This document discusses and compares topical and systemic fluorides. It provides a history of fluoride use and research. Key points include: topical fluorides such as sodium fluoride, stannous fluoride, and acidulated phosphate fluoride have been used since the 1940s to reduce dental caries. Water, salt, and milk have been vehicles for systemic fluoride delivery. Topical fluorides provide a direct source of fluoride to the tooth surface while systemic fluorides incorporate fluoride into teeth and bone. Both methods have benefits and limitations.

1. By,
Lakshana K.H.D
Final year
Topical and systemic fluorides

2. Synopsis
• INTRODUCTION
• HISTORY OF FLUORIDES
• SYSTEMIC FLUORIDE
• TOPICAL FLUORIDE
• COMPARISON AND COMBINATIONS

3. INRODUCTION
*Continuous low level exposure of fluoride in oral environment decrease caries
most
electronegative
reactive
element
Fluorine
rarely
found in free
or

4. How fluoride decreases caries ?
Actions :
•Inhibit
glycolysis by
the cariogenic
bacteria
•When
present in saliva
and plaque helps in
remineralisation of
incipient caries
•The
remineralised tooth
containing fluoride is
more resistant to
caries and stronger

5. Fluorides in lithosphere
•fluorspar,
cryolite, apatite
mica and
•concentration
of fluoride in soil also
increases with depth.

6. Fluoride in water
In seawater
0.8 to 1.4mg/l
• Due to the universal presence of fluoride , it is present in all forms of water
•lakes ,river and well is
less than 0.5 mg/ dl
• Highest fluoride contains
water in Rift Valley in Kenya
(2800mg/l)

7. Fluoride in food and beverages
Brewed tea typically
contains higher levels of
fl
uoride than most foods,
depending on the type of tea and
its source, because tea plants
take up
fl
uoride from soil

8. Water Fluoride content in India

9. Fluoride metabolism
Distribution
:
In plasma, fluoride
exists in two forms
:
Ionic and non ionic
Mostly in ionic form
Half life is 4 to 10 hrs
Excretion
:
The main route of
fluoride excretion is via
the kidneys
Absorption:
Fluoride is primarily
absorbed from stomach. This
process occurs by passive
diffusion and is also inversely
related to p
H

11. Distribution of fluoride in body
• It depends upon physical form of dose, presence of food in stomach,
gastric pH, gastric motility and concurrent oral administration.
• – Plasma Concentration: 0.7 to 2.4 um
• – Kidney: 4.16 ppm
• – Bone: 99 percent
• – Enamel: 2200 to 3200 ppm
• – Dentin: 200 to 300 ppm
• – Cementum: 4500 ppm
• – Pulp: 100 to 650 ppm.

12. History of fluoride

13. G.V. Black
Dr.Trendley Dean

15. Shoe leather survey
• The study of relationship between USA.
fl
uoride concentration in
drinkingwater, mottled enamel and dentalcaries
• a young Dental Of
fi
cer Dr H Trendley Dean to pursue full time research on
mottled enamel
.
• His
fi
rst task was to continue Mckay’s work
• He sent a questionnaire to the secretary of every local and state Dental
Society in the country and asked if mottled enamel existed in their area
s
• His aim was to
fi
nd out the minimal threshold of
fl
uoride— The level at
which
fl
uorine began to blemish the teeth.

16. S.n
o
Fluoride concentration in water Signs
1 4ppm or more
Discrete pitting
2 3ppm or more Mottling was wide
spread
3 2 to 3ppm Teeth had full
chalky appearance
4 1ppm or less No mottling of any
esthetic significance
Dean’s observation

18. Mechanism of action

20. Fluoridation
Systemic
Topical

21. Systemic
Water
Salt
Milk

22. Water fluoridation
• It is defined as the upward adjustment of the
concentration of fluoride ion in public water
supply in such way that the concentration of
fluoride ion in the water may be consistently
maintained at one part per million (ppm) by
weight.

23. History

24. Fluoride component used
• Fluorspar( calcium fluoride )
• Sodium fluoride
• Silicofluorides
• Sodium silicofluoride
• Hydrofluosilicic acid
• Ammonium silicofluoride.

25. Equipment for fluoridation.
• Saturator system
• Dry feeder system
• Solution feeder system.

26. Procedure

27. Optimum level of fluoride
• Based on extensive research, the United States
Public Health Service (USPH) (1986) established
the optimum concentration for fluoride in the
water in the range of 0.7 to 1.2 parts per million.
This range effectively reduces toothdecay, with
minimal chances to cause dental fluorosis.

28. Formula
• Galagan and Vermillion (1957) developed an
empiric formula for estimating the amount of
daily fluid intake

29. Large number
of people are
benefite
d
Consumption
is regula
r
also has
topical effect
through the
release in saliva
least
expensive and
most effective
on large scale
Advantages

30. Other modes are
not considere
d
Interfere with
human right
s
Common source
of water supply
may not be
present
Disadvantages

31. School water fluoridation
• This program helps in limiting caries in school children
who are our prime concern. School water fluoridation is a
suitable alternative where community water fluoridation is
not feasible.
• This procedure was first started in 1954 in St Thomas VS
Virgin Islands by US Public Health Service Division.
• The current recommended regimen for school water
fluoridation is adding 4.5 times more fluoride.

32. Minimal
equipmen
t
Not expensive.
Good results in
reducing
carie
s
Advantages

33. Disadvantages
• Not all children
go to school in
poor countrie
s
• Amount of water
drunk can not be
regulated
.

34. Salt fluoridation
• Wespi in 1955 introduced salt
fluoridation in Switzerland.
• Second to water fluoridation
• Concentration 200 to 350 mg/
kg

35. Methods
Dry method
Wet method

36. Procedure
• The procedure of salt fluoridation can be either by spraying concentrated
solutions of NaF or KF on salt on a conveyor belt or by mixing with PO4
carrier salt and then adding to the main bulk. Till now salt fluoridation has
been tried in Columbia, Hungary, Mexico and Switzerland, with Switzerland
being the oldest.

37. Caries reduction
• A study conducted by Toth, in Hungary after 8
years of use of fluoridated salt, showed a
reduction of 39 percent in deft in 6 years old
children.

38. • safe
• Low cos
t
• Theoretically
fluoridated salt
prevents dental caries
by both systemic as
• No supervision
of set up or
distribution
syste
m
• Depends on
individual
acceptance and
rejection.
Advantages

39. Disadvantages
International
efforts to
reduce sodium
uptake
.
Fluoridated salt consumption is
lowest when the need for
fluorides is greatest: in the
early years of life
.
salt intake varies
greatly among
people
.

40. Milk fluoridation
• Ziegler in 1956 was the first person to
mention milk fluoridation
• The concentration of fluoride in 250
mL milk bottle was 0.625 mg.
• It targets the fluoride directly to the
children and this could be less
expensive than water fluoridation. But
considerable number of children in
most countries will not drink milk for
one or another reason.

41. Compounds for milk fluoridation
• Calcium fluoride
• Sodium fluoride
• Disodiummonofluorophosphate
• Disodium silicofluoride.

42. Controversy
• In spite of the controversy concerning
the binding and complexing of fluoride
with calcium and protein of the milk
and thus making it unavailable for its
anticariogenic action
• Ericsson (1985) using radioactive
isotope technique proved that
availability of fluoride from milk is the
same as from water 4 hours after
consumption

43. Advantages
consumption can be
confined to groups
who need it most
staple food for
children
Advantages

44. Disadvantage
Disadvantages
• rural and urban areas
cannot afford milk
• Variation of intake
and quantity of
milk

45. Dietary fluoride supplement
• perceived to be a reasonable
alternative where water
fluoridation was not possible.
But supplements need co-
operation to a high degree and
so these should be directed
only to needy population for
whom caries or its treatment
may be difficult.
• Caries reduction -24%

46. Examples
• Some examples of supplements are fluoride
drops, fluoritab liquid, Vi-Daylin/F ADC drops,
pediaflor drops, etc.

47. Dosage
• The dosage will depend upon the age of the
child and the concentration of fluoride in the
area. American Academy of Pediatrics
recommends that fluoride supplements can be
started 2 weeks after birth and continue till 16
years of age.

48. Schedule

49. Prenatal fluoride
• Prior to 1969, fluoride was prescribed in prenatal supplements for
potential caries prevention in teeth whose development began
before birth. It was assumed that fluoride would cross the
placental barrier and that it would be acquired by the developing
teeth
• The United States Food and Drug Administration concluded that
sufficient evidence did not exist to support claims of efficacy of
prenatal fluoride supplements therefore in 1966 the Food and Drug
Administration banned advertising claiming that prenatal fluoride

50. Dose limit
• It is recommended that a child consume no
more than 1 mg of fluoride per day from
fluoride supplements and from the drinking
water.

51. Topical fluoride

52. Topical fluoride
• History:
• early 1940s, it was demonstrated that extracted teeth when
exposed to dilute solutions of fluoride on for a few seconds were
found to have completely bound fluoride on the enamel surface
which subsequently was less soluble than the original enamel
surface.
• In 1941, began the era of topical fluorides when the first clinical
study of NaF was carried out by Bibby using a 0.1 percent NaF
solution.

53. Stannous
fluoride
(1947)
APF (1963) Na MPP
(1963)
amine
fluoride
(1965)
varnish
containing
fluoride
(1968)

54. Types

55. Sodium fluoride
•Milestone
studies were
conducted by Bibby in
1941 and JW Knutson
in 1942
•Sodium
fluoride has neutral
pH, 9200 ppm of F–
•Knutson
and Feldman (1948)
recommended a technique of
4 applications of 2 % NaF
•In 3,7,11,13
•Caries
reduction in 1st
year was 45 %
and in 2nd year
was 36 %.

56. Method of preparation
• Two percent NaF solution can be prepared by dissolving
20 g of NaF powder in 1 liter of distilled water in a plastic
bottle.
• It is essential to store fluoride in plastic bottles because if
stored in glass containers, the fluoride ion of solution can
react with silica of glass forming SiF2, thus reducing the
availability of free active fluoride for anticaries action.

57. Method of application ( knutson technique)
Permit to dry for 4 minutes
Quadrants are isolated with cotton rolls and dried thoroughly
Sodium fluoride applied with cotton applicator in each quadrant
Cleaning and polishing the teeth
Repeat in the remaining quadrants
Patient is instructed to avoid eating,drinking or rinsing
for 30 minutes
Same procedure is repeated in 3,7,11,13years

58. Mechanism of action
Sodium fluoride reacts with hydroxy
apetite crystals forms calcium fluoride (a
thick layer on the tooth surface)
Calcium fluoride +
hydroxyapatite = fluoridated
Choking off
effect

59. Advantages
• Chemically stable
• Acceptable taste
• Nonirritating to gingival tissues
• Does not discolor the teeth
• Cheap and inexpensive.

60. Disadvantage
• Continuous application for 4 minutes
• Patient has to make four visits in a short time
• Follow-up is difficult.

61. Stannous fluoride
• 1950s
occupied a central
role in the saga of
•SnF2 was found to
be three times more
effective than NaF.
•Dudding and
Muhler in 1957 tried
single annual
application
•32 percent
caries reduction

62. Method of preparation
10ml
distilled
water
Freshly
prepared
0.8 g
powder
Stannous form Stannic form
No shelf
life

63. Method of application
. Quadrants are isolated with cotton rolls and dried thoroughly
Stannous fluoride applied with cotton applicator in each quadrant
Reapplied for every 15 to 30 seconds
4
mins
Applied annually

64. Mechanism of action

65. Disadvantage
• Should be prepared freshly
• LowpH
• Metallic taste
• Causes gingival irritation
• Produces discoloration of teeth
• Causes staining on margins of restorations.

66. Acidulated phosphate fluoride
Bibby in 1947
,
Ph sodium fluoride
lowered ,fluoride
absorption more
Finn brudevold and
co workers
Found ( fluoride acid
solution )
Semiannual application
of 1.23 % apf
decreased caries 28%

67. Method of preparation
20 mg of
Naf
1 litre of
0.1M
phosphoric
acid
50%
hydro
fluoride
acid
Ph - 3
Conc- 1.23
Gel ( Methylcellulose or
Hydroxyethyl cellulose )
ph - 4-
5

68. Mechanism of action

69. Advantages
• Has acceptable taste
• No staining
• No gingival irritation
• Stable with long shelf life
• Cheap.

70. Disadvantages
• Teeth have to be kept wet for 4 minutes
• Solution is acidic

71. Newer fluorides
• Amine fluoride :
• In 1945 Muhlemann of the University of Zurich first studied effects of AMF.
• • Amine fluoride is superior to inorganic fluorides in reducing enamel solubility
because of chemical protection by fluoride and physicochemical protection by organic
portion.
• • They are also surface active because they hold fluoride on enamel surface for longer
time.
• Stannous Hexafluorozirconat
e
• Researchers at Indiana University have developed SnZrF6 effective in reducing the
solubility of enamel and in preventing dental caries.

72. Fluoride varnish
• To achieve prolonged fluoride action in mouth Schmidt
in 1964 developed a new coating method in which the
teeth were coated with a lacquer containing fluoride
called F-lacquer, which released fluoride ions to the
dental enamel in high concentrations for several hours
in the moist atmosphere of the mouth. Consequently
the use of fluoride containing varnishes in caries
prevention has become the treatment of choice.

73. Commonly used
• Duraphat
• Fluor protector

74. Benefits over other fluorides
• they remain in contact with teeth for a very short time, i.e.
5 to 10 minutes before getting diluted by saliva and
consequently can exert relatively a superficial effect on the
dental enamel.
• A second drawback with topical fluoride solutions is that
soon after application much of the acquired fluoride,
probably representing unreacted F and CaF2, leaches
away.

75. Composition
• Fluor protector is a colorless, polyurethane lacquer dissolved in
chloroform and dispensed in 1 mL ampules. The fluoride
compound is a difluorosilane. The fluoride content in fluor
protector is 0.7 percent by weight and the active fluoride available
is 7000 ppm
• • Duraphat is sodium fluoride in varnish form containing 22.6 mg
F/mL (2.26%) suspended in an alcoholic solution of natural organic
varnishes. It’s available in bottles of 30 mL suspension containing
50 mg NaF/mg. The active fluoride available is 22,600 ppm

76. Technique for application

77. Mechanism of action
• Duraphat
• NaF in varnish form with neutral pH. When applied topically under clinically
controlled conditions, a reservoir of fluoride ions gets built up around the
enamel of teeth. From this, fluoride keeps on slowly releasing and continuously
reacting with the hydroxyapatite crystals of enamel over a long period of time
leading to deeper penetration of fluoride and more formation of fluorapatite.
• • A part of CaF2 so formed in low concentrations further reacts with crystals of
hydroxyapatite and forms fluorapetite.
•
•10Ca5 (PO4) 3OH + 10 F = 6 Ca5 (PO4) 3F + 2CaF2 + 6 Ca3 (PO4)2 + 10
• 2Ca5 (PO4) 3OH + CaF2 = 2 Ca5 (PO4) 3F + Ca

78. Fluoroprotector
• lower fluoride content in
fluorprotector
• deposited in enamel is twice
• ability to inhibit caries is far
less than duraphat.
• Fluororpretector reacts with saline
and forms hydrofluoric acid (HF)
( penetrates enamel more )
• Flourosilane more retention using
•R-SiF2 OH + H2O = R-Si (OH)3 + 2 HF

79. Safety features in varnish
• recommended dose of
• 0.5 mL duraphat - 11.3 mg F
• 0.5 mL of fluor protector- 3.1 mg F.
• The highest plasma fluoride concentration varied
between 60 and 120 mg/mL and was seen within 2
hours of application. These values are far below the
toxic doses and hence adjudged to be safe.

80. Fluoride dentrifices
• almost 95 percent of the available
toothpastes in the market are
fluoridated.
• The most commonly evaluated
fluoride dentifrices are sodium
fluoride and stannous fluoride
and more recently the sodium
monofluorophosphate and amine
fluoride, are also being used.

81. Sodium Fluoride and Stannous
Fluoride Dentifrices
• NaF was the first fluoride compound
to be added as an active ingredient
but its efficacy was very limited
• In 1955 another milestone
development in history of dentifrices
was the introduction of divalent tin
fluoride compound (SnF2) in
dentifrices containing 0.4 percent
SnF2 in a calcium pyrophosphate
abrasive system

82. Drawbacks
• this also failed to get the desired results
because of its compatibility with abrasives,
staining of anterior restorations of composites
resins and a metallic astringent taste, which
was not acceptable.

83. Amine Fluoride Dentifrices
• This was first tested for its cariostatic
potential in Zurich, Switzerland.
• This showed organic fluorides to
have antibacterial and anticariogenic
properties, which were superior to
inorganic fluorides and demonstrated
significant reduction in caries rate.
• These dentifrices are marketed only
in Europe

84. Monofluorophosphate
• History
• Monofluorophosphate (MFP) is the basic
incompatibility of the NaF and SnF2
compounds with calcium abrasives leading
to decrease available fluoride 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

85. •MFP at a concentration of 0.76 percent, 0.1 percent
F with sodium metaphosphate as abrasive
• reductions in caries rates ranging from 17 percent for
unsupervised brushing and about 34 percent for
supervised brushing

86. Mechanism of action
Two modes of action
• Ericsson (1963)
• MFP is deposited in the crystalline
lattice and in subsequent
intracrystalline transposition, and
fluoride is released and replaces
the hydroxyl group to form
fluorapatite.
•Ingram (1972) attributes to the
anticariogenic activity. MFP differs
from other agents, in the aspect that
its F-atom is covalently bonded to
phosphorous atom. The mechanisms
include direct incorporation into
hydroxyapatite or hydrolysis to
phosphate and fluoride ions,
followed by reaction to form
fluoroapatite.

87. Advantages
• Neutral pH
• greater stability to oxidation and hydrolysis
• longer shelf life
• increased availability of fluoride
• no staining of teeth.

88. Activity
• Controversy around milk fluoridation
• The specific disadvantage of each topical
fluoride that gave the rise to new topical
fluorides

89. Mouth rinses
Neutral sodium
fluoride ( most
commonly used )
•First trial Scandilivia
• Recommended for
adults ( permanent
dentition )
• Effectivenes
s
• Low cost
• Ease of storage
• Lack of bad taste
and staining
Effective conc
=200 and 1000mg
Not recommended
for children
Can be used in
both fluoridated
and non
fluoridated area

90. Solutions and gels applied with tooth brush
Drawbacks
:
• Expensive
• Supervision needed
• Depends on the method
used
Tooth brushing with
concentrated solution or gel
(5 times per year )
Caries reduction
by 25%

91. Gel trays
Same regimen : thrice a
week for children water with
optimal fluoridation there
was only a modest additional
caries reduction .
Concentrated fluoride gel in custom tray
decreases caries by 75-80 % in community
with non fluoridated water .
Use in small
quantities In trays
pressed against the
tooth undiluted with
saliva
Drawbacks
:
Demand much time and
cooperation from pt
High supervision
needed
Expensive

92. Comparison and combination
Other topical fluoride vs varnish
Others Leach out where as varnish adheres
to the enamel leading to sustained action
Tooth paste with mouth rinse
is used in many studies
NaF rinse + APF gel
Although the
combinations are effective
they are not the
addition
There is no justification for the use of more than
one systemic but systemic + topical is beneficial

93. Fluoride mouth rinses not
recommended below the age of 5
Neutral sodium fluoride
is preferable for school
based programmes
( taste )
Fluoride dentrifices - both children
and adults
Fluoride tooth paste - suitable for all in optimal
fluoride levels
Children under 5 - toothpaste in peasize
School based mouth rise where water fluoride is low
Professional applied
Children - high risk
Adults - xerostomia
Radiation

94. MCQ
1.Highest fluoride water content
A.Lake kivu B.Lake Nakuru C.Lake Albert. D.Lake Turkana
2. Who introduced the term Mottled enamel ?
A. G.V Black B. McKay C.Dean
3. Optimum level of water fluoridation
A. 0.5 to 1.5ppm. B. 0.9 to 1.2.ppm C. 0.7 to 1.2 ppm
4.Wide spread mottling is seen in water fluorides levels of
A.4 ppm. B..3ppm C. 5ppm
5. Salt fluoridation introduced in the year
A.Wespi BZiegler C. Churchill

95. 6. NaF applied in all ages expect
A. 11 years B. 13 years C.9 years
7. Which of the following topical fluoride is long acting ?
A. Stannous fluoride B. Fluoride Varnish C. APF
8. Which of the following is freshly prepared and why ?
A. NaF B. SnF2 C. Fluoride varnish
9. A dental camp is conducted in a school in the locality with optimum level of water fluoridation , the
population includes children of classes LKG and UKG with moderate caries risk what is preferred method
fluoride program ?
A. Tooth paste B. Mouth wash C. School water fluoridation D. Topical fluoride application
10 . Which is the most expensive among the self applied topical fluoride?
A. Mouth rinse. B. Gel tray C. Self paint on

96. Answer key :
1. C
2.A
3.C
4. B
5. A
6.C
7.B
8.B
9.A
10.B

97. References
• https://ods.od.nih.gov/factsheets/Fluoride-
HealthProfessional/
• https://dciindia.gov.in/Download/
NOHSBOOK.pdf#page43( fluoride content in food )
• https://www.nidcr.nih.gov/health-info/fluoride/the-story-of-
fluoridation (history of fluoride)
• https://www.cdc.gov/fluoridation/basics/timeline.html( time
of fluoride)

98. • https://water.mecc.edu/courses/ENV115/lesson9.htm ( water fluoridation )
• Tubert-Jeannin S, Auclair C, Amsallem E, et al. Fluoride supplements (tablets,
drops, lozenges or chewing gums) for preventing dental caries in children. Cochrane
Database Syst Rev. 2011;2011(12):CD007592. Published 2011 Dec 7.
doi:10.1002/14651858.CD007592.pub
2
• https://www.dhs.wisconsin.gov/publications/p4/p44531.pdf
• Yadav S, Sachdev V, Malik M, Chopra R. Effect of three different compositions of
topical fluoride varnishes with and without prior oral prophylaxis on Streptococcus
mutans count in biofilm samples of children aged 2–8 years: A randomized controlled
trial. J Indian Soc Pedod Prev Dent 2019;37:286-91

99. • https://assets.ctfassets.net/u2qv1tdtdbbu/
Pkhy82S0Hs8NwrSieH8za/
ddaa703ae6d4248fbae6842493e7481b/ce94_7-10-20.pdf
• Pushpalatha C, Bharkhavy KV, Shakir A, Augustine D,
Sowmya SV, Bahammam HA, Bahammam SA, Mohammad
Albar NH, Zidane B and Patil S (2022) The Anticariogenic
Efficacy of Nano Silver Fluoride. Front. Bioeng. Biotechnol.
10:931327. doi: 10.3389/fbioe.2022.931327

100. • Textbook_of_Pediatric_dentistry_Nikhil_Marwah_4thedition
• NATIONAL ORAL HEALTH SURVEY & FLUORIDE MAPPING 2002-2003
• Fluoride and oral health A report of Who expert member of oral
health and fluoride use
• Fluoridation facts - by Ada
• Appropriate use of fluorides for human health by J.J.Murray
• Fluoride in dentistry 2nd edition by Ole Fejerskov ,Jan Ekstrand,
Brian A Burt