remineralisation
Changes morphology of Occusal surfaces
Least expensive – large group
Bottled beverages- diffusion/ halo effect

Safety of water fluoridation (1940-1978)
Leone et al 1959-
Bart let Texas- 8ppm F (15yr) – mottled enamel
` Cameron- 0.4ppm
Weidman 1963
up to 4ppm- no radiographic evidence
Hodge 1963 – 11ppm- no kidney/ thyroid damage
Ericson 1978 – no evidence of cancer
WHO 1978 – no harmful effect, less dental decay

Limitations of water fluoridation
Financial and technical resources
Fear of adverse effects
Implementation of fluoride schemes
Feasibility in India
Most effective, practical and economical public health
measure
Shortcoming – central pipe water supply system (30%)

India does not need water fluoridation – an
illusion
Rama Subramanian et al 1979
7 states – A.P, tamilnadu, gujarat, maharashtra, U.P, himachal
pradesh & punjab
A.P & gujarat -6-16PPM
only 5% - high F area
3% - optimal F area
90% - water deficient F
66% - <0.5ppm
Lakdawala & punekar 1979 – Bombay – 0.08ppm

Alternatives to water fluoridation
Fluoridated salt
Milk
Fluoride tablets
Fluoride drops
Fluoride oral rinses

1954 –Virginia island, 2.3ppm,
1962 - 21.9% caries reduction
Pennsylvania – 5ppm
5yrs – 28.6%, 10yrs – 39% less dmft
USA - North Carolina- Vermont, Kentucky, Nebraska,
Florida, Montana
Heifetz et al 1983 – 12yr study (6.3ppm) – 47% reduction
Results of these several studies - Effective public
health measure

Venturi fluoridator system
Advantages
Effective public health measure
Disadvantages
Limited pre eruptive contact (5-6yr)
Intermittent exposure of F to children (5-6hrs 4.5ppm
over dosage

Salt fluoridation
Introduced in Switzerland 1955
Salt fluoridated –90 mgF/kg (canton of Zurich)
250mgF/kg (canton of vaud 1970)
Belgium, France, Germany, Spain, Hungary
Clinical trials
Wespi et al 1955 – 20-25%
Muhlemann 1967- 300mgF/kg - 1.5mgF/5gm of salt
Toth 1976 – 250mgF/kg salt - 41% (2-6yr) - 8yr
- 58%(7-11yr)
- 36% (12-14yr)

Production of fluoride containing salt
Spraying conc. solutions of NaF on salt on a conveyer belt
(Switzerland and Hungary)
NaF & CaF mixed Po4 - salt (U.S.A)
Requirements for application of fluoridated salt
Low fluoride drinking water
Lack of political will and resources to fluoridate water

Factors favoring the implementation of salt
fluoridation in Switzerland
Decentralized water supply
Uniform low water F
Centralized salt production
Public ownership
Low cost

Advantages of salt fluoridation
Safe
Supplement
Consumer free choice
No supervised water distribution systems
Lifelong daily compliance
Small amounts
Low cost
Disadvantages
Low consumption
Safety - Hypertension ?
No problem of acute toxicity

Limitations
Limited to domestic salt
Variation in salt intake
Difficulty in controlling the distribution of various conc
Requires refined salt produced with modern technology
Technical expertise
Multiple sources of water

Feasibility in India
Effectively controlled supply
Individual monitoring not required (5-8gms of salt/day)
Freely available
Cariostatic effectiveness and excretion
Does not alter its color

Milk fluoridation
Ziegler 1955 (Swiss city of winterthur)
0.03 ppm F (Erickson 1971)
Compounds
NaF- conc. aqueous solution
disodiummonofluorophosphate –reacts ca
disodiumsilicofluoride –pasteurized milk
Manufacture
fl added to milk in appropriate quantity
Fluoridated milk- pasteurized / sterilised (liquid)
- powder
WHO 1994 - 0-1mgF/day (age+water F)

Studies
Inamura 1956 (Japan) – 36.3% - (2.5mg NaF )
Rusoff et al 1962 (U.S.A) – 35% (3.5ppm F)
Benoczy 1984 – longitudinal study (3-9yr old) – 3yr
200ml milk +0.4mg F (3-5yyr old)
0.75mgF (6-9yr old)
Primary teeth
Ziegler 1964 – 14 – 31% (1ppm)
Benoczy 1983 – 74%
Effectiveness of milk F
bioavailability is not reduced
promotes remineralisation (low level of ionised F)

Rationale
Target children directly
Less expensive
Consumers choice
Advantages
Staple food
Consumption confined to groups who need it most
Concerns
Absorption – long
Children who do not drink milk / consumption declines with
age

Stamm 1972 – 4 criticisms of milk fluoridation as public
health measure
1) low socioeconomic
2) less benefit
3) cost
4) slow absorption
Feasibility of milk fluoridation in India
Controversy – binding and complexing of F + ca, p
Ericson1958 – 4hr
Cannot afford milk
No centralised milk supply system
Variation of intake and quantity

fluoride supplements
1940 , pre eruptive effect
Common dietary supplements-
Fluoride drops – vitamins
Fluoride tablets - vitamins
Lozenges
Oral rinse supplements

Commercially available
NaF tablets
fluoroday
tymafluor,
luride (U.K)
Vitamins
dosage
2.2mg (1mgF)
1.1mg (0.5mgF)
0.55mg (0.25mgF)
APF tablets/ KF/CaF
Drops
0.125,0.25,0.50mg
Oral rinse
1mg/5ml

Luride Chewable Tablets Luride drops
Fluor-A-Day Chewable Tablets

Lozenges oral rinse
Sodium fluoride tablets and drops

Factors to be considered before
determining proper F dosage
Concentration of fluoride in drinking water
Total amount of bioavailable fluoride
Age of the child
Dosage forms commercially available
milk & milk products

Fluoride dosage based on F content of drinking
water (ADA)
F content of
drinking water
2wks-2yr 2-3yr 3-14yr
<0.3ppm o.25 mg 0.50 1mg
0.3-0.7ppm 0 0.25 0.50
>0.7ppm - - -

Recommendations to fluoride supplements
(British society of pediatric dentistry)
1) Not a public health measure- recommended for individual
children
2) <0.3ppm/ high risk patients- recommended dosage
6mon-3yr 0.25mgF/day
3-6yrs 0.50mgF/day
>6yrs 1mgF/day

Indications for use
No central water supply
low F conc
parental motivation high
Interim measure
Water/ salt F cannot be implemented
Frequent changes in work
Precautions
Stomach upset
Risk of mild fluorosis

Effect of fluoride tablets on deciduous teeth
Hoskova 1968 – 93% (prenatally) – 82%
- 54% (birth) 56% (kailis et al)
Since birth – 6-8yr -40% (Prichard 1969)
- 3 yr – 78% (hennon 1971)
After 3yr – 0-38%
Caries reduction 50-80% (bef 2yr – 3-4yr)

Effect of fluoride tablets on permanent teeth
Sodium fluoride tablets
0% caries reduction – Bibby 1955
33-38% (Berner 1967, Pollack 1960)
APF tablets
23- 30% (depaola 1968,aasenden 1972)
Aasenden& peebles 1974 -0.5mgF daily (<3yr)
1mg (8-11yr) – 80%
20-40% caries reduction

Prenatal fluoride supplements
1966 FDA banned marketing of products bearing claim that
caries would be prevented in their offspring of women who
used the products in their pregnancy
Rationale for the use of prenatal fluorides in caries
prevention
Transfer of F from maternal circulation to fetal circulation
Clinical trials with prenatal fluorides

Placental transfer of F ?
1) Fluorosis in primary teeth - thylstrup (3-21ppm)
2) Prenatal fluoride metabolism

3) Elevated maternal blood conc. ?
4) Prenatal exposure to fluoridated water
- blayney & hill, tank & storvick 1964- benefit primary teeth
- Horowitz & heifitz 1967, Katz & muhler- minor
- Carlos 1962 - prevalence differed
- Arnold- greater reduction- pre/post
5) fluoride supplements
- felt man & kozell 1961- pre+postnatal
- Pritchard
-Glenn study 1977-79- prenatal
Legros et al 1983 –protect teeth
Changing the morphology of teeth
Densely placed enamel rods
No evidence

Defluoridation
Deflouridation - scientific means to improve the
quality of water with high fluoride conc by
adjusting the optimum level in drinking water
Methods
Adsorption and ion exchange methods
Adsorb F + exchange negative ions
activated alumina, fluidized activated alumina, activated
bauxite, zeolite, tricalcium phosphate,super phosphate,
activated bone char, magnesite

Precipitation method
- High ph – co-precipitation of several elements +
fl ions
- Alum, alum + lime, lime softening, CaCl
Methods based on membrane separation
Reverse osmosis – expensive
30% of raw water is lost

Reverse osmosis unit

Ion exchange resins
Anion exchange resins
- polystyrene, quaternary ammonium
- 10-15 cycles replacement - High cost, unacceptable taste.
Cation exchange resins
- saw dust carbon, defluoron 1, carbion

Defluoron 1
Sulphonated saw dust impregnated with 2% alum.
High attritional losses (bhakuni 1964, 1970)
Carbion
Good durability , bulk density – 680g/lt
Pilot plant – gangapur - Rajasthan (4.8ppm)
8:1 Carbion & defluoron 1, alum

Magnesia (Thergaonkar 1971-73)
removed excess fluoride- ph>10
High cost, large conc., complexity of preparation
Defluoron 2 (1968)
Sulphonated coal +alum cycles, 2-4yrs life
regeneration and maintenance of plant – skilled operation

Indian technology for deflouridation
NEERI ,Nagpur - 1960
Nawlakhe 1974
Nalgonda technique – 1975 (Andhra Pradesh)

Nalgonda technique (Nawlakhe 1974)
Addition of 2 readily available chemicals
Sodium aluminate /lime- hastens settlement of ppt
bleaching powder – disinfection
filter alum added to F water
•Domestic / community water supplies

•Domestic treatment
container – 20- 50lt
Lime water + bleaching
powder
Alum solution (10min)
Clear water (1hr)
• Community level- fill and draw type
200-2000 poulation

Community level- fill and draw type

The picture shows Defluoridation Plant attached to Hand Pump.
CHEMICAL TANK
OUTLET
INLET
CHEMICAL DOSING SYSTEM
HAND PUMP
PERFORATED SHEET
GRAVEL
VALVE 1
VALVE 2
GRAVEL LAND
BACK WASHLINE
MASONARY
M.S. STAND
DRAIN

Indications for adopting Nalgonda
technique
Absence of acceptable, alternate low fluoride source within
transportable distance
Total dissolve solids below1500mg/l
Raw water fluoride ranging from 1.5 – 20mg F /l

Salient features of Nalgonda technique
No regeneration media
No handling of caustic acids and alkalis
Domestic and community levels
Manual operated
Chemicals – municipal water supplies
Cost effective
Flexible design
<1mg/l
Little wastage of water and least disposal problem
Needs minimum of mechanical and electrical equipment

Combined Nalgonda and calcined
magnesite technique
In Tanzania (1985- 1990)
Nalgonda technique was passed thru a filter bed
consisting of calcined magnesite granules
Ph rise >10
Impractical for rural regions

Prasanti technology 1998
Activated alumina
Bio-science dept, A.P
25 community defluoridation plants – 200-
400people
500 domestic defluoridation plants
Cost effective

Activated alumina

Other materials tried in India
Fish bone charcoal – university of Roorkee
Drumstick plant – (ca, mg) reduce water turbidity
Askali – extract mycetial biomass, Hyderabad
Clay minerals
Tricalcium phosphate

References
Fluorides in dentistry – Fejerskov
Fluorides – Amrit tewari
Salt fluoridation - Adv dent res 1995
Dcna 1999
Essentials of preventive and community dentistry
– soben peter
J of Indian dental association 1986
JDR 1992
clinical uses of Fluorides- stephen wei
j dent child 1981

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