5. History
Dr. Fredrick Mc.Kay (Dentist)
noticed that the patients having
stained teeth & he named it as
Mottled Enamel.
Fluorides & Its role started
beginning of the 20th century.
1901
Local inhabitants given the
name as Colorado stains.
6. 1908
Mc collum studying elements
known to occur in teeth. He
noticed Fluoride is one of the
element . But not able to relate.
1925
In Brilton, South Dakota, a
study revealed uniform
mottling.
1916
Dr. Fredrick Mc.Kay invited
Dr. G.V. Black to carry out
local survey.
7. 1928
1931
Bauxite, noticed high incidence
of high mottling teeth.
Churchill H.V. Chief Chemist.
Bauxite water send for analysis
Churchill noticed that Fluoride
was present in Bauxite at a level of
13 ppm after thorough Spectra
graphic analysis of rare elements.
8. During this period H. T. Dean also conducted
survey and noticed that wherever fluoride is
their drinking water and severity of
discoloration of teeth. Later he introduced
Fluorosis index.
9. Various Concentrations of Fluoride & Their Effects
on Human Health
Concentration Effect
0 – 0.7 ppm
0.8 – 1.2 ppm
2 – 8 ppm
> 8 ppm
2.5 – 5 gms.
Prone to get DC
Optimum level
Dental fluorosis
Skeletal fluorosis
Lethal dose
10. The relationship between caries experience (---),
Dental fluorosis (---) & the fluoride concentration of
drinking water.
0
1
2
3
4
5
6
7
8
Water (F), ppm
Caries
Experience
per
child
0.2 1 2 3
0
1
2
Fluorosis
index
Optimum F level
0.8-1.2ppm
11. Occurrence of
Fluoride
Fluoride is the most electronegative
of all chemical element and is
therefore never encountered in
nature in the element form.
12. Fluoride in Soil
Fluoride may occur in combined
form in a wide variety of minerals, -
Fluorspar, Cryolite, Appetite, Mica
and Hornblende.
13. Fluoride in Water
Water contains fluoride in varying
Concentration.
- 2800 mg/liter - soil at lake shore - 5600mg/ltr.
The highest natural fluoride
concentration found in water is in
lake nakura in the Rift Valley in
Kenya.
Sea water contains 1-1.4 p.p.m.
14. Fluorides are also widely distributed
in the atmosphere from the dusts of
fluoride containing soil, gaseous
industrial waste, the burning of coal
fires and from the gases emitted in
areas of volcanic activity.
Fluoride in Air
15. Fish products - canned fish such as
salmon and sardines have a
fluoride content up to 40 mg/kg.
Beer contains 0.3 to 0.8 mg/ltr.
Food And Drinks
Tea leaves contain high
fluoride up to 400 mg/kg.
Wine 6 - 8 mg/ltr.
16. Metabolism
(Absorption, Retention & Excretion)
Ingested fluoride is absorbed mainly from the
stomach. Absorbed fluoride is transported in
the plasma, and reaches the plasma level within
the 30 minutes and is either excreted or
deposited in the calcified tissues. Most
absorbed fluoride is excreted in the urine.
18. Hours
Typical plasma fluoride concentration curve after the ingestion of
a small amount of the ion. The major determinants responsible
for the shape of the curve are shown.
19. Mechanism of Action
of Fluoride
Fluorides action in preventing caries is multi
factorial, it effects come from a combination of
several mechanism. Principal mechanisms by
which fluoride is considered to inhabit dental
caries as
2. Inhibition of glycolysis, the process by
which cariogenic bacteria metabolize
fermentable carbohydrates.
1. Promoting remineralization and inhibiting
demineralization of early carious lesions.
Post eruptive
20. 1. During the tooth development and at the
time of enamel maturation, the fluoride
reacts with the hydroxyapatite crystal and
forms fluoroapatite crystal which is
resistant to acid dissolution (attach).
Pre-eruptive
3. Some reduction in enamel solubility in acid by
pre-eruptive incorporation of fluoride into the
hydroxyapatite crystal.
Fluoride and enamel
21. Ca10(PO4)6(OH)2
2. It may enter the dental plaque and there
effect the bacteria by depressing their
production of acids and thus reducing the
process of demineralization.
(Anti enzymatic action on bacteria)
It reacts with the mineral element on the
surface of the teeth to make more insoluble
to the acid end products of bacterial
metabolism.
Hydroxyapatite Fluorhydroxyapatite
CaF + Ca10(PO4)2(OH)2+F
+ F
Fluoride and plaque
22. Changes morphology of tooth.
4. It also makes the deep pit and fissure as
shallow.
3. It facilitates the remineralization (Repair)
of teeth that has been slightly
demineralized by acid end products.
23. Ways of Administration
of Fluorides
1. Systemic administration
Water fluoridation
Fluoride Tablet
Milk fluoridation
Salt fluoridation
b) School W.F. 4 to 5ppm
a) Community W.F. 0.8 to 1.2
24. 2. Topical application
a) Fluoride rinses
Application
- NaF
- APF
- SnF
d) Gels & Solution
c) Pastes
b) Dentifrice's
25. Systemic Administration
Systemic methods are those in which fluoride
is ingested and the un erupted teeth are the
targets of fluoride activity.
Systemic fluorides
are through
Tablets
Milk
Salt
Water
26. Water Fluoridation
The upward adjustment of concentration of
fluoride ion in a public water supply in such a
way the conc. of fluoride in the water maintain
constantly at 1ppm.
First water fluoridation started in the year 1945
in four cities in USA.
Grand Rapids, Newburgh, Evanston,
Brantford.
Cold climate - 1.2 ppm
Hot climate - 0.8 ppm
27. Pre-requirements of Water
Fluoridation
1. Presence of Caries in the community /
public.
5. Installation & Maintenance cost
4. Community acceptance / approval
3. Centralized water supply to the community
2. Level of fluoride concentration in their
drinking water.
28. Material Used In Water Fluoridation
Dry compound such as Ammonium silica
fluoride, Fluorospar, Sodium silica fluoride.
Solution of hydro fluoro silicic acid.
3. Saturation method
2. Solution feeder
1. Dry feeder
Three types of Fluoride equipment
29. Fluoride is added to the water, after it is
purified and before it is ready for
consumption, with the help of Fluoride
equipment.
Constant monitoring is required once the
water is fluoridated to maintain the constant
level of fluoride i.e., 0.8 to 1.2 ppm.
30. Dental Benefits of Fluorides
There are several ways to evaluate cost health
benefit. They can be assessed on the basis of
better dental health or based on the amount of
money that is saved through prevention.
1. Various studies showed that caries
reduction in deciduous teeth was between
40 to 50 percent.
31. 2. For permanent teeth caries reduction was
50 to 60%. The reduction is greater on
smooth surface of the tooth than pit and
fissure areas.
5. Orthodontic problems are approximately 20
% less in preventive among children 6 to 14
yr. of age.
4. 75% reduction in prevalence of extraction
of first Molar teeth.
3. Stamm & Bunting showed lifelong
consumption of fluoride reduces root
caries.
6. There is about 95% less prevalence of inter
proximal caries.
32. Osteo porosis and thinner
trabaculation of bone. Fractures of
bone is significantly less in Fluoridated
area, than non fluoridated.
Non - Dental Benefits
33. The limitation of water fluoridation raised,
where there is no central piped water supply to
the Community / Public, in spite of enormous
and consistent evidence showed on the caries
prevention.
Other Systemic Administration
of Fluorides
Various dietary components have been tried
as alternative to water fluoridation in order to
provide a continued systemic ingestion of
Fluoride.
34. Salt Fluoridation
First Fluoridated salt was introduced in
Switzerland in 1955. Experiments have been
conducted with concentration of fluoride in
salt ranging from 90 mg of fluoride per kg. salt
to 200 - 350 mg/kg. Initial clinical trial of
90mg/kg fluoride salt showed 20 - 25% of
reduction of dental caries.
35. Preparation of Fluoridated salt
1) Fluoride is added to salt by spraying
concentrated solutions of sodium
fluoride or potassium fluoride.
2) Premixed granules of NaF and CaF2
with PO4 carrier are added to common
salt.
36. Advantages
2) Economic
1) No Supervision required
1) Variation in individual consumption.
Disadvantages
2) Less Sodium (Na) in take to help
control Hypertension.
37. Practicability of salt Fluoridation in
INDIA
Salt fluoridation appears to be viable and
feasible method because
3) Even lowest community can effort the
common salt
2) Individual monitoring is not required
1) Easily monitored the supply of salt to
those areas where there is no fluoride in
water supply.
38. Milk Fluoridation
Milk is another vehicle through which
fluoride can be incorporated systemically.
Benoczy from Hungery 1 ppm of
fluoride milk reduction 74% D.C. in
deciduous teeth.
Rusoff from USA reported with
3.5mg/liter 35% reduction of D.C.
Inamura from Japan 2.5 mg/liter &
noticed, Dental caries reduction by
35%
Concentration of Fluoride used in milk.
In 1959,
In 1962,
In 1983,
40. Fluoride Tablets
- 1.00 mg/day
2.2 mg of NaF Can be taken in night to
maintain high level in Saliva as Glomerular
filtrate is less during sleep -- Reduction of D.C.
20 - 40%.
Dosage 0 - 1 yr. - 0.25 mg/day
1 - 2 yr. - 0.50 mg/day
3 - 12 yr.
41. Topical Fluorides
The topical fluorides refers to the use of
systems containing relatively large
concentration of fluoride that are applied
locally or topically, to erupted tooth surface to
prevent the occurrence of dental caries.
42. Topical fluorides are applied directly to
erupted tooth and exerts their effect at or near
to the tooth surface. The anti-cariogenic
(Protective) effect may vary depending on the
agent used, its concentration and frequency of
applications.
Mechanism
It reacts with the mineral element on the
surface of the teeth to make more insoluble to
the acid end products of bacterial
metabolism.
43. It facilitates the remineralization (Repair) of
teeth that has been slightly demineralized by
acid and end products.
45. Fluoride Dentifrice's
The term ‘dentifrice’ derived from the Latin
word ‘dens’ = tooth ; ‘fricare’ = to rub.
4) Flavoring Agents.
3) Coloring Agents
2) Detergents
1) Abrasive Agents
Basic Composition of a tooth pastes are :
46. A part from these, Fluoridated tooth
pastes contain fluoride agents like
Sodium Mono Fluoro Phosphate.
- OR -
NaF
SnF2
47. Concentration of fluoride in fluoride dentifrice
ranges from 800ppm to 1500ppm.
Various studies showed, through the use of
fluoride tooth pastes, reduction of dental
caries was 20-30%
Caries Reduction
Supervision is necessary when children are
using fluoride dentifrice's.
Recommendation to Children.
48. This is another method of administration of
topical fluorides by person himself.
Mouth rinses are available either for daily
usage or for weekly usage. The concentration
of fluoride in mouth rinses ranges from 200-
1000ppm.
Mouth rinses are not recommended for
Children.
Studies showed caries reduction by using
mouth rinses is 20 -30%
Mouth Rinsing
50. -Operator Administered
These are high concentrated fluorides ranging
from 10 to 23 gms of fluoride/ltr. These topical
fluorides administered locally on to the tooth
surface either by dentist or by dental
auxiliaries.
Topical Fluorides
52. Sodium Fluoride
Available both in powder and liquid form. The
compound recommended for use is 2%
solution.
The 2% NaF is prepared by dissolving 0.2gms
of powder in 10ml of distilled water.
The solution is stable if stored in Plastic
Containers.
53. Application of NaF
Solution
The application of 2% NaF topical fluoride is
also called as Knutson’s Technique. The
procedure is as follows.
The duration of application is 3 - 4mts.
Then apply the NaF solution with the help of
cotton.
Drying
Isolation of quadrants
Prophylaxis.
54. Recommended Patients
Children at ages of 3,7,11 and 13.
Adults with active caries.
Adults with exposed root surfaces.
Recommended Practice
A series of FOUR application at ages specified
above.
(3,7,11 & 13 yr..)
55. Advantages of NaF
Application
1) Acceptable taste.
Disadvantages
1) Procedure requires FOUR visits to
the dentist in a relatively short period of
time.
2) Stable if stored in plastic container and
refrigerated.
56. Stannous Fluoride
Available either in powder or in liquid form.
The recommended application of SnF2 for
topical application is 8 % solution.
The preparation of 8% solution is by
dissolving 0.8gms of powder in 10ml of
distilled water.
57. Children at ages 2 through 15.
Adults with active caries.
Adults with exposed root surfaces.
Single application at 6 to 12 month intervals.
Recommended practice
Recommended patients
59. SnF2
Disadvantages
1) Bitter metallic taste.
5) Staining at margins of restorations.
4) May cause reversible tissue irritations.
3) Not stable in solution.
2) Need to be freshly prepared for each
application.
60. Acidulated Phosphate Fluoride Gel
(APF Gel)
1) NaF
Composition
4) Gelling agent like Methyl Cellulose or Hydroxy
ethyl cellulose.
3) Hydrofluoric Acid
2) Phosphoric Acid
61. Preparation
Dissolve 20mgs of NaF in 1 ltr of 0.1m
Phosphoric acid. To this add 50% Hydrofluoric
acid to adjust pH at 3 & fluoride concentration
at 1.23 %.
Solution
For the above preparation add gelling agent
and here pH is adjusted between 4 - 3.
APF Gel Preparation
62. Recommended
Patients
Children ages 2 through 12.
Adults with exposed root surfaces.
Adults with active caries.
Recommended Practice
Single application at 6 to 12 month
intervals. Total of 28 applications.
64. Toxicity of Fluorides
Fluorides are extensively used in the practice
of Dentistry to reduce the incidence of Dental
caries.
Probable toxic dose (PTD) is 5mg/kg body
weight.
Used in excessive quantities, F. can produce
toxic and even lethal outcome when ingested,
inhaled or absorbed in to the body.
65. Toxicity of Fluoride
Acute Toxicity Chronic toxicity
A single large dose
2.5 - 5 gram
More than optimum
level for longer
duration
Dental fluorosis
2 - 8 ppm
(0 year to 10year)
Skeletal fluorosis
More than 8 ppm
for 10 - 20yrs of
any age
66. Symptoms of Fluoride Toxicity
1) When F. Salts contact with moist skin or
mucous membrane, Hydrofluoric acid forms
cause chemical burn.
4) A hyperkalemia occurs that contribute to
cardio toxicity.
3) It binds calcium that is needed for nerve
action.
2) It is generally protoplasmic poison that acts
to inhibit enzyme system.
Fluoride acts in Four general ways
67. Following ingestion of Fluoride, nausea and
vomiting can occur. It is due to Production of
Hydrofluoric acid in the acid environment of
stomach, causes irritation of the stomach wall.
This can be accompanied by abdominal
cramps and pain.
• Local or general signs of muscle tetany
ensure due to the drop of blood calcium.
68. Finally, hypocalcemia and hyperkalemia
intensity results in either coma, convulsions
or cardiac arrhythmia's.
Treatment of F. Toxicity
1. Immediate treatment
4. Maintenance of blood calcium level with I.V.
Calcium.
3. Protection of stomach by binding F with
orally Administered calcium.
2. Induced vomiting
- Four actions.
69. Dental Fluorosis
Dental Fluorosis is disturbance affecting the
Enamel during formation of the teeth due to
the presence of Fluoride in EXCESS in the
drinking water hence, all damage occurs
before eruption of the teeth.
Normal Fluoride level is 0.8 to 1.2 ppm.
Mottling starts from 2ppm concentration of
Fluoride. Dental Fluorosis is an Endemic in
certain geographically well defined area.
70. - Symmetrical, bilateral involvement of lesion
of teeth. The lesions may be a white
opacity of enamel or Brownish stains or
pits on enamel.
The characteristic features of Dental Fluorosis.
71. As the Fluoride concentration increases in the
water the Dental caries reduces until the score
on Dean’s index reaches 4 or 5., then caries
increases when the teeth are effected severely.
The increase in caries associated with loss of
integrity of the enamel and exposure of
underlying dentine. Several concepts may be
relevant to the etiological mechanism of
Dental Fluorosis.
72. 2. The maturation of enamel is delayed, and
the general meneralization process may be
inhibited, perhaps through interference with
nucleation and crystal growth - In addition
calcium homeostatic mechanism may be
affected.
1. The enamel forming cells, the
ameloblasts are effected.
73. Dean’s Index
(Dental Fluorosis, Mottled Enamel)
Dental fluorosis appears as enamel alteration
resulting from toxic damage to the
ameloblasts by fluoride during enamel
development. The distribution of mottling is
symmetrical and corresponding to the
chronology of enamel development.
74. Labial tooth surface are more severely
affected than oral surfaces. Maxillary anterior
teeth generally exhibit more pronounced
mottling than do mandibular anterior teeth.
It is recommended that the Dean’s Index
criteria be used. The recording is made on the
basis of two teeth that are most affected, i.e.
the score recorded must apply to two teeth.
75. 1 : Questionable, The enamel
shows slight aberrations from
the translucency of normal
enamel, which may range from
a few white flecks to
occasional spots. This
classification is used where
the classification ‘normal ’ is
not justified.
The Criteria of scoring is :
0 : Normal, The enamel surface is
smooth, glossy and usually a
pale creamy-white colour.
76. 2 : Very mild, Small opaque
paper-white areas scattered
irregularly over the tooth but
involving less than 25% of
the labial tooth surface.
3 : Mild, the white opacity of
the enamel of the teeth is
more extensive than in
category 2, but covers less
than 50% of the tooth
surface.
77. 5 : Severe, The enamel surface
is badly affected and
hypoplasia is marked that
the general from of the tooth
may be affected. There are
pitted or worn areas and
brown stains are widespread;
the teeth often have a
corroded appearance.
4 : Moderate, The enamel
surfaces of the teeth show
marked wear and brown stain
is frequently a disfiguring
feature.
78. Skeletal Fluorosis
Elevated intake of fluoride over a prolonged
period of time may result in skeletal Fluorosis
i.e., an accumulation of fluoride in the skeletal
tissue associated with pathological bone
formation.
The chronic toxic effects of fluoride on the
skeletal system have been described from
certain geographical regions of the world
where drinking water contains excessive
natural fluoride.
79. Water Defluoridation
It can be defined as downward adjustment of
fluoride ion concentration in a public water
supply in such a way that the fluoride ion
concentration in the water may be constantly
maintained at 1ppm by weight.
Definition
Its a process of removing excess fluoride
naturally present in water supply in order to
prevent dental Fluorosis or more severe
disability.
- OR -
80. Punjab, Hariyana, Rajasthan, Gujarat, Madya-
Pradesh, Andhra-Pradesh, Tamil-Nadu,
Karnataka.
• Based on addition of Chemicals to water
during treatment.
• Based on ion exchange process OR
Adsorption.
Methods of Defluoridation.
States With High Fluoride Belt
(Endemic Fluoride Belts)
81. Ion Exchange Method
processed Bone, Natural or Synthetic
Tricalcium Phosphate, Hydroxyapatite,
Magnesia, Activated Alum, Activated carbons
& Ion Exchangers.
In this method the materials used are
• Cation Exchange Resins
• Anion Exchange Resins
82. 1) Defluoron - 1 : Sulphonated saw dust
with 2% Alum solution.
i.e., Saw dust is treated with sulfuric acid
and this sulphonated product is soaked in
Alum solution for 2Hrs. Later it is washed
to remove excess Alum.
Cation Exchange Resins
4) Defluoron - 2 : Sulphonated coal and
works on Aluminum cycles.
3) Magnesia
2) Carbon - A good cation exchange resin
83. Is one of the Defluoridation method to remove
excess fluoride concentration in drinking
water in small scale.
Nalgonda Technique
• This technique is useful for domestic & for
Community water supply.
• Bleaching powder ensures Disinfection.
• Sodium Aluminate or Lime Hastens
settlement of precipitate.
• In this method addition of in sequence of
sodium Aluminate / Lime, Bleaching powder
& Filter alum to water.
84. A container of 20 - 50 ltr. is suitable.
The Lime and Bleaching powder are sprinkled
into the water & mix thoroughly.
Alum solution then poured, stirred for 10min.
i.e., 50 ltr. water with 8ppm - for this 510mg/lt.
Lime, 1mg/lt Alum is added.
After adding these material allow one hour and
later clear water is with drawn.
Domestic Treatment
85. Fill & Draw Type Defluoridation
Plant For Small Community
For Community with population ranging from
200 - 2000, A Defluoridation plant is used.
Plant consists of cylindrical tank with a depth
of 2mts. Diameter based on quantity of water.
Stirring mechanism is either hand operated or
power driven.
Raw water is pumped into the plant &
bleaching powder, Lime & Alum are added.
86. Contents are stirred for 10mins. and allowed to
settle for 1 -2 hrs. Settled sludge can be
discarded and the defluoridated water is
supplied.
• Semi - skilled operator is enough to operate.
• Plant can be located in open with
precautions to cover the motor.
• Material cost is less and they are easily
available.
• Entire operation is completed by 4hrs. & 3
batches of defluoridated water can be
obtained in a day.
Advantages
87. Current Status of Defluoridation
• Incidence of Fluorosis
• Information on Fluoride levels
Pre - Requisites of comprehensive plan for
deflouridation.
• Defluoridation has not received much
attention due to Non-availability of
techniques.
