14-topical fluorides - part 2 advanced.pdf

CONTENTS
Introduction
Professionally applied Topical fluoride (preparation, application, mechanism of action)
Sodium fluoride
Stannous fluoride
Acidulated phosphate fluoride (APF)
Fluoride Varnishes
Fluoride containing restorative materials
Fluoride control release devices
2
topical fluorides

SELF-APPLIED TOPICAL FLUORIDES
Fluoride Dentifrices
Fluoride Mouth rinses
Fluoride Gels
Fluoride chewing gums
Fluoridated toothpicks, dental tape & dental floss
Fluoridated artificial saliva
Conclusion
Bibliography
3
topical fluorides

topical fluorides 4
PROFESSIONALLY APPLIED
TOPICAL FLUORIDES
REVISION

CLASSIFICATION OF
FLUORIDES IN DENTISTRY
topical fluorides 5
1.PROFFESSIONALY APPLIED-
Sodium Fluoride-2%
Stannous Fluoride-8% and 10%
Acidulated Phosphate Fluoride-1.23%
FLUORIDE VARNISHES-
1. Duraphat-2.26%
2. Fluorprotector- 0.7% silane fluoride
2.SELF APPLIED-
Dentifrices
Fluoride mouth rinses
Fluoride Gels

De Paola 1967
Not recommended
6
topical fluorides

 TOPICAL SOLUTIONS vs GELS
 The use of viscous gels instead of solutions as a vehicle for
topical fluoride reagents has several practical advantages.
 The gel adheres to teeth for a considerable time and
eliminates the continuous wetting of enamel surfaces
required of the operator when solutions are used.
topical fluorides 7

 When trays are used for applying the gel solutions, it is
possible to treat two or four quadrants simultaneously and
this results in a substantial saving of time.
 Fluoride gels (1.23% fluoride) are commercially available.
topical fluorides 8

 FLUORIDE VARNISH- Introduction
 Fluoride varnish have been available for more than 3o years
and are widely used for professional application in caries-
susceptible patients.
 Duraphat, the first commercial varnish, was introduced in
Europe in 1964; it was followed in 1975 by Fluor Protector.
topical fluorides 9

 They may be regarded as slow-releasing or semi-slow-release
agents: prolonged exposure time and high fluoride
concentrations result in the formation of large CaF2
reservoirs, which are available during demineralization and
remineralization.
topical fluorides 10

 AVAILABILITY
1. DURAPHAT: 22.6 mg F/ml
 5% NaF in Colophonium base-available in 10 ml tube.
 1% difluorisilane in polyurethane base (1 mg/ml)
2. FLUORPROTECTOR:
 pH lower than Duraphat and it is available in box with 20
vials-each vial contains 0.4 ml of solution.

 AVAILABILITY
3. DURAFLOUR : 22.6 mg/ml.
 5% NaF in alcoholic suspension of natural resins. Addition of
sweetening agent-xylitol.
4. CAVITY SHIELD:
 5% NaF in resinous base.

 Each pack contains 0.25 ml/0.4 ml depending on number of
teeth to be treated.
 It avoids wastes and improves cost effectiveness. Each
patient gets controlled amount of fluoride and this prevents
over-application.
 It reduces chances of over ingestion and prevents fluoride
toxicity.

 RATIONALE
 After topical fluoride application, there is substantial
leaching of absorbed fluoride from surface enamel.
 To prevent this immediate loss, fluoride has been
incorporated in varnishes that have ability to adhere to
enamel, for long period, and it is hypothesised that it will
slowly release fluoride to the teeth.

 RATIONALE
 The retentive and possible slow release of fluoride from
these products increase the exposure time of the fluoride by
several days, without increasing chairside time, and
presumably allow fluoride to be more permanently bound
to the teeth.

 DURAPHAT
 Duraphat contains 5 wt% NaF (2.26% F)
 Extremely high fluoride- compared to other agents.
 It is viscous, resinous varnish.
 It is supplied in tubes
(10ml or 5×30 ml)for application
with pointed brushes or
 In glass ampoules(5×1.6ml) for
application with a syringe.

 COMPOSITION OF DURAPHAT
 Colourless, polyurethane lacquer.
 The fluoride compound is a difluorosilane(3-methoxy-4
hydroxy-cyclohexyl)-ethyl-difluorohydroxy silane in
concentration of 2% (w).

 Duraphat is sodium fluoride in varnish form containing 22.6
mg F/ml suspended in an alcoholic solution of natural
organic varnishes.
 The active fluoride available is 22,600 ppm.

 TECHNIQUE OF VARNISH APPLICATION
 After prophylaxis, teeth are dried, but not isolated with
cotton rolls as varnish being sticky has a tendency to stick to
cotton.
 A total of 0.3-0.5 ml of varnish equivalent to 6.9-11.5 mg F is
required to cover the full dentition.

 The application is done first on lower arch (as saliva collects
more rapidly around it) and then on upper arch with the
help of single tufted small brush starting with the proximal
surfaces.
 After application the patient is made to sit with mouth open
for four minutes before, spitting to let duraphat varnish set
on teeth which is further enhanced by the moist
environment created by saliva (fluorprotector sets faster
than duraphat).

 The patients should be clearly instructed not to rinse or
drink anything at all for one hour and not to eat anything
solid but take liquids and semisolids only till next morning.
 A special emphasis on instructions is needed to maintain the
contact between Varnish and tooth surfaces for about 18
hours for prolonged interaction between Fand enamel

 Ekstrand et al (1980) found no toxic effects with respect to
fluoride plasma levels or renal function in preschool children
treated with Duraphat.
 This is attributable to the fast-setting varnish base, the slow
release of fluoride over time, and the comparatively small
amounts of he varnish required for selective application to
the key-risk surfaces.

 No frequent or serious side effects reported.
 The varnish should not be applied in contact with bleeding
gingival tissues because of the risk of contact allergy to the
colophonium base.
 Duraphat, particularly when packed in a tube, must be kept
safely from assess of small children.

 FLUOR PROTECTOR
 Fluor Protector is a polyurethane-based varnish containing
0.9 wt% silane fuoride (0.1%).
 The standard standard package consists of :
 50 glass ampoules of Fluor Protector (1ml each)
 1 rubber foot
 one brush holder
 50 disposable brushes
 3 Ampoule breakers

 APPLICATION
 Perform PMTC and dry the tooth surfaces
 The colourless varnish is selectively applied with the
disposable brush or a minipipette.
 The varnish is acidic and hardens in air to a colourless,
transparent film within 2-3 mins.
 It is retained on the teeth as a slow-release fluoride agent
for 1-2 weeks and particularly well retained on the caries-
susceptible posterior approximal surfaces, which are not
subjected to abrasion from chewing.

 MECHANISM
 Compared to Duraphat and Bifluorid 12, the exposure time is
markedly prolonged, and the tooth surface is protected
from direct contact with cariogenic plaque as long as the
varnish film remains.
 In contrast to other fluoride compounds, the silane fluoride
in Fluor Protector varnish is insoluble in water but reacts on
contact with saliva, releasing small amounts of hydrogen
fluoride.
 Because of its considerably higher diffusion coefficient,
hydrogen fluoride penetrates enamel more rapidly and
readily than do fluoride ions.

 This process occurs at the contact area between the varnish
and the enamel, given the necessary traces of moisture
there.
The molecules of hydrogen fluoride that penetrate the enamel
or enamel lesion again react with water in the intercrystalline
fluid and yield fluoride ions
Influence demineralization and remineralization at a greater
depth in the enamel than can be achieved by other fluoride
agents with higher fluoride concentrations.

 No severe side effects have been reported from the use of
Fluor Protector.
 However, the varnish should not be applied in contact with
bleeding gingival tissue to prevent the development of
contact allergy to the polyurethane vehicle.

 BIFLUORIDE 12
 Bifluoride 12 is a clear varnish
 Contains 6% NaF and 6% CaF2
 Which corresponds to 60 mg of each fluoride compound per
1 g of the preparation.
 Only 1 g of the preparation contains 56.3 mg of fluoride.
 However, CaF2 is not water soluble and thus nontoxic.
 The varnish base consists of collodion and an organic
solvent.
•4g or 10g fluoride varnish,
solvent(bottle)
•Special foam pellets for
application.
•A large pack containing 3, 10g
bottles is also available.

 Toxicology tests confirm the safety compared to the most
common varnish bases.
 Bifluoride 12 varnish is not only a cariostatic agent but also
an agent for treatment of hypersensitivity of exposed root
dentin.
 To ensure optimum distribution of particle sizes, it contains
a homogenous mixture of highly dispersed NaF and CaF
particles, between 0.5 and 2.0 mu m in size, which allows
them to penetrate and block the dentinal tubules and even
fill small gaps and spaces around the margins of
restorations, ensuring the formation of CaF2 depots.

 APPLICATION
1. Perform PMTC and tooth surfaces are dried.
2. The bottle is shaken thoroughly to mix the sediment of NaF
and CaF2 completely with the solvent.
3. Varnish is applied with a foam pellet to the selected tooth
surfaces. Because of the low viscosity, only about 0.02 ml is
used per tooth. After 10-20 secs of absorption, the tooth
surfaces are dried with air syringe.
4. Abrasive chewing of food and mechanical toothcleaning
should be avoided for 4 and 24 hours, respectively, after
treatment.

 USE OF FLUORIDATED PROPHYLACTIC PASTES
 The fluoride concentrations of prophylaxis paste for PMTC and
polishing restorative materials range from 0.1% to 1.0%.
 Sodium fluoride is most commonly used agent, but SnF2, AmF and
SMFP are also used.
 Fluoride prophylaxis pastes remove plaque biofilms, polish
restorative materials, and concurrently deliver fluoride. Therefore,
the prophylaxis pastes contain abrasives as well as fluoride.

 Diffusion and uptake of fluoride
by enamel surfaces is reduced in
the presence of substantial and
old dental plaques.
 For this reason, a dental
prophylaxis with a mildly
abrasive paste using a brush or
rubber cup in a dental handpiece
usually precedes topical fluoride
applications.

 Prophylaxis of enamel surfaces results in removal of a
superficial layer of enamel as well as the pellicle (Vrbic et al.,
1967).
 It has been mentioned that surface enamel contains higher
levels of fluoride than is found in internal layers, therefore, a
prophylaxis removes a fluoride-rich layer.
 If prophylaxis pastes containing fluoride are used, the lost
fluoride is replenished and there is a small, but significant,
net gain in the concentration of fluoride [Steams, 1973]

 Fluoride-containing prophylactic pastes currently widely
used in North America include APF-containing pastes which
contain silicon dioxide, or zirconium silicate or insoluble
sodium metaphosphate as the abrasive material [Clarkson
and Wei, 1982].
 Mixing topical fluoride solution such as APF with flour of
pumice for use as a paste is not recommended. The pumice
binds and, therefore, inactivates the fluoride and raises the
pH thereby causing a reduction in fluoride uptake by
enamel.

 A summary of the different fluoride agents commonly used
in clinical practice showing the concentration of fluoride in
each agent. the amount of the agent used and mgs of
fluoride with each application is shown below:

 FLUORIDE IMPREGNATED PROPHYLAXIS CUPS
 Dental prophylaxis cups is been impregnated with fluorides
as additional methods of imparting fluoride to the teeth.
 The temperature of the enamel surface is raised during
prophylaxis procedure because of the friction between
prophylaxis cup and the tooth.
 High temperatures enhance fluoride uptake from topical
fluoride solutions.

 Therefore, if a fluoride impregnated prophylaxis cup is used
during prophylaxis, fluoride would be released from the
prophylaxis cup and be deposited in the outer layer of the
enamel.
 However, when fluoride containing prophylaxis paste is
used, there is no need for using fluoride impregnated
prophylaxis cup.

 FLUORIDE CONTAINING DENTAL MATERIALS & DEVICES
 In 1960 Hallsworth and Weatherell examined sections cut
from two upper permanent incisors with silicate
restorations.
 They reported that sound enamel directly exposed to the
material had a very high fluoride content, whereas that
separated from the silicate by even a thin barrier of dentine
tended to possess the low concentrations typical of interior
enamel.

 They concluded that their findings supported the suggestion that
silicate cements have cariostatic properties, probably due to their
fluoride content which can be as high as 1,30,000ppm.

 Caries along the margins of the restorations is called
secondary or recurrent caries. This is more common in case
of silver amalgam restorations.
 Dental researchers have deliberately added fluoride to
dental restorative materials, luting cements and cavity
varnishes in order to impart a cariostatic property.
 They have demonstrated that these materials have the
ability to impart fluoride to enamel or to reduce enamel
solubility at the margins of restorations, in turn, might
prevent development of secondary caries.

 Silicate restorative materials and glass-ionomer cements contain
large amounts of fluoride (about 15% to 20%), explaining the
documented higher concentration of fluoride in the tooth
structures surrounding such restorations and the lower
incidence of recurrent caries.
(Forss and Seppa, 1990; Seppa, 1994; Svanberg, 1992; ten Cate
and van Duinen, 1995; Weerheijm et al, 1993).

 Because glass-ionomer materials are very sticky, for ease of
handling they are generally supplied in capsules and inserted
into the cavity with a syringe.

 FLUORIDE CONTAINING DEVICES
 (SLOW RELEASE or CONTROLLED RELEASE DEVICES)
 As the current scientific consensus regards a constant supply
of low levels of fluoride, especially at the biofilm/
saliva/dental interface, as being of the most benefit in
preventing dental caries, it is reasonable to expect a positive
effect on caries prevalence of a treatment able to raise
intraoral F concentrations at constant rates, without relying
on patient compliance.

 There are three types of slow-release F devices:
1. The copolymer membrane type, developed in US
2. The glass bead, developed in UK
3. More recently, a third type, which consists in a mixture of
sodium fluoride (NaF) and hydroxyapatite.

 COPOLYMER MEMBRANE DEVICE
 This type of slow-release fluoride device was developed by
Cowsar, et al (1976), consisting of a small pellet which could
be attached on or near the tooth surface.
 This system was designed as a membrane-controlled
reservoir-type and has an inner core of hydroxyethyl
methacrylate (HEMA)/methyl methacrylate (MMA)
copolymer (50:50 mixture), containing a precise amount of
sodium fluoride (NaF).

 The device is approximately 8 mm in length, 3 mm in width, and
2 mm in thickness as shown, and is usually attached to the buccal
surface of the first permanent molar by means of stainless steel
retainers that are spot welded to plain, standard orthodontic
bands or are bonded to the tooth surfaces using adhesive resins.
Rate of fluoride release:
0.02 to 1 mg/day for upto
6 months

 GLASS DEVICE
 The original device was dome shape, with a diameter of 4 mm and about 2 mm
thick, being usually attached to the buccal surface of the first permanent molar
using adhesive resins. Due to the low retention rates of the original device, it was
further substantially changed to a kidney-shaped device, being 6 mm long, 2.5
mm in width and 2.3 mm in depth, and it was proven to be effective regarding
both F release and retention rate.

 HYDROXYAPATITE-EUDRAGIT RS100 DIFFUSION
CONTROLLED F SYSTEM
 This is the newest type of slow-release F device, which
consists of a mixture of hydroxyapatite, NaF and Eudragit
RS100; it contains 18 mg of NaF and is intended to release
0.15 mg F/ day.
 Altinova YB, Alacan A, Aydin A, Sanisoglu SY (2005),
demonstrated that the use of this device is able to
significantly increase salivary and urinary F concentrations
for at least 1 month.

SELF APPLIED
TOPICAL FLUORIDES

 Fluoride Dentifrices
 Fluoride Mouth rinses
 Fluoride Gels
 Fluoride chewing gums
 Fluoridates toothpicks, dental tape & dental floss
 Fluoridated artificial saliva

FLUORIDE
DENTIFRICES

Dentifrices are universally used in conjunction with tooth
brushing in oral hygiene programs.
 The objective of oral hygiene procedures is to assist in the
maintenance of oral health through the mechanical cleansing
of teeth and oral tissues and by the introduction of specific
therapeutic agents in a dentifrice.

An understanding of the composition and action of
dentifrices is essential if a dentist is to respond intelligently to
some of the most frequently asked questions in dental practice,
namely:
What toothpaste should I use?
How effective are dentifrices in reducing dental caries?

DENTIFRICES (Latin: dens--tooth; fricare--to rub)
Initially introduced as a cosmetic product to be used in
conjunction with a toothbrush for the purpose of cleansing and
polishing the teeth and as a breath freshener.
Early efforts at improving dentifrice formulations mostly
involved new constituents to improve cleansing and reduce
abrasive effects.

Critical evaluation of the voluminous literature concerning
cariostatic efficacy of sodium fluoride divides it into two eras
according to the developments in abrasive systems.
In the first era, Torrel and Ericsson, 1965 (using sodium
bicarbonate); Brudevold et al 1966 (using di-calcium
phosphate dihydrate) and Peterson et al.,1968 (using insoluble
sodium metaphosphate) reported reduction of dental caries
ranging from 6% to 20%.
In the second era, ranging from 1968 to 1972, Zachorl 1968;
Reed et al., 1970; Weisenstein, 1972(using calcium
pyrophosphate) and Koch 1970 (using plastic abrasives)
reported 28% to 48% reduction.

With SnF2, dentifrices containing calcium pyrophosphates as
abrasives the percetage reduction reported was inconsistent
ranging from 9% reported by Mergele, 1964; 21% by Muhler,
1962, 3 % by Muliler and Radhike, 1957 to 54% by Bixler et al.,
1966.
However both Stannous fluoride and sodium fluoride are not
widely used today because of lack of compatibility with
abrasives, staining of anterior restorations of composites
resins (by SnF2) which have completely replaced other
materials and metallic astringent taste which is not acceptable.

RECENT INTRODUCTION-AMINE FLUORIDE
Amine fluoride were first tested for their cariostatic potential
in Zurich, Switzerland since laboratory experiments showed
organic fluorides to have antibacterial and antisolubility
properties which were superior to inorganic fluorides
(Muhlemaum at al., 1957; Marthaler, 1961).
 Clinical studies from 3-7 years with total fluoride conc. of
0.1%, to 5% in the amine fluoride dentifrices have demonstrated
significant reduction in caries rates. However, correberation by
independent research groups in different age groups is
essential prior to definitive assessment of the dentifrice. These
dentifrices are marketed only in Europe and not in United
States of America.

DENTIFRICES CONTAINING MONOFLUOROPHOSPHATE
The basic incompatibility of the NaF and SnF2 compounds
with calcium abrasives leading to decreased available F has
been overcome with the introduction of MFP which has
become the preferred chemical form of fluoride in most of the
major commercial fluoridated tooth pastes used throughout
the world ever since 1969, when the council on dental
therapeutics of American Dental Association also classified it as
'accepted’.

Dentifrices containing MFP at a concentration of 0.76% 0.1%F
with sodium metaphosphate as abrasive, have led to variable
reductions in caries rates ranging from 17% for unsupervised
brushing in the areas of optimal F levels to about 34% for
unsupervised brushing in non-fluoride areas (Finn and Jamison,
1963; Naylor and Emslie, 1967; Moller et al., 1968; Zacherl,
1972).
Generally studies indicated that caries reductions were
greatest in proximal surfaces and newly erupted teeth (Andlaw
and Tucker, 1975)

In recent formulations less expensive abrasives like
alumnium oxide have been used to eliminate any possibility of
the presence of orthophosphate ions (Po3F2-) which are
thought to inhibit uptake of fluoride by enamel.
Using this abrasive in 2% NaMFP dentifrices, Hargreaves and
Chester (1973) and Lind et al., (1974) have over a period of 3
years under unsupervised conditions reported about 30% caries
reductions.

Monofluorophosphate dentifrices are considered to be more
advantageous than SnF2 and NaF because MFP has a neutral
(6.5) compared to SnF2 (pH--4.8), greater stability to oxidation
and hydrolysis than SnF2 providing it a greater shelf life and
increased availability of fluoride and no staining of teeth.

MECHANISM OF ACTION
At present there are expressed two possible modes of action
regarding caries inhibitory mechanism of monofluorophosphate
(MFP).

1. As per first mode, it is essentially a fluoride effect
(Erricsson, 1963; Gron et al., 1971) but there appears to be a
controversy, regarding the mechanism of fluoride release
between these investigators.
 According to Erricsson 1963, MFP is deposited in the
crystalline lattice and in subsequent intra-crystalline
transportation, fluoride is released and replaces the
hydroxyl group to form fluorapatite.
 Gron et al 1971 postulates that F ion is released at the
solution crystal interface by means of hydrolysis:
Po3F2+H2o--------H2Po4+ F and this F reacts with
hydroxyapatite to form fluorapatite.

2. The second mode of action (Ingram et al., 1972) attributes
the anticariogenic activity due to MFP as such and it may
exchange with the phosphate groups in the apatite crystals
and this reaction is not competitive of fluoride.
Some investigators further believe that since commercial
grades of MFP contain about I % NaF as impurity, so this
anticaries activity may be due to NaF (Hodge et al., 1980).

CONTENTS OF TOOTHPASTE FORMULATIONS
1. Active agents:
One fluoride compound or two in combination
Agents for enhancement of the fluoride effect
Chemical plaque control agents
Anticalculus agents
Antimercury agents
Buffer systems
2. Abrasive particles
3. Detergents
4. Flavoring agents, preservatives, and coloring agents
5. Thickeners, agents to regulate viscosity
6. Water

The following fluoride compounds are used as active agents
in toothpastes:
1. Inorganic fluorides:
NaF
SMFP (Na7PO3F)
SnF2
Potassium fluoride (KF)
Aluminum fluoride (AIF3)
2. Organic fluoride:
AmF (Olafluor; GABA International)
3. Combinations of fluorides:
NaF and SMFP
AmF and SnF7
 AmF and NaF

STUDIES

HIGH FLUORIDE (> 1000 ppm) TOOTHPASTES
The possible benefit of using toothpastes containing more
than 1000 ppm fluoride has been tested in clinical trials which
have compared conventional 1000 ppm products with test
pastes containing concentrations of 1500-2800 ppm.

Overall, the results of these studies show that there is a dose-
response relationship in favor of using fluoride concentrations
above 1000 ppm.
Large numbers of subjects were used in many of these trials in
order to achieve statistical significance for relatively small
improvements in efficacy which may not be considered of
clinical significance in populations with low caries prevalences.

 INGESTION OF DENTIFRICES
Fluoride dentifrices, as opposed to purely cosmetic formulas,
now comprise about 80-85% of the North American and over
90% of the British dentifrice market.
The potential for ingestion of large amounts of a fluoride
dentifrice prompted several investigations into the relationship
between the amount of dentifrice swallowed and the amount
of fluoride absorbed.
(Hargreaves et al., 1972; Forsman and Ericsson, 1973;
Barnhart et al., 1974; Ekstrand and Ehrnebo, 1980,
Ekstrand et al., 1983; Whitford and Findori, 1983).

 The approximate amount of dentifrice used at each brushing
is 1 g. Assuming that the fluoride concentration in most
dentifrices is about 1,000 ppm, then about 1 mg fluoride ion is
available per brushing. Ingestion of a dentifrice varies inversely
with age.

 Ericsson and Forsman [1969] found that children aged 4-5
years who used 0.5 g of dentifrice per brushing retained
(presumably ingested) from 26 to 33% while a 6- to 7- year
group retained 25-28%.
This corresponds to a retention of about 0.12 mg fluoride per
brushing or 0.25 mg/day.
In a group of children (5-7 years) who used 1.0 g dentifrice
per brushing. Barnhart et al. [1974] found that about 0.5 mg
fluoride was ingested with two brushings.

It is also prudent to monitor the preparations available and
used by children.
Younger children living in a fluoridated community, brushing
their teeth with a fluoride dentifrice should be supervised and
only very small amounts of a fluoridated dentifrice should be
used in children under 4 years of age.
However, the consequences of ingesting fluoride from
dentifrices by young children are unlikely to be more serious
than the development of mild enamel fluorosis.

SAFETY OF FLUORIDE DENTIFRICES
Fluoride tooth paste generally contains around 800 to 1000
ppm of F- and the free available F- is approximately 500 to 600
ppm i.e. about 30 mg fluoride in a tube of 50 gm.
The certainly Lethal Dose (CLD) of F- for 70 kg adult is 5000 to
10,000 mg of NaF or 32 to 64 mg F- per kg body weight and
safely tolerated dose (STD) is approx. 1/4 of certainly lethal
dose (CGD).

Safely tolerated dose and certainly lethal dose of F for
children of various ages:
Age(years) Weight( in lbs ) CLD (mg) STD (mg)
2 22 320 80
4 29 422 106
6 37 538 135
8 45 655 164
10 53 771 193
12 64 931 233
14 83 1206 301
16 92 1338 334
18 95 1382 346

Usually, the largest size tooth paste manufactured is about
200 gms and it can at best contain about 200 mg F- whereas
the available be only about 140 mg.
This amount of F- is within the range of safely tolerated dose
(STD) for a 6 years old child i.e. even if a 6 year old child eats
whole of the economy size tooth paste, of 200 gms at one time,
the child is still within the safely tolerated dose (STD) of F.

The above statement though ridiculous, as how can a 6 years
old child eat up the whole of 200 gms tooth paste at one time?
amply demonstrates the safety for use of F tooth paste even in
children.
Recently, dentifrices containing as low as 200 ppm fluoride
have been found to have some cariostatic effect as that of
dentifrices containing 1000 ppm F(Goran Koch, 1982).

However, with available dentifrices enough precautions are
still taken and the recommendations for use of F tooth paste in
children are as follows:
1. For children below 4 years: F tooth paste is not
recommended.
2. For children 4-6 years : brushing once daily with F tooth
paste and other two times without a paste.
3. For children 6-10 years : brushing twice daily with F tooth
paste and once without paste.
4. For children above 10 years : brushing three times with
fluoride tooth paste.

 c
FLUORIDE
MOUTHRINSES

The first test of a fluoride mouthrinse was conducted in the
1940s (Knutson, 1948).
An acidified NaF mouthrinse used three times a week for 1
year by dental students failed to achieve a significant caries
reduction, possibly because of very low fluoride
concentrations.

 c
CHOICE AND CONCENTRATION OF AGENT
Neutral preparations of sodium fluoride are recommended
over other agents.
A 0.2% solution is used on a weekly basis, while a 0.05%
solution is used daily.
Some rinse preparations are modified by the addition of
flavoring agents, surfactants or, for adults, small amounts of
alcohol.
10 ml of fluoride mouthwash is used per rinse.

 c
Users are instructed to swish the solution for 60 s with lips
closed and teeth in contact, then to expectorate thoroughly
and not to eat or drink for 30 min following the rinse.
 In kindergarten-age children a slightly reduced volume of 7 ml
and shorter duration (e.g. 30 s) may be used.
The preparation of a 0.05% sodium fluoride solution for daily
use is as follows:
Sodium fluoride---0.50 g
Aqua dest. ad. ---1,000 ml

 c
A 0.2% sodium fluoride solution to be used weekly or
fortnightly is similarly prepared except that 2 g of sodium
fluoride are weighed and distilled water added to make up I
liter.
There are also numerous commercial preparations designed
for use by families at home or for use by large numbers of
school children in supervised mouthrinse programs in schools.
 The estimated annual cost of a sodium fluoride mouthrinse
program in school is approximately $0.75 (US) per student,
assuming that each student rinses 36 times in a school year
[Wei, 1982].

 c
The supervised use of
fluoride rinses is
recommended as an
effective caries-reducing
regimen for school children
over the age of 5 years.
The method is simple,
inexpensive and safe if used
as directed.
A guide for implementing
self-applied fluoride in
schools has been proposed
[US National Institute for
Dental Research, 1977].

 c
Fluoride mouthrinses are also recommended for persons with
a high caries activity or susceptibility.
Patients who have:
orthodontic
prosthetic appliance
patients with medical or physical handicaps who are able to
cooperate in a rinse program
whom dental treatment may be difficult or expensive are also
target groups for fluoride rinses.

 c
FREQUENCY OF RINSING
There is some clinical support for the proposition that
frequent use of low levels of fluoride is more cariostatic than
less frequent use of formulations containing higher
concentrations of fluoride.
 What is clear is that a schedule of monthly rinsing is not as
effective as rinsing daily, weekly or fortnightly [Toren and
Ericsson, 1974; Birkeland and Toren, 1978].

 c
Daily rinsing with a 0.05% sodium fluoride solution is not
sufficiently superior to a weekly rinse to justify the greater time
and resources it demands when employed in a school program
(Driscoll et al.,1982).
Weekly or fortnightly rinsing with a 0.2% solution by school
children is a generally accepted procedure that should yield
significant caries reductions of about 40% in the permanent
dentition.

 c
INGESTION OF MOUTHRINSES
Both Hellstrom [1960] and Ericsson and Eorsnum [1969]
reported that fluoride retention after the use of mouthrinses in
children age 6 and over was about 20%.
Wei and Kanellis [1983] confirmed the work of previous
investigators that preschool children usually swallow as much
as 30-40% of the rinse.
The younger the age group of greater the percentage of the
rinse swallowed.

 c
Ericsson and Forsman [1969] also found that below the age of
4, children often cannot control their swallowing reflexes and
may consistently swallow 100% of the rinse.
Such children, of whatever age, should be excluded from
fluoride rinse programs in order to avoid excessive systemic
intake. The volume of the mouthrinse and its duration have also
been shown to influence the degree of retention.
Birkeland [1973] found that in older children significantly more
fluoride was ingested when using 10 than 7 ml of mouthrinse.
 Similarly Birkeland and Lokken [1972] showed that adults
swallowed more mouthrinse when longer rinsing times were
used.

 c
Based on 7 ml of an 0.1% fluoride solution a maximum of 7 mg
fluoride can be ingested.
Kindergarten children may swallow 40% or 2.8 mg fluoride and
older children 20% or 1.4 mg fluoride.
 Since the bioavailability of ingested fluoride is very high these
figures should be borne in mind when considering the age at
which fluoride mouthwashes should he introduced as well as
the concentration of fluoride and their place in multiple
fluoride regimens.

 c
FLUORIDE GELS
FOR SELF CARE

 c
FLUORIDE GELS FOR SELF-CARE
Gels were introduced as fluoride delivery systems more than
30 years ago.
In the United States, fluoride gels have long been the
predominant supplement to fluoride toothpastes.
Fluoride gels are also widely used in Europe, particularly in
Sweden, Germany, Switzerland, and the Netherlands.

 c
Fluoride gels may be used daily for self-care or applied
professionally at needs-related intervals.
The fluoride concentration is usually lower in gels for self-care
(0.1% to 0.5% F) than in gels for professional use (1% to 2%).
The active ingredients may be compounds with fluoride effects
(neutral NaF and APF) or combinations of fluoride and agents
with antiplaque and antigingivitis effects (SnF, AmF, AmF and
NaF, and CHX and NaF)

 c
COMPOSITION
In the United States, APF and SnF2 gels are the most commonly
used formulations for self-care.
In Europe, neutral NaF gels and gels containing both AmF and
NaF are also readily available commercially.
CHX is the most efficient antiplaque agent, with a well-
documented, specific effect on mutans streptococci.
Therefore, a gel containing NaF in combination with CHX
should be a more efficient cariostatic agent than one containing
only NaF.

 c
APPLICATION
The application time for self-administered gels should be no less
than 4 or 5 minutes.
Because of the relatively high fluoride concentration and the
risk of ingestion, self-administration of fluoride gels is not
recommended for children, particularly those younger than 10
years.

 c
The probable toxic dose of fluoride is about 5 mg per 1 kg of
body weight.
The body weights of 1- and 5- to 6-year-old children are about
10 and 20 kg, respectively.
These facts should be taken into account when gels with high
concentrations of fluoride are used by professionals, for
example, in disabled children with high caries risk.
Parents using fluoride gels at home must be warned that such
attractively flavored and colored gels should be stored out of
reach of small children.

 c
It is estimated that 4 and 8 ml of 1.2% APF gel represent the
PTD for 1- and 5- to 6-year-old children, respectively.
The quantity of APF gel used is about 5 ml per application in a
prefabricated tray but can be reduced to about 2 ml in a
customized tray.

 c
C
FLUORIDE
CHEWING GUMS

 c
FLUORIDE CHEWING GUM
Recently fluoride chewing gum has become commercially
available (Fluorette and Fludent).
It is sugarless; xylitol and sorbitol are used as sweeteners.
Each piece contains 0.25 mg of fluoride

 c
It is well known that patients with decreased salivary secretion
rate (hyposalivation: <0.7 mL/min; xerostomia: <0.1 mL/min of
stimulated saliva) are highly susceptible to caries (Axelsson et al,
1990; Axelsson and Paulander, 1994; Dreizen and Brown, 1976).
 Such patients are predominantly elderly; 20% and 25% of 65 and
75-year-old individuals, respectively, have decreased salivary
secretion rates (Axelsson et al, 1990).
In addition, most elderly people have exposed root surfaces and
therefore a relatively high prevalence of root caries.

FLUORIDATED TOOTHPICKS
DENTAL TAPE
DENTAL FLOSS

 c
In populations with regular toothbrushing habits in children as
well as young adults and adults, the approximal surfaces of the
molars and premolars and the occlusal surfaces of the molars
have the highest prevalence of DFSs.
To improve caries prevention and control, plaque control and
topical use of fluorides, through both self-care and professional
therapy, must be targeted to these specific key-risk surfaces.
 Oral hygiene aids, specially designed for approximal plaque
removal, can also deliver fluoride to these surfaces.

 c
The potential benefits of fluoridated toothpicks, dental tape,
and dental floss have been largely neglected, although data
from the early 1980s showed high fluoride uptake and release
from NaF-impregnated wooden toothpicks (March and Bjorvatn,
1981).

 c
Several brands of fluoridated wooden toothpicks (TePe [TePe,
Malmo, Sweden], Butler [Butler, Chicago, IL], Elmex, and Jordan
[Jordan, Oslo, Norway]) and dental tape and floss (Johnson &
Johnson [Johnson & Johnson, New Brunswick, NJ], Butler,
Elmex, Oral-B [Gilette, Boston, MA] and Jordan) have recently
been introduced.

 c
To date, there are no longitudinal clinical trials evaluating the
caries-reducing effect of these devices on approximal surfaces.
 However, two in vitro and in vivo studies strongly indicate that
fluoridated wooden toothpicks would be a very efficient delivery
system; the combined mechanical removal of cariogenic plaque
and topical application of fluoride would achieve both
prevention and control of approximal caries in one step.

 c
For most adults, the fluoridated, triangular, pointed wooden
toothpick is the aid of choice for posterior interproximal oral
hygiene.
For teenagers and young adults, fluoridated dental tape is more
suitable.

 c
FLUORIDATED
ARTIFICIAL SALIVA

 c
By far the most caries-susceptible patients are those with
xerostomia.
 Xerostomia, or dry mouth, is most commonly related to
radiotherapy for tumors of the head and neck or to Sjogren
syndrome.
Various artificial saliva products have been formulated as gels
or sprays to relieve the extremely distressing subjective
problems of dry mouth.

 c
The sprays are well accepted and applied 20 to 30 times a day.
 Because of the extremely high caries risk in patients with
xerostomia, all artificial saliva products should contain fluoride.
 Because of the extremely low salivary flow or the absence of
saliva, 20 to 30 spray applications of artificial saliva containing
fluoride will markedly prolong fluoride clearance time.

MULTIPLE
FLUORIDE THERAPY

From the prior discussions of various measures to apply
fluoride to erupted teeth, it is apparent that no single fluoride
treatment provides total protection against dental caries.
 Recognition of this fact led early investigators to evaluate the
use of combinations of fluoride measures.

Multiple fluoride therapy is a term that has been used to
describe these fluoride combination programs.
As originally developed, this program included the application
of fluoride in the dental office in the form of both a fluoride-
containing prophylactic paste and a topically applied fluoride
solution and the home use of an approved fluoride dentifrice.
 In addition, some form of systemic fluoride ingestion,
preferably communal-water fluoridation, was included.

TOPICAL FLUORIDE
RECOMMENDATIONS
FOR HIGH-RISK
CHILDREN (< 6years)
Recommendations from
Maternal & Child Health
Bureau (MCHB) Expert
Panel.
October 22–23, 2007
Altarum Institute
Washington, DC

 c
CASE REPORTS OF MISUSE OF TOPICAL FLUORIDE

 c
CASE REPORT 2

 c
William Kennerly died after "routine" topical fluoride treatment
Saturday, Jan. 20, 1979
$750,000 Given In Child's Death In Fluoride Case.
Boy was in City Clinic for Routine Cleaning.
By Robert D. McFadden
A State Supreme Court jury awarded $750,000 yesterday to the
parents of a 3-year-old Brooklyn boy who, on his first trip to the
dentist in 1974, was given a lethal dose of fluoride at a city dental
clinic and then ignored for nearly five hours in the waiting rooms
of a pediatric clinic and Brookdale Hospital while his mother
pleaded for help, and he lapsed into a coma and died.

 c
FATAL SOLUTION SWALLOWED
According to Mrs. Kennerly, Miss Cohen was engrossed in
conversation with a co-worker while working on William and,
after handing him a cup of water, failed to instruct him to
wash his mouth out with it and spit out the solution. Mrs.
Kennerly said that Miss Cohen was not paying attention when
William drank the water about 9:30 A.M.
In drinking the water, according to a Nassau County
toxicologist, Dr. Jesse Bidanset, William ingested 45 cubic
centimeters of 2 percent stannous fluoride solution, triple an
amount sufficient to have been fatal.

BIBLIOGRAPHY
 UNDERSTANDING DENTAL CARIES, PREVENTION, BASIC AND
CLINICAL ASPECTS, GORDAN NIKIFORUK, 1985.
 FLUORIDES IN CARIES PREVENTION, JJ MURRAY, 1991, 3RD
EDITION.
 PRIMARY PREVENTIVE DENTISTRY, NORMAN O HARRIS, 2004, 6TH
EDITION.
 PREVENTIVE MATERIALS, METHODS AND PROGNOSIS, VOL 4,
PER AXELSSON, 2004.
123
topical fluorides

BIBLIOGRAPHY
 PREVENTION IN CLINICAL ORAL HEALTH CARE, DAVID P CAPELLI,
2008.
 DENTAL CARIES, THE DISEASE AND ITS CLINICAL MANAGEMENT,
OLE FEJERSKOV AND EDWINA KIDD, 2ND EDITION,2008.
 FLUORIDES AND DENTAL CARIES, DR. AMRIT TIWARI.
 FLUORIDES, ENVIRONMENTAL HEALTH CRITERIA, WHO GENEVA,
2002.
124
topical fluorides

BIBLIOGRAPHY
 PRINCIPLES OF DENTAL PUBLIC HEALTH, JAMES MORSE
DUNNING , 4TH EDITION, 1986.
 JONG,S COMMUNITY DENTAL HEALTH, 5TH EDITION, 2002.
 FLUORIDE IN PREVENTIVE DENTISTRY, THEORY AND CLINICAL
APPLICATION, JAMES R MELLBURG, 1986.
 ESSENTIAL DENTAL PUBLIC HEALTH, BLANAID DALY.
 COMMUNITY ORAL HEALTH, CYNTHIA PINE, 2007.
125
topical fluorides

BIBLIOGRAPHY
 TEXTBOOK OF PREVENTIVE AND COMMUNITY DENTISTRY, SS
HIREMATH, 1ST EDITION, 2007.
 TEXTBOOK OF COMMUNITY DENTISTRY, SS MARYA, 1ST EDITION,
2011.
 ESSENTIALS OF PREVENTIVE AND COMMUNITY DENTISTRY,
SOBEN PETER, 4TH EDITION, 2009.
126
topical fluorides

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