The document provides a comprehensive overview of fluoride, including its history, metabolism, mechanisms of action, and various types of fluoridation. It discusses fluoride as an essential nutrient recognized by organizations like the FDA and WHO, and details its role in dental health, emphasizing its effectiveness in reducing dental caries through systemic and topical effects. Additionally, it covers the historical progression of fluoride use in dentistry, various fluoridation methods, and implementation challenges, particularly in different socioeconomic contexts.

1. FLUORIDE
HISTORY AND SYSYTEMIC FLUORIDE
PRESENTED BY
DR. MAYURI SOPAN MUNDHE
JR1
PAEDIATRIC AND PREVENTIVE DENTISTRY
FODS, KGMU, LUCKNOW
PART ONE

2. Table of contents
01
04
02
05
03
06
Introduction History Metabolism
Mechanism
Types of
fluoridation
Fluoride
supplementation

3. Fluoride: An Essential Nutrient
• The Federal Register of United States Food and Drug Administration
describes fluoride as an essential nutrient.
• The WHO expert committee on trace elements included fluorine as one of
the 14 physiologically essential elements.
• These essential elements are required for the normal growth and
development of Human Beings

4. FLUORIDE IN ENVIRONMENT
Vithanage, M., Bhattacharya, P. Fluoride in the environment: sources, distribution and defluoridation. Environ Chem Lett13, 131–147 (2015).
https://doi.org/10.1007/s10311-015-0496-4

5. F L U O R I D E R A N G E
I N
G R O U N D W A T E R
Ali, S., Fakhri, Y., Golbini, M., Thakur, S. K., Alinejad, A., Parseh, I., … Bhattacharya, P.
(2019). Concentration of fluoride in groundwater of India: A systematic review, meta-analysis and risk
assessment. Groundwater for Sustainable Development, 100224.doi:10.1016/j.gsd.2019.100224

6. MINISTRY OF JAL SHAKTI
DEPT. OF WATER RESOURCES,
RIVER DEVELOPMENT & GANGA REJUVENATION
CENTRAL GROUND WATER BOARD
GROUND WATER QUALITY IN SHALLOW AQUIFER OF UTTAR
PRADESH
(AAP 2023-24)
Fluoride concentration in the state of Uttar
Pradesh

8. HISTORY OF EVOLUTION OF
FLUORIDES IN DENTISTRY
The history of fluoride is more than 100 years old.
The first hint of possible connection of fluoride and
dental health was given by SIR JAMES CRICHTON
BROWNE in 1802. He emphasized the importance
of fluoride.

9. 1901
1901- DR. FREDRICK McKay Permanent
stains present on the teeth of local
inhabitants of Colarado Spring, U.S.A.
known as COLARADO STAINS noticed.
He called the stain Mottled Enamel
1902
1902- DR. J.M. EAGER described similar
stains present on teeth of certain Italian
emigrants embarking at Naples as “denti di
chiaie”
1916
Dr Green Vardmin Black supported McKay
work with histologic evidence reporting it
as "an endemic imperfection of the enamel
of the teeth

10. 1925
1925,Dr F McKay change of water supply
from spring water of the Great Salt Lake
of Oakely, Idaho City, showed no brown
stains in children.
1928
1928,Dr McKay and Gromer Kempt
Similar observation found in Bauxite
where changed water supply from a
shallow well to foot well resulted in
children with badly stained teeth.
1931
1931,Mr HV Churchill -A spectrographic
analysis of Bauxite city water showed the
presence of fluoride at the level of
13.7ppm

11. 1933
1933,Dr H Trendley Dean
Shoe Leather Survey
1939
1939,Dean and McKay
Came out with the most conclusive and
direct proof that fluoride in domestic water is
primary cause of human mottled enamel.
1939
1939,Dr H Trendley Dean
Hypothesis showing the inverse relationship
between endemic dental fluorosis and
dental caries emerged with survey of four
illinois cities

12. METABOLISM
OF FLUORIDE
Textbook of Public Health Dentistry 3Rd Edition S S
Hiremath

13. 0.01-0.1ppm 4.16ppm
DISTRIBUTION OF FLUORIDE IN BODY
0.7-2.4µm
2200-3200ppm 4500ppm 100-650ppm
Plasma Saliva Kidney
Enamel Cementum Pulp
Martínez-Mier EA. Fluoride: Its Metabolism, Toxicity, and Role in Dental Health. Journal of Evidence-Based Complementary & Alternative
Medicine. 2012;17(1):28-32. doi:10.1177/2156587211428076

14. HOW DOES FLUORIDE WORK?
SYSTEMIC
EFFECT
TOPICAL
EFFECT
Fluoride is ingested in
a small amount
during tooth
formation in the jaw
and gets built into
the enamel
• Fluoride is concentrated in
saliva that bathes the teeth
• Remineralizes tooth enamel to
build a strong, cavity-resistant
outer surface
• Decreases bacterial activity in
the mouth

15. Cariostatic Mechanism Of Fluoride
1. increases enamel resistance or reduction in enamel
solubility.
2. increases rate of post eruptive maturation.
3. remineralization of incipient lesions.
4. Interference with plaque microorganisms.
5. modification in tooth morphology

16. Cariostatic Mechanism Of Fluoride
Mankar N, Kumbhare S, Nikhade P, et al. (December 21, 2023) Role of Fluoride in Dentistry: A Narrative Review. Cureus 15(12): e50884. DOI 10.7759/cureus.50884

19. Antibacterial Effect
fluoride
High
Concentration
Low
Concentration
BACTRICIDAL BACTERIOSTATIC
Fluoride inhibit
1. ENOLASE
2. PHOSPHATASE
3. CATION TRANSPORT
Ying Liao, Bernd W. Brandt, Jiyao Li, Wim Crielaard, Cor Van Loveren & Dong Mei Deng (2017) Fluoride
resistance in Streptococcus mutans: a mini review, Journal of Oral Microbiology, 9:1, 1344509, DOI:
10.1080/20002297.2017.1344509

21. FLUORIDATION
SYSTEMIC
WATER,
MILK
DIETARY
SUPPLEMENTS,
SALT
TOPICAL
PROFESSIONAL
SELF APPLIED

22. 1. limit of fluoride
2. Fluoride and Dental caries
3. Optimal time for fluoride
Classical Studies Regarding
Water Fluoridation

23. Limit of ppm????
 1931, work was assigned to Trendley H. Dean and in 1933 he began SHOE
LEATHER SURVEY.
 5,824 children from 22 cities of 10 states of US.
 Concluded that,
1ppm – no mottling
2.5ppm- Dull chalky appearance
4ppm- Discrete pitting.
 Proved that 1ppm F in water wasn’t hazardous for public health
Mullen, J. History of Water Fluoridation. Br Dent J 199, 1-4 (2005).
https://doi.org/10.1038/sj.bdj.4812863

24. Fluoride And Caries???
• Ainsworth, 1933 reported caries in fluoride areas.
• To confirm this hypothesis, 1939 Dean considered 4 Illinois Cities, concluded on a
positive note and went ahead for an epidemiological study, 7257 kids in 21 cities
and 4 states of US.
• RESULTS: No Fluoride - 6-10 DMFT
1 ppm F -2-3 DMFT
● 1942, reported that 1ppm leads to 60% reduction in caries.
Mullen, J. History of Water Fluoridation. Br Dent J 199, 1-4 (2005).
https://doi.org/10.1038/sj.bdj.4812863

25. Optimal Time For Fluoride???
 Klein,1946 when people of Japanese ancestory were transferred to Arizona (0.1-3ppm)
 Observed, teeth in process of eruption received max benefits.
 And also teeth which were exposed to fluorides shortly after eruption
Mullen, J. History of Water Fluoridation. Br Dent J 199, 1-4 (2005).
https://doi.org/10.1038/sj.bdj.4812863

26. HISTORY

27. WATER FLUORIDATION
● The recommended levels vary between 0.8- 1.2 ppm
● Varies with climate
Determining Optimum Fluoride Concentrations DONALD J. GALAGAN, D.D.S., M.P.H., and JACK R. VERMILLION, M.P.H.
What AAPD recommends?

28. Effects Of Fluoridation
1. 50-60% caries reduction in deciduous teeth if children are exposed
since birth.
2. Among permanent teeth: caries reduction is 43% on pits and
fissures, 74% on proximal surfaces , 88% on gingival surfaces.
3. Even if dental caries develops, progression of lesion slows down.
Textbook of Public Health Dentistry 3Rd Edition S S
Hiremath

29. Countries Which Have
Implemented Water
Fluoridation
● Australia, Brazil, Canada, Chile, Greece, Finland, Ireland,
New Zealand, Spain, United Kingdom
● About 350 million persons worldwide are estimated to
regularly consume artificially fluoridated water.

30. ENGINEERING ASPECT
1. The three commonly used chemicals for fluoridation
include:
1. Sodium fluoride (powder)- Dry feeders
2. Sodium silicofluoride (powder)- Dry feeders
3. Hydroxyfluorosilicic acid- Solution feeders

31. DEFLUORIDATION
ABSORPTION
TECHNIQUE
BONE CHARCOAL,
PROCESSED BONE,
TRICALCIUM PHOSPHATE,
ACTIVATED
CARBON,ACTIVATED
MAGNESIA,TAMARIND
GEL,SERPENTINE,ACTIVATED
ALUMINA, PLANT MATERIAL,
BURNT CLAY.
ION EXCHANGE
TECHNIQUE
PRECIPITATION
TECHNIQUE
NALGONDA
TECHNIQUE

32. SCHOOL WATER FLUORIDATION
• First began in 1954 in Virgin island in US.
• School with its own source of water & not
connected to a community water supply system
(i.e., stand-alone systems).
• The current recommended regimen for school
water fluoridation is adding 4.5-6.3ppm of F.
• There has been around 25 to 40 % decrease in
dental caries with this program.

33. ADVANTAGES
 Good results in reducing
caries, Minimal equipment
and Not expensive.
DISADVANTAGES
 Children do not receive the benefit
until they go to school.
 Not all children go to the school go
the school in poor countries and
towns and villages.
 Amount of amount water drunk
can’t be regulated.
 5 to 6 years old upon starting
school- will not provide preeruptive
contact.
 Intermittent fluoride exposure-less
than 180 days in a year
SCHOOL WATER FLUORIDATION

34. Milk And Salt Fluoridation: An Alternate Methods Of
Systemic Fluoridation
● Milk and salt are widely consumed across diverse
populations
● Less expensive compared to water fluoridation
infrastructure
● Can be easily distributed to children and vulnerable
population

35. SALT FLUORIDATION
● Salt fluoridation was introduced by Wespi in
Switzerland in 1955. It is most popular in
Colombia, Hungary and Spain.
● The methods of addition of fluoride into salt
include:
(i) fluoride can be added to salt by spraying
concentrated solution of NaF or KF on
salt on a conveyor bed and
(ii) it can also be prepared by mixing
premixed granules added to the salt.
● Recommended concentration is 250 mg of
fluoride/ kg salt.
Marthaler TM. Salt fluoridation and oral health. Acta Med Acad.
2013 Nov;42(2):140-55. doi: 10.5644/ama2006-124.82. PMID:
24308394.

36. ADVANTAGES
1.Quite economical
2. Practical/ feasible
3. Caries reduction is
about 40 to 50%
DISADVANTAGES
1. Consumption of salts till 4-
5 years after birth is
negligible, hence no benefit
for younger children.
2. Not useful in case of
medically compromised
patients (hypertension and
renal failure).
SALT FLUORIDATION

37. MILK FLUORIDATION
● Milk fluoridation was strongly promoted by Ziegler,
a paediatrician. In 1962, the first project with
fluoridated milk began in the Swiss city Winterthur
in 1965.
● It is mainly recommended for growing children.
● The substantial caries preventive effects have been
noticed, especially when milk consumption began
before the eruption of the permanent teeth.

38. CONCENTRATION
● 2.2 mg of sodium
fluoride (containing 1
mg of F) was added to
250 ml of milk.
● Later, milk bottles of
250 ml, containing
0.625 mg of fluoride are
introduced in
Switzerland and UK.
Caries reduction is
about 60%.
FEASIBILITY IN INDIA
• In India, majority of the
children population living in
rural and urban areas cannot
afford milk daily.
• Variation of intake and
quantity of milk is another
factor which cannot be
controlled.
MILK FLUORIDATION

40. ● Fluoride supplements can be given in the form of fluoride tablets,
fluoride drops and lozenges. The cariostatic effect ranges from 30 to
70%
● Fluoride supplements are taken on a daily basis from 6 months to 16
years of age.
● The factors to be considered for the correct dosage in prescribing
fluoride supplements are dependent on:
(i) age of child,
(ii) the existing fluoride concentration in the water supply and
(iii) climatic conditions.
FLUORIDE SUPPLEMENT

42. ● Ali, S., Fakhri, Y., Golbini, M., Thakur, S. K., Alinejad, A., Parseh, I., … Bhattacharya, P.
(2019). Concentration Of Fluoride In Groundwater Of India: A Systematic Review, Meta-analysis
And Risk Assessment. Groundwater For Sustainable Development,
100224.Doi:10.1016/J.Gsd.2019.100224
● Ministry Of Jal Shakti Dept. Of Water Resources, River Development & Ganga Rejuvenation Central
Ground Water Board Ground Water Quality In Shallow Aquifer Of Uttar Pradesh(aap 2023-24)
● Textbook Of Public Health Dentistry 3rd Edition S S Hiremath
● Martínez-mier EA. Fluoride: Its Metabolism, Toxicity, And Role In Dental Health. Journal Of
Evidence-based Complementary & Alternative Medicine. 2012;17(1):28-32.
Doi:10.1177/2156587211428076
● Mankar N, Kumbhare S, Nikhade P, Et Al. (December 21, 2023) Role Of Fluoride In Dentistry: A
Narrative Review. Cureus 15(12): E50884. Doi 10.7759/Cureus.50884
● Mullen, J. History Of Water Fluoridation. Br Dent J 199, 1-4 (2005).
Https://Doi.Org/10.1038/Sj.Bdj.4812863
REFRENCES

43. ● Determining Optimum Fluoride Concentrations DONALD J. GALAGAN, D.D.S., M.P.H., and JACK R.
VERMILLION, M.P.H.
● Marthaler TM. Salt fluoridation and oral health. Acta Med Acad. 2013 Nov;42(2):140-55. doi:
10.5644/ama2006-124.82. PMID: 24308394.
● Vithanage, M., Bhattacharya, P. Fluoride in the environment: sources, distribution and
defluoridation. Environ Chem Lett13, 131–147 (2015). https://doi.org/10.1007/s10311-015-0496-4
● Moran GP, Zgaga L, Daly B, Harding M, Montgomery T. Does fluoride exposure impact on the
human microbiome? Toxicol Lett. 2023 Apr 15;379:11-19. doi: 10.1016/j.toxlet.2023.03.001. Epub
2023 Mar 4. PMID: 36871794.
● Gupta P, Gupta N, Meena K, Moon NJ, Kumar P, Kaur R. Concentration of Fluoride in Cow's and
Buffalo's Milk in Relation to Varying Levels of Fluoride Concentration in Drinking Water of Mathura
City in India- A Pilot Study. J Clin Diagn Res. 2015 May;9(5):LC05-7. doi:
10.7860/JCDR/2015/12850.5902. Epub 2015 May 1. PMID: 26155499; PMCID: PMC4484091.
REFRENCES

44. THANK YOU!!