This document discusses a preventive dentistry program focused on fluoride and fissure sealants presented by Heidi Emmerling. It covers the goals of fluoride administration, recommended fluoride levels in water, potential toxicity of fluoride ingestion, emergency treatment, topical fluoride applications, and fissure sealant indications and limitations. The goals are to prevent decay, arrest active decay, and remineralize teeth using optimal fluoride levels tailored to climate. Potential fluoride toxicity and treatments are also outlined.

1. Preventive dentistry program
Fluoride &fissure sealant
Third year
Heidi Emmerling, RDH, PhD
DHYG 104 Pt Ed and Nutrition
Fall 2007

2. Heidi Emmerling, RDH, PhD
DHYG 104 Pt Ed and Nutrition
Fall 2007

3. Goals of Fluoride (F) Administration
1) Do not harm the patient.
2) Prevent decay on intact dental
surfaces.
3) Arrest active decay.
4) Remineralize decalcified tooth
surfaces.

4. Recommended Optimal Fluoride Level
(ppm) in Water Supply depends on
temperature and amount already in water
Average Daily
Air Temperature
(°c)
Optimal
Fluoride
Level (ppm)
Control Range
(ppm)
(10-12)
(12-15)
(15-18)
(18-21)
(21-26)
(26-33)
1.2
1.1
1.0
0.9
0.8
0.7
1.1 to 1.7
1.0 to 1.6
0.9 to 1.5
0.8 to 1.4
0.7 to 1.3
0.6 to 1.2
DHYG 104 Pt Ed and Nutrition
Fall 2007

5. Probable toxic dose:
Symptoms:
5 mg F / kg body weight
20 kg 6 year old, PTD= 100 mg F
1. Vomiting
2. Excess
salivary and
mucous
discharge
3. Cold wet
skin
DHYG 104 Pt Ed and Nutrition
Fall 2007
4. Convulsion
at higher
dose

6. A serious systemic consequence is binding of F to Ca
which needed for heart function.
F
F
Ca
Ca
DHYG 104 Pt Ed and Nutrition
Fall 2007

7. Counter Measures:
1. Emetics
2. 1% calcium chloride
3. Calcium gluconate
4. milk
Divalent
cations like Ca
cause
precipitation,
of F and
prevent
absorbtion in
the intestine.
DHYG 104 Pt Ed and Nutrition
Fall 2007
F
Ca
F
Ca
Ca
F

8. 
Can be toxic/lethal
Chemical burn
 Inhibits enzyme systems (protoplasmic
poison)
 Binds calcium need for nerve action
 Hyperkalemia: cardio toxicity
 Adult: 2.5-10g (15 mg/kg = lethal)


In industry, skeletal fluorosis, calcification
of tendons
DHYG 104 Pt Ed and Nutrition
Fall 2007

9. Emergency Treatment

4 actions
Immediate treatment:
 Induced vomiting
 Orally administered calcium or aluminum
preparations to protect stomach
 Maintenance of blood calcium levels with
intravenous calcium

DHYG 104 Pt Ed and Nutrition
Fall 2007

10. 1. Immediate treatment
DHYG 104 Pt Ed and Nutrition
Fall 2007

11. First Aid Treatment

2. Milk or milk with eggs

Plenty of fluid including milk should be ingested
3. Lime water (CaOH)
 4. Maalox (aluminum preparation)

Protects mucous membranes of upper GI from
chemical burns
 Contains calcium as a binder

DHYG 104 Pt Ed and Nutrition
Fall 2007

12. DHYG 104 Pt Ed and Nutrition
Fall 2007

13. Fluorosis occurs when teeth are developing. The most
critical ages are from 0 to 6 years. After 8 years, risk of
fluorosis is essentially past. During the critical ages F intake
in excess of 0.1mg/kg body weight/day can lead to
fluorosis. This is roughly 1mg/day for a 1 to 2 year old or 1.5
to 2 mg for a 5 year old. Remember that all forms of F intake
comprise the daily consumption. This includes water intake
(up to 1.5mg/day), foods (0.3 to 1.0mg) and especially
significant in young children, swallowed toothpaste.
Children under 2 years swallow 50% of toothpaste during
tooth brushing and at 5years, 25%, both of which may
amount to 1mg F/day.

14. FLUOROSIS
5 year olds swallow 25% of
toothpaste
Children under 2 years
swallow 50% of toothpaste
1 to 3 grams
Toothpaste = 1 mg F /
gram (1000 ppmF)
“pea” size amount (0.5g) is
recommenred for fluorosis susceptible
children.

15. Classification of fluorosis
DHYG 104 Pt Ed and Nutrition
Fall 2007

16. Very Mild
Small opaque, paper white
areas scattered irregularly
over the tooth but not
involving as much as 25% of
the tooth surface. Frequently
included in this classification
are teeth showing no more
than about 1-2 mm of white
opacity at the tip of the
summit of the cusps of the
bicuspids or second molars.
Mild
The white opaque areas in
the enamel of the teeth are
more extensive but do not
involve as much as 50% of
the tooth.
Heidi Emmerling, RDH, PhD
DHYG 104 Pt Ed and Nutrition
Fall 2007

17. Mild Fluorosis
Heidi Emmerling, RDH, PhD
DHYG 104 Pt Ed and Nutrition
Fall 2007

18. Moderate
All enamel surfaces of the teeth
are affected, and the surfaces
subject to attrition show wear.
Brown stain is frequently a
disfiguring feature.
Severe
Includes teeth formerly classified
as "moderately severe and
severe." All enamel surfaces are
affected and hypoplasia is so
marked that the general form of
the tooth may be affected. The
major diagnostic sign of this
classification is discrete or
confluent pitting. Brown stains
are widespread and teeth often
present a corroded-like
appearance.
Heidi Emmerling, RDH, PhD
DHYG 104 Pt Ed and Nutrition
Fall 2007

19. Moderate Fluorosis
Heidi Emmerling, RDH, PhD
DHYG 104 Pt Ed and Nutrition
Fall 2007

20. DHYG 104 Pt Ed and Nutrition
Fall 2007

21. Severe Fluorosis
DHYG 104 Pt Ed and Nutrition
Fall 2007

22. Systemic fluorides


Program began with the younger children
should be continued at least until all permanent
teeth except third molar erupted
Posterior teeth will erupt and need fluoride till
post eruption maturation occur

23. Water fluoridation



Water fluoridation associated with reduced tooth
decay
50-60%reduction of caries in communities have
water fluoridation between 0.7-1.2
Good cost in comparison to size of population

24. School water fluoridation



Alternative to community water fluoridation
4-5 times higher that that recommended for
community fluoridation
Student spent only part of the year on their
school also fraction of the daily water intake at
school

25. Salt fluoridation



Salt intake is difficult to determined
Research showed that salt contained of 90PPM
may be beneficial for reduction of caries
May be it is the best method in developing
countries where piped water supply is rare

26. Milk fluoridation


It is not completely supported
Milk in the gastrointestinal tract may reduce
absorption of ingested fluoride

27. DHYG 104 Pt Ed and Nutrition
Fall 2007

28. Topical fluoride



Topical fluoride at office every 6 months or for
school preventive program (mouth rinsing
program at school )
Topical application at home particularaly at high
risk activity or handicapped patient or with
orthodontic appliance
Fluoride rinse 0.2%NaF ,0.4%SnFapplies

29. 


Students rinse for one or two minutes with 710ml
Younger children under school age
contraindicated
Weekly program with 0.2 %Na F is
recommended for school age

30. Methods of topical applications

Cotton application
Tray technique

31. Cotton applicators method
Seat patient upright
▪▪Isolate both upper and lower right or left quadrant using
cotton roll isolation and saliva evacuation (half mouth
technique)
▪▪ Dry isolated teeth with compressed air
▪▪ Keep tooth surfaces continually soaked with fluoride
solution for 4-minutes application if active caries
present and 1-minutes if caries inactive
▪▪ Repeat procedures on opposite side of the mouth
▪▪ Have the patient expectorate immediately and
repeatedly upon completion of the topical treatment
▪▪ Advise patient not to eat ,drink ar rinse for 30 minutes
after treatment

32. Tray technique




Teeth should be dried and free of saliva
Patient in upright
Place enough gel to fill one third of the trough
area of the tray so that they properly fit over
each dental arch
Avoid overloading to reduce oozing of gel
,which may lead to excessive ingestion

33. 



Place loaded tray over the arch and squeeze the
buccual and lingual surfaces forcing gel between
teeth
With light biting presssure ,allow tray to remain
in the mouth for 4- minutes
Provide patient with drool bag or saliva ejector
to avoid swallowing excessive fluoride
After 4- minutes remove trays and use high
volume evacuation to thoroughly remove gel
that remains on teeth

34. ▪▪ Have the patient expectorate immediately and
repeatedly upon completion of the topical
treatment
▪▪ Advise patient not to eat ,drink or rinse for 30
minutes after treatment

35. APF foams and gels
(use trays)
DHYG 104 Pt Ed and Nutrition
Fall 2007

36. DHYG 104 Pt Ed and Nutrition
Fall 2007

37. DHYG 104 Pt Ed and Nutrition
Fall 2007

38. FLUORIDE SUPPLEMENTS
F in drinking water
AGE
Birth-6m
6m-3y
F
<0.3ppm
0
0.30.6ppm
0
>0.6ppm
0
0.25
0
0
3-6y
0.5
0.25
0
6-16y
1.0
0.5
0
Academy of Pediatric Dentistry current recommendations

39. Fluoride Protection for You



Sensitivity: This condition affects 25% of most adults.
Gum recession and natural wear can cause sensitivity.
Fluoride gels can help strengthen these area to insulate
them from hot and cold.
Root surface caries: Fluoride can help protect this
area from acid- producing bacteria.
Cavity control: Fluoride helps to remineralize enamel.
Fluoride blocks cavities by forming a more acidresistant surface layer.
DHYG 104 Pt Ed and Nutrition
Fall 2007

40. Who should receive fluoride varnish?


Children are at risk for
developing dental caries.
Risk assessment based on the
Caries Risk Assessment

41. Advantages of fluoride varnish:

There is less fluoride ingestion with a fluoride
varnish than with conventional office caries
treatments because the fluoride adheres to the
tooth surface for longer periods of time.

Duraphat releases fluoride for 28 weeks. Twothirds of the fluoride is released by 6 months.**

No special equipment is needed for the
application.
DHYG 104 Pt Ed and Nutrition
Fall 2007

42. Advantages of fluoride varnish:

Teeth do not need to be professionally
cleaned prior to varnish application.

Children can eat and drink immediately
after application.

Fluoride varnish can prevent decay in both
smooth surface and pit and groove sites.
DHYG 104 Pt Ed and Nutrition
Fall 2007

43. Advantages of fluoride varnish:

It is fast and easy and can be done in one appointment
with no injections. This varnish is a sticky, yellow semiliquid containing 5% sodium fluoride in a resin base
mixed with alcohol to dry quickly after application.

You can leave immediately after application. There are
no fluoride trays which prevents gagging.

It can be used as a cavity liner or desensitizer or painted
on cervical areas in geriatric patients. It can also be
applied to tooth surfaces between teeth for young
children.
DHYG 104 Pt Ed and Nutrition
Fall 2007

50. Post application instructions for
parents




Varnish will set on contact with saliva and look like a
yellowish film
Child can eat or drink right after application but
should try to eat soft foods
Instruct parent not to brush their child’s teeth until
the next day.
The first toothbrushing will remove the yellow film
on the teeth.

51. Epidemiology of pit and fissure
caries




Occlusal caries 60%of total caries experience in
children and adolescents
Morphology of pits and fissures
A-shallow,wide v-shaped fissures
B-deep,narrow ,I shaped fissures (narrow neck
and wide base )like bottle neck
DHYG 104 Pt Ed and Nutrition
Fall 2007

53. DHYG 104 Pt Ed and Nutrition
Fall 2007

54. Sealant indications




Deep&retentive pits and fissures
Stained pits and fissures
No radiographic or clinical evidence of
interproximal caries
Patient receiving other preventive treatment
DHYG 104 Pt Ed and Nutrition
Fall 2007

55. Sealant contraindications





Rampant caries
Interproximal caries
Low risk patients
Well coalesced pits and fissures
Uncoapertive patient
DHYG 104 Pt Ed and Nutrition
Fall 2007

56. Sealant limitations




Moisture control of utmost importance
Patient cooperation for dry field
Isolation with rubber dam or cotton rolls
Life span of primary tooth
DHYG 104 Pt Ed and Nutrition
Fall 2007

57. Heidi Emmerling, RDH, PhD
DHYG 104 Pt Ed and Nutrition
Fall 2007

58. Heidi Emmerling, RDH, PhD
DHYG 104 Pt Ed and Nutrition
Fall 2007

59. Heidi Emmerling, RDH, PhD
DHYG 104 Pt Ed and Nutrition
Fall 2007