The role of fluoride and chlorhexidine in the prevention of dental caries

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o Introduction
o Historical evolution as caries preventive agent
o Mechanism of action
o Modes of administration
o Systemic
o Topical
 Professionally applied
 Self applied
 Fluoride vehicles
 Clinical applications
o Advances in fluoride applications

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Essential agent
in preventive
dentistry
‘Flour’ – To Flow
The most electronegative element – never exists
in free state ; exists as fluoride compound
Federal Register of United states Food and Drug
Administration - 1973
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Rao A. Fluorides. Principles and Practice of pedodontics. New Delhi: Jaypee Medical publishers;2006 p. 204 – 18.

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Distribution of
fluoride
PLASMA
SOFT TISSUE
HARD TISSUE – Bone, Teeth
Deposition in teeth
Sucessive stages during life of tooth
o Initial deposition while organic & mineral phases
laid down
o Next deposition – from tissue fluids during
preeruptive maturation
o Finally – acquired topically – posteruptive
maturation & aging period
AMOUNT
o OUTER EN
o DENTIN- 2
o CEMENTU
o PULP- 100
2 Rao A. Fluorides. Principles and Practice of pedodontics. New Delhi: Jaypee Medical publishers;2006 p. 204 – 18.
Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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1901 Fredrick Mc Kay – permanent stain on teeth of patients
– COLORADO BROWN STAIN
Mc Kay & Black – examined 6873 individuals – unkonwn
causitive factor of mottled enamel possibly in domestic
water during tooth calcification
Spectrographic analysis – identification of fluoride in
the drinking water-Churchill hv, Smith MC, Velu H
1916
1931

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1935
Dean gave mottling index- 1ppm no stain, 2.5-3ppm
dull chalky appearance, 4ppm discrete pitting
1941
“ 21 city” Study by Dean et al – to define water fluoride
levels which represented compromise between low
caries & acceptable level of fluorosis – 0.7-1mg
Worlds first artificial fluoridation started – Grand
rapids, USA
Fluoridation endorsed by WHO
1945
1969

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HYDROXYAPATITE
CRYSTALS
BACTERIA
ENAMEL SURFACE
ALTERATION OF
TOOTH
MORPHOLOGY
o Decreasing solubility
o Improoving crystallinity
o Remineralisation
o Inhibition of enzymes
o Supressing cariogenic bacteria
o Desorbing protein/bacteria
o Lowering free surface energy
o Rounded cusps, shallow fissures

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EFFECT ON HYDROXYAPATITE
CRYSTALS – DECREASING SOLUBILITY
VOID THEORY – Voids normally
present in any crystal which
decrease stability & increase
chemical reactivity
IN HA
CRYSTAL
Fluoride fills up
spaces
Formation of
additional & stronger
hydrogen bonds
CRYSTAL
• More stable
• Lower solubility
• Greater resistence
to dissolution in
acids

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EFFECT ON HYDROXYAPATITE
CRYSTALS – DECREASING SOLUBILITY
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APATITE CRYSTAL
WITHOUT F
INCOORPORATION
APATITE CRYSTAL
WITH F
INCOORPORATION
INCREASE IN SIZE
OF APATITE
CRYSTAL
LARGER CRYSTALS –
LESS SURFACE AREA
DISSOLVES MORE
SLOWLY
Murray JJ, Rugg-gunn AJ, Jenkins GN. Anticaries mechanisms of fluoride. Fluorides in caries prevention. 3rd Ed. Butterworth- Heinemann 1991.p

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EFFECT ON HYDROXYAPATITE-
IMPROVING CRYSTALLINITY OF HA
Fluorides
• Increase crystal size
• Produce less strain in crystal lattice
Causes crystals to change from
carbonated apatite & HA to FA &
FHAP

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EFFECT ON HYDROXYAPATITE-
REMINERALIZATION -Apatite like crystals
ENAMEL MINERALS MINERALS OF SALIVA
Continuously in exchange & in
state of equilibrium
METABOLISM OF
FERMENTABLE
CARBOHYDRATE
PH DROPS
Equilibrium disturbed
Dissolution of enamel minerals
In the presence of fluoride process
is reversed - REMINERALIZATION

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EFFECT ON BACTERIA - SUPRESSING
FLORA
ENZYME INHIBITION- ENOLASE – transport of
glucose involving PEP phosphotransferase
system
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Bacterial phosphatases – degradation of
sugar phosphates
Cation transport [potassium]

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EFFECT ON BACTERIA- BACTERIAL
ENZYME INHIBITION
ENOLASE- metalloenzyme
requires Mg ++ for activity
Fluoride due to its increased
reactivity forms complexes with
divalent cations inhibiting the
metalloenzyme
Mg+
+
INACTIVE
ENOLASE
ACTIVE
ENOLASE
Mg+
+
F
INACTIVE
ENOLASE

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EFFECT ON ENAMEL SURFACE-
DESORPTION OF PROTEINS & BACTERIA
HA CRYSTALS – AMPHOTERIC With
both positive & negetive receptor
site
HA
Ca
++
PO4
--
ACIDIC
PROTEIN GRP
Acidic protein grp binds at Ca site
Fluoride inhibits binding of acidic
protein to hydroxyapatite
F
F

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EFFECT ON ENAMEL SURFACE-
LOWERING THE FREE SURFACE
ENERGY
Prevents the accumulation of plaque
ALTERATION OF TOOTH MORPHOLOGY
dentition in fluoridated communities show
tendency towards rounded cusps, shallow
fissures, wider tooth & improved alignment

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SYSTEMIC
WATER
FLUORIDATION
o Community
o School
DIETARY
SUPPLEMENTS
o Fluoride drops
o Fluoride tablets
o Fluoride rinse
supplements
TOPICAL
PROFESSIONAL
o Topical solutions
o Gels
o Varnish
o Foam
o Prophylactic
pastes
SELF APPLIED
o Fluoride rinse
o Fluoride gels
o Fluoride dentifrice

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METHOD AVERAGE % REDUCTION OF
CARIES
SELF APPLIED TOPICAL FLUORIDE
COMMUNITY WATER
FLUORIDATION
SCHOOL WATER FLUORIDATION
DIETARY FLUORIDE SUPPLIMNTN
PROFESSIONALLY APPLIED
TOPICAL FLUORIDE
50-65%
40%
50-65 %
30-40%
20-50%

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Controlled adjustment of the concentration of fluoride in
a community water supply so as to achieve maximum
caries reduction & a clinically insignificant level of
fluorosis
STUDIES
o 1945- grand rapids/Muskegon
o 1945- Newburg/Kingston
o 1946- Evanston/Oak park
RESULTS
o Caries reduction in primary teeth was 40-
50%, permanent 50-60%
o Fluoride benefit is not uniform & varies
depending on tooth surfaces
Buccal & lingual- 85%
Proximal- 75%
Pit & fissures- 35%
17 Peter S. Fluorides in preventive dentistry. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house;2007 p 270 – 358.

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Optimum concentration of fluoride in drinking
water is used to produce maximum
anticaries benefit & minimum toxicity
GALGAN & VERMILLION FORMULA
Amt of fluoride = 0.34/E
E = -0.038 + 0.0062 ˣ Temperature
Recommended 0.7 – 1.2
SCHOOL WATER FLUORIDATION
Level of fluoride is 4.5 times that of
optimum level

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1955 By Wesp, Switzerland
o 20-25 % reduction in caries with 90mg
F/Kg
o To obtain same amount of benefit as
water fluoridation amt in salt increased to
300mg F/Kg

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1956 By Zeigler
o 36 % reduction in caries with 2.5mg NaF

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o Professionally applied topical fluorides:
o Introduced by Bibby in 1942
o Involve the use of high fluoride concentration
products ranging from 5000-19,000ppm equivalent to
5-19 mgF/ml
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o Self applied products:
o Include fluoride dentifrices, mouth rinses & gels
o Are low fluoride concentration products ranging from
200-1000ppm or 0.2-1 mgF/ml

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o Lead fluoride
o Potassium fluoride
o Ammonium fluoride
o Zirconium fluoride
o Titanium tetra fluoride
o Potassium fluorostannate
o Sodium fluorostannate
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o Neutral sodium fluoride
o Acidulated phosphate fluoride
o Stannous fluoride
o Amine fluoride

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INDICATIONS
o Past caries experience & incidence
o Number of initial smooth surface lesions
o Dietary factors
o Microbiological factors
o Salivary & tooth factors
o Age
o Oral hygiene & attitude

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FLUORIDES
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F-
DEPTH RELATED TO
o CONCENTRATION
o TREATMENT TIME
o Ph
o TYPE OF FLUORIDE
AGENT
o TEMPERATURE
Tandon S. Preventive control to caries approach: Fluorides. Textbook of Pedodontics. 2nd Ed. New Delhi;Paras Medical Publisher; 2008.p 258-65.

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AQUEOUS SOLUTIONS
GEL
FOAM
VARNISH
o Easily prepared
o No need for continuous wetting
o 2/4 quadrants simultaneously
o Hazards of accidental ingestion
o Much lighter- require small amt
o Surfactant-lowers surface tension- better
INTRPROXIMAL penetration
o Increased time of contact
PAINT ON TECHN
TRAY TECHNIQUE

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Minimum of four applications with a 2% (9200 ppm)
sodium fluoride solution gives a caries reduction of 30%
METHOD OF PREPARATION:
It is prepared by dissolving 20 gms of NaF powder in 1L of
distilled water in a plastic bottle

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KNUTSONS TECHNIQUE
o Teeth cleaned with pumice
slurry
o isolated with cotton rolls,
dried with compressed air
o cotton-tipped applicators
used to paint 2% NaF -all
tooth surfaces are visibly wet
o solution allowed to dry for 3-4
min

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KNUTSONS TECHNIQUE
o Procedure repeated for each of the isolated
segments until all the teeth are treated
o 2nd, 3rd and 4th fluoride application- scheduled at
intervals of approximately one week
o The four-visit procedure recommended for ages 3, 7,
11 and 13 years- coinciding with the eruption of
different groups of primary and permanent teeth

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Applications of 8% (19500ppm) stannous fluoride solution
gives a caries reduction of 30%
METHOD OF PREPARATION:
o Solutions of stannous fluoride-not stable due to the
formation of tin hydroxide.
o Fresh solution of stannous fluoride be prepared for
each patient
o To prepare 8% stannous fluoride solution, 0.8 grams of
stannous fluoride is dissolved in 10 ml of distilled water
in a plastic container

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MUHLER’S TECHNIQUE
o Each tooth surface
cleaned with
pumice for 5 to 10
seconds
o Stannous fluoride
applied
o solution is kept
for 4 minutes
o Dental floss
passed between
interproximal
areas
o Repeat applications-every 6 months/more frequently if patient
susceptible to caries

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Applications of 1.23% (12300 ppm)solution gives a caries
reduction of 28%
METHOD OF PREPARATION: aqueous solution prepared by
dissolving 20 gm of NaF in 1L 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%
Brudevold’s solution
For APF gel, a gelling agent methylcellulose/hydroxyethyl
cellulose added to solution

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TECHNIQUE
o Oral prophylaxis is
done
o Teeth to be
treated isolated
and thoroughly
dried with air
o Application of
(gels) using trays
that fit upper &
lower arches

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TECHNIQUE
o Saliva ejector is used to evacuate the stimulated
saliva and excess fluoride
o Patient is instructed to not eat, drink or rinse his
mouth for atleast 30 minutes
o Minimum amt of fluoride gel for complete coverage
of the tooth surfaces to be dispensed
o Repeat applications-every 6 months/more
frequently if patient susceptible to caries

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DURAPHAT: viscous yellow material, containing 22,600
ppm fluoride as sodium fluoride in a neutral
colophonium base
FLUORPROTECTOR:clear polyurethane based product
containing 7000 ppm fluoride from difluorosilane
Increase time of contact between enamel & topical
fluoride- deposition of fluorapatite & fluorhydroxyapatite
CAREX: Containing 1800ppm fluoride as sodium
fluoride

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Following oral prophylaxis, teeth dried
Application done with single tufted brush
Patient asked to keep mouth open for 4 mins
Patient asked not to rinse/drink – I hr

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CLINICAL APPLICATIONS
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Pumicing /professional prophylaxis removes fluoride rich layer of enamel
Prophylactic pastes containing fluoride to be avoided prior to acid etching
procedures
Topical fluorides – not used in open cavities –DECREASED Ph & FLUORIDE
BOMBS
Osmunson B. Editorial Water fluoridation intervention: dentistry's crown jewel or dark hour? Fluoride 2007;40(4):214-221.
Important to apply topical fluorides after procedures such as interproximal
stripping
FLUORIDE BOMB

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o Dentifrices
o Mouth rinses
o Gels
Frequent source of fluoride in low concentrationDentifrice Recommendations
o Below 4yrs - Not recommended
o 4-6yrs - Once daily with fluoridated & twice
with non fluoridated
o 6- 12 yrs - Twice with fluoridated & once with
non fluoridated
o Above 12 yrs - Thrice with fluoridated dentifrice
Mouthrinse - NaF, APF, SnF2 – reduced caries by 20 – 50%
o Non prescribed mouth rinse 0.05%NaF (225ppm)
Once a day
o Prescribed mouth rinses 0.2%NaF (900ppm)
Once a week
Swished – 1 min
Tandon S. Preventive control to caries approach: Fluorides. Textbook of Pedodontics. 2nd Ed. New Delhi;Paras Medical Publisher; 2008.p 258-65.

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0-3 YRS
3-17 YRS 17 YRS & ABOVE
FLUORIDATED
WATER
FLUORIDATED
WATER
FLUORIDATED
WATER
FLUORIDE
DENTIFRICE
FLUORIDE
DENTIFRICE
PROFESSIONAL
TOPICAL
PROFESSIONAL
TOPICAL
FLUORIDE ORAL
RINSE
SUPPLEMENTS
FLUORIDE ORAL
RINSES
LOW
HIGH
FLUORIDE
DENTIFRICE

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0-3 YRS
3-17 YRS 17 YRS & ABOVE
FLUORIDE
DENTIFRICE
FLUORIDE
DENTIFRICE
PROFESSIONAL
TOPICAL
PROFESSIONAL
TOPICAL
FLUORIDE ORAL
RINSE
SUPPLEMENTS
FLUORIDE ORAL
RINSES
LOW
HIGH
FLUORIDE
DENTIFRICE
DIETARY
SUPPLEMENTS
DIETARY
SUPPLEMENTS

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o Fluoride chewing gum
o Fluoride containing dental floss
o Fluoride impregnated prophylaxis paste & cup
o Iontophoresis
o Dental cements
o Pit & fissure sealants
o Fluoride containing amalgams
o Fluoride containing alginates

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o Introduction
o Historical evolution as caries preventive agent
o Mechanism of action
• Antimicrobial activity
• Antiplaque activity
o Modes of administration
o Advances in chlorhexidine applications
o Fluoride chlorhexidine combination
preparations
o FluOride Vs Chlorhexidine

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Chlorhexidine a gold standard in chemical plaque control
outstanding bacteriostatic and bactericidal
properties
Effective on both gram positive and gram negative
bacteria
Peter S. Plaque control. Essentials of preventive and community dentistry. 3rd ed. New Delhi: Arya publishing house; 2007 p 432-51.

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CHEMICAL STRUCTURE
Symmetrical molecule consisting of 2 chlorophenyl
rings and 2 bisguanide groups connected by a central
hexamethylene bridge
strongly basic & dicationic at ph levels above 3.5 with
positive charges on either side of hexamethylene
bridge
the Dicationic nature of chlorhexidine makes it
extremely interactive with anions, which is relevant
to its efficacy

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First report of Antiplaque activity – Schroeder 1962
1970, Loe & Schiott – use of 0.2% Chlorhexidine gluconate twice
daily as mouthrinse
Total inhibition of plaque formation
1947 - study to synthesize new antimalarial agents led to
the development of the polybiguanides

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ANTIMICROBIAL ACTIVITY
Bacteriostatic at low conc; bactericidal at high conc
Wide spectrum – gram positive and gram negative
bacteria, yeasts, dermatophytes & lipophilic yeasts
"membrane-active agents" , acts on the cell
membrane to increase its permeability and
facilitate the release of intracytoplasmic material

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-vely charged PO4 grps
on microbial cell wall
CHLORHEXIDINE
Leakage of vital
cell elementsCell lysis/coagulation

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Long lasting bacteriostatic action, also termed as
‘substantivity’
Its action lasts for about 12 hours in the oral
cavity after a single rinse
Not to be used before/ immediately after using
toothpaste – interaction with anionic surfactants
The Dicationic CHX molecule, attaches to the pellicle
by one cation, to the bacteria attempting to
colonize the tooth surface with the other. This is
called the ‘Pin-Cushion Effect’

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+
+
PIN CUSHION EFFECT

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ANTIPLAQUE ACTIVITY
Blocking of the acidic group of salivary glycoproteins
reduce their adsorption to hydroxyapatite and
formation of acquired pellicle
The ability of bacteria to bind to tooth surface
reduced by adsorption of CHX to the extracellular
polysaccharides of their capsule

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Mouth rinse- aqueous/ alcohol solutions of 0.2%
[Peridex, Periogard, Periosol]
Advanced applications
o Sprays [Hibispray}
o Varnishes
o Chewing gums
o Subgingival plaque control [Periochip]
Gels
Tooth pastes

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USUAL DOSAGE - 15ml (1 tablespoon) of undiluted
chlorhexidine oral rinse
Recommended use - twice daily oral rinsing for 30
seconds after tooth brushing
Patient should be instructed not to rinse with water or
brush teeth or eat immediately after CHX oral rinse
ADVERSE EFFECTS
o Discolouration of teeth, the tongue, restorations,
and dentures

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o FLUORIDE – Prevent dental caries
Autio-Gold J. The role of chlorhexidine in caries prevention. Operative Dentistry 2008;33(6):710–6.
o CHLORHEXIDINE – Powerful inhibitor of ginigivitis &
plaque formation
COMPATIBILITY
“SUGGESTIVE BUT
INCOMPLETE”

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LOCATION OF ACTION
ANTI MICROBIAL SPECTRUM
EVIDENCE BASED EFFICACY
AVAILABILITY & DEGRADATION
PATIENT COMPLIANCE
TOXICITY
USAGE RECOMMENDATIONS
BACTERIAL RESISTANCE COST EFFECTIVENESS
MECHANISM OF ACTION

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MECHANISM OF
ACTION
INHIBIT
DEMINERALIZATION
PROMOTE
REMINERALIZATION
SUPRESSION OF
S. MUTANS
PREVENTION OF
FORMATION OF
BACTERIAL
BIOFILM

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LOCATION OF
ACTION
SUPERFICIAL
NOT
INCORPORATED
IN TOOTH
INTERNAL
INCORPORATED
IN TOOTH

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ANTIMICROBIAL
SPECTRUM
NARROW
ENZYME
INHIBITION
BROAD
SPECTRUM
CELL LEAKAGE &
COAGULATION
BACTERIOSTATIC
BACTERICIDAL

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USAGE
RECOMMENDATIONS
LONG TERM USE
LOCAL
APPLICATION>
SYSTEMIC
APPLICATION
INTERMITTENT
SHORT TERM
USE

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BACTERIAL
RESISTANCE
MICOORGANISMS
DEVELOP
RESISTANCE
(REVERSIBLE)
RESISTANCE IN
MICROORGANIMS
NOT
DOCUMENTED
Santos A. Evidence-based control of plaque and gingivitis. Journal of Clinical Periodontology 2003;30 Suppl 5:13–6.

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TOXICITY
FLUOROSIS
ACUTE/CHRONIC
TOXICITY
EXCRETED
ALMOST 100%

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AVAILABILITY &
DEGRADATION
• SALIVARY
RESERVOIR
• SMALL SIZE OF
MOLECULE
• INORGANIC
MOLECULE –
NOT DEGRADED
• SUBSTANSIVITY
• LARGE SIZE OF
MOLECULE
• ORGANIC
MOLECULE -
DEGRADES

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EFFECTIVE DELIVARY
METHOD
ALL TOPICAL –
SIMILAR CARIES
PREVENTION
VARNISH
GELS
MOUTHWASH
Emilson CG. Potential efficacy of chlorhexidine against mutans streptococci and human dental caries. Journal of Dental Research 1994;73(3):682–91.
Marinho VC, Higgins JP, Logan S, Sheiham A. Topical fluoride (toothpastes, mouthrinses, gels or varnishes) for preventing dental caries in children and adolescents.
Cochrane Database of Systematic Reviews 2003, Issue 4.

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PATIENT
COMPLIANCE
MYRIAD
INNOVATIVE
DELIVARY SYSTEMS
NEW DELIVERY
SYSTEMS NOT
POPULARLY
MARKETED

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COST
EFFECTIVENESS
WATER
FLUORIDATION
DENTIFRICE
MOUTH RINSE –
NOT ECONOMICAL

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EVIDENCE BASED
EFFICACY
EVIDENCE-
“SUGGESTIVE
BUT
INCOMPLETE.”
ESTABLISHED
EVIDENCE
BASED METHOD
Santos A. Evidence-based control of plaque and gingivitis. Journal of Clinical Periodontology 2003;30 Suppl 5:13–6.

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DEVELOPMENT AND
APPLICATION OF
EFFECTIVE ANTICARIOGENIC
AGENTS
USE OF AGENTS TO BE JUSTIFIEDFOUNDATION OF PREVENTION
FOR MODERN
ORAL PREVENTIVE
HEALTH CARE
EVIDENCE BASED
o SUPPORTED BY CONCLUSIVE
LITERATURE
o LONG TERM CLINICAL
STUDIES
o GOOD ORAL HYGEINE
o DIET MODIFICATION

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o Ismail Al, Hasson H. Fluoride supplements, dental caries and fluorosis. A
systematic review. Journal of the American Dental Association
2008;139(11):1457–68.
o Beazly VC, Thrane P, Rölla G. Effect of mouthrinses with SnF2, LaCI3, NaF and
chlorhexidine on the amount of lipoteichoic acid formed in plaque.
Scandinavian Journal of Dental Research 1980;88(3):193–200.
o Emilson CG. Potential efficacy of chlorhexidine against mutans streptococci
and human dental caries. Journal of Dental Research 1994;73(3):682–91.
o Marinho VC, Higgins JP, Logan S, Sheiham A. Topical fluoride (toothpastes,
mouthrinses, gels or varnishes) for preventing dental caries in children and
adolescents. Cochrane Database of Systematic Reviews 2003, Issue 4.
o Santos A. Evidence-based control of plaque and gingivitis. Journal of Clinical
Periodontology 2003;30 Suppl 5:13–6.

66
o Wong MC, Glenny AM, Tsang BW, Lo EC, Worthington HV, Marinho VC.
Topical fluoride as a cause of dental fluorosis in children. CochraneDatabase
of Systematic Reviews 2010, Issue 1.
o Murray JJ, Rugg-gunn AJ, Jenkins GN. Anticaries mechanisms of fluoride.
Fluorides in caries prevention. 3rd Ed. Butterworth- Heinemann 1991.p
o Eberhard J et al. Chlorhexidine versus topical fluoride treatment for the
prevention and management of dental caries in children and Adolescents.
Cochrane Database of Systematic Reviews 2012, Issue 7.
o Autio-Gold J. The role of chlorhexidine in caries prevention. Operative
Dentistry 2008;33(6):710–6.
o Tandon S. Preventive control to caries approach: Fluorides. Textbook of
Pedodontics. 2nd Ed. New Delhi;Paras Medical Publisher; 2008.p 258-65.

67
o Rao A. Fluorides. Principles and Practice of pedodontics. New Delhi: Jaypee
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The role of fluoride and chlorhexidine in the prevention of dental caries

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