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SYSTEMIC FLUORIDES

This document discusses the history and metabolism of fluorides. It begins with an outline of the topics to be covered, including the history of fluorides, fluoride concentration in tissues, and systemic fluoride sources like water and salt fluoridation. It then covers the chemistry and distribution of fluoride in the environment, foods, and body. The majority of the document discusses fluoride absorption, distribution in serum and tissues like bone and teeth, and excretion through urine, feces, and sweat. It notes that most absorbed fluoride is deposited in mineralizing tissues and the remainder is cleared by the kidneys.

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History of fluorides 1
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Systemic fluorides 6 Presented by: Suhail, 2nd year postgraduate.
 History of fluorides  Fluoride metabolism  Fluoride concentration in enamel, dentin & cementum  Mechanism of action of fluorides in caries reduction  Topical vs systemic fluorides  Systemic fluorides  Water fluoridation  Salt fluoridation  Milk fluoridation  Sugar & flour fluoridation  Fluoride supplements 7
Fluoride  Latin word ‘fluore’ to flow  Pale, yellow-green gas  Fluoride is a ubiquitous mineral.  Trace element & halogen  Atomic weight  19 & atomic number 9  Combined forms fluorspar(48.5%), fluorapatite & cryolite. 8
Fluorine is an element of many mosts: most reactive of all of the elements the most powerful oxidizing agent most electronegative. compounds it forms--some of the most stable and inert substances known to man 9
Distributed widely in: Fluoride in Air- HF , carbon tetrafluoride (CF4), hexafluoroethane (C2F6) and silicon tetrafluoride Dust of f2 containing soils, gaseous industrial, coal smoke, and volcanic emulsion. Levels of air borne- Aluminum factories: 5micro grams/ m3 Fluoride in plants- Roots form soil and Leaves form air Camellia sinensis –acidic soils, Indian Tea leaves – 70 to 375 ppm Vegetables- factories- 10ppm Fruits and vegetables- 0.2 to 0.5 microgram/gram wet wt. grown near aluminums In India, the natural level of fluoride in ground water varies from very low levels to over 4 ppm. The fluoride level of the oceans ranges from 1.2 to 1.4 ppm. 10
 Fluoride in animal products-  Mutton and pork -0.3ppm  Higher in Chicken- contamination bone and cartilage fragments  Fish products- up to 20ppm  Dried sea foods also fluoride rich 84.5ppm (South East Asia)  Fluoride in beverages-  Ranges from 0.05 to 1.05 ppm  Fluoride content in alcoholic beverages generally reflects that of water used. 11
Total daily intake of fluoride Fluoride from Air  Minimal Fluoride from Water  Most important single source of fluoride  Dependent on fluoride concentration and amount  Fluctuation –climatic and geographical areas Fluoride from food  0.3 to 0.6 mg/day  Fluoride intake 6months of life- bottle/breast fed  Breast fed infant receives 0.003 to 0.004mg/day- formula fed infants (1.2ppm) fluoride intake increased 50 times 12
 Excessive consumption of tea and sea foods- increased flr  National Research Council 1980 – safe and adequate 1.5 to 4.0 mg/day in adults 0.05 to 0.07 mg/day in children for optimal dental health 13 Total daily intake of fluoride
Fluoride metabolism Any increase of fluoride in the cell can cause interference with cellular function. In the neutral pH environment of the cytoplasm, HF dissociates into protons and fluoride ions. HF being neutral can readily penetrate gut epithelial cell walls and enter the cell cytoplasm. Because of high dissociation constant (Ka) of −3.189, 99.9% fluoride ions will be protonated by HCl in the stomach to produce HF. It then enters the GI system where it is absorbed and metabolized. Fluoride from systemic administration (supplements, milk, water, and salt) enters the oral cavity where it provides topical benefits before it is swallowed. 14
 90% of the absorbed fluoride  serum where it is quickly distributed and diluted (clearance depends on pH balance) (Whitford 1990)  Serum fluoride levels seldom exceed 0.06 ppm but are more typically in the 0.01- ppm range (Sowers et al. 2005)  Fluoride concentration of saliva, sweat and breast milk is less than the serum  these biological fluids would not be efficient for eliminating fluoride (besides, nearly all of the saliva is re-ingested). 15
As the serum circulates, about 50% is sequestered into the mineral phases of developing teeth and bones (1000 ppm) A small amount of fluoride is excreted in feces (Whitford 1990). Remaining fluoride is freely filtered in the kidneys(5ppm), stored in the bladder, and excreted. 16
Fate of 1 mg of fluoride ingested 17 Breast milk
Fluoride metabolism & Bioavailability  Therapeutic action and safety of fluoride – kinetic process Mechanism and site of absorption:-  Water soluble fluorides- NaF, HF, H2SiF6, Na2PO3F and StF  Less soluble fluorides- CaF2 , Ca10(PO4)6F2  Passive in nature  Rapid absorption stomach- nonionic diffusion of HF  PH of gastric fluid-free F in the form of HF  With milk, F bioavailability decreased..  Formation of low soluble calcium fluoride  Binding to casein and colloidal calcium phosphate  Clotting of milk (acidity)-physical barrier over mucosal surfaces 18
Fluoride metabolism & Bioavailability…  Absorption from solid foods is less compare to liquid  80% of ingested is absorbed From fluoride preparation and dental materials:-  Dentifrices- less  Alginate (4450 to 24,240 ppm)- systemic absorption peak in 30 min Single impression Zelgan- 119ng/ml in plasma level Double impression -200ng/ml 150 ng/ml from 3mg F in aqueous solution  Fluoridated anesthesia- halothane, methoxyfluorane, Enflurane -630ng/ml 19
Physiologic Distribution of fluoride Fluoride in Blood:-  Blood plasma is most reliable indicator  ¾ in plasma and ¼ in RBC  Fluoride exists in both forms -bounded from -ionic form- varies concentration F in drinking water  Increase in plasma F with age and in presence of renal failure Drinking water 0.25 or 1.25 ppm –plasma level 0.01 or 0.025ppm Increased reactive sites and voids in old bone is more saturated and filled with F than young bone 20
Effects on Hematopoietic cells  Effects vary depending upon fluoride dose, duration of exposure, and species, and include anemia and leukopenia (Mehdi et al., 1978; Eren et al., 2005).  Bone marrow cells  CFU (pluripotent characteristics) multiple hematopoietic lineages (e.g., granulocytic, monocytic, and erythroid) or one hematopoietic lineage.  Potential shift in differentiation of BM progenitor cells away from monocytic lineage may affect osteoclast formation. 21
Fluoride in soft tissue:-  Tissue/ plasma ratio = 0.4 to 1  Ectopic calcification loci- F accumulation in Aorta, tendon, cartilage and placenta 22Physiologic Distribution of fluoride
Effects on kidney  Fluoride is normally cleared from the blood by deposition in bone, excretion in urine- unable to find toxic effect on kidney endemic fluorosis.  Patients with chronic renal failure- dialysed with fluoridated have additional load of fluoride So fluoride free water is used for kidney dialysis 23
Fluoride in hard tissue Bone:-  Total amount-2.6mg  Most of F in the body retained in the skeleton-vary according to the renal clearance  F enter in mineralized tissue-replacing 0H-, C03 2- and HC03 -  Remodeling bones deposit more fluoride than older people  Fluoride deposition is a reversible process 24
Actions on Bone Physicochemical interaction of fluoride with the bone mineral matrix (Grynpas, 1990; Grynpas and Rey, 1992; Pak et al., 1995; Chachra et al., 1999). Carbonated hydroxylapatite  carbonated fluorapatite Reduction in mechanical strength properties Alters bone crystal structure Delays mineralization 25
Teeth:-  Deposition occurs in successive stages. Initial deposition – organic and mineral phases are laid down Pre-eruptive maturation phase-before eruption Post eruptive maturation and aging period  Dentine contains 4 times more than enamel  Fluoride concentration not uniform  Fluoride concentration –initial stages is higher than on completion ( mineralization process- release of F to the bathing fluid)  Primary teeth less fluoride concentration than permanent teeth Fluoride in hard tissue… 26
Actions on Ameloblasts Ameloblasts in the maturational phase  chronic fluoride exposure (DenBesten and Thariani, 1992) Transitional and early- secretory ameloblasts  acute fluoride toxicity (Lyaruu et al., 2006). 27
Fluoride in hard tissue…  Fluoride concentration in the outer enamel (2micrometer)- 1700ppm-non fluoridated areas (0.1ppm) 2200 to 3200ppm- optimally fluoridated areas (1ppm) 4800ppm- 5 to 7ppm  Depth 5 micrometer- Permanentteeth Primaryteeth Non-fluoridated areas Fluoridated areas 1100ppm 2200ppm 670ppm 950ppm 28
Fluoride in hard tissue…  F concentration in newly erupted teeth- higher in in incisal than cervical margin  Diffusion of F in enamel NaF and monoflurophosphate(100pmm)- 10-9cm2/sec  Speed at which F penetrates in enamel- 38 micrometer/ hour (186micrometer/ day) 29
Fluoride in hard tissue… Concentration in dentin:- more than enamel-apatite crystals are smaller -surface area and capacity to take is much larger In permanent teeth: Highest near the pulpal surface low in secondary dentin In primary teeth complicated –physiologic resorption occurs towards pulpal side greatest rise and fall – Pulpal surface of multirooted teeth 30
Fluoride in hard tissue… Fluoride concentration in Cementum:-  Higher than any skeleton or dental tissue  Tissue is very thin  Near the tissue surface- accessible to fluoride present in blood  Increases with age 31
Excretion of fluoride 3 main avenues are urine, feces and perspiration Via kidneys:-  40 t0 50% of single dose excreted in urine during 24 hours  Factors influencing are  Previous exposure to fluoride  Age  Urinary flow  Urine PH  Kidney status  Glomerular filtration –tubular reabsorption in the form of HF- greater the acidic urine 32
Excretion of fluoride…  PH- < 5.6: Excreted fraction of filtered fluoride <5% Reabsorbtion-95%  Above 5.6: increased fraction of F excretion In acute poisoning: increased PH urine alkalizing agents enhance the elimination of F 33
Via the Gut:-  Undissolved and not absorbed excreted unchanged in feces  10% of total fluoride intake is excreted in feces Via sweat:-  Varying proportions of absorbed fluoride may lost from the body in perspiration  Under normal conditions of F intake-concentration of Fin sweating range of 0.07 to 0.5ppm 34 Excretion of fluoride…
Via saliva:-  Less than 1% of absorbed from saliva was recovered from saliva  0.01 to 0.05ppm Via breast milk:-  0.01 to 0.05ppm  Selective in taking up fluoride- no evidence of transfer of F from plasma to milk  Cow’s milk higher F content than human milk 35 Excretion of fluoride…
Placental transfer of fluoride  Fluoride in primary teeth and bones: placental transfer  Placenta does not selectively inhibit fluoride transfer  Higher the fluoride ingestion: partial barrier may exist 36
Mechanism of action of fluoride in caries reduction.  Increased enamel resistance (or) reduction in enamel solubility  Increased rate of post eruptive maturation  Remineralization of incipient lesions  Interference with plaque microorganisms  Modification in tooth morphology 37
How does fluoride help prevent dental decay?  Systemic fluorides are those ingested into the body.  During tooth formation, ingested fluorides become incorporated into tooth structures.  Fluorides ingested regularly during the time when teeth are developing (preeruptively) are deposited throughout the entire tooth surface and provide longer-lasting protection than those applied topically.  Systemic fluorides can also give topical protection because ingested fluoride is present in saliva, which continually bathes the teeth providing a reservoir of fluoride that can be incorporated into the tooth surface to prevent decay.  Fluoride also becomes incorporated into dental plaque and facilitates further remineralization. 38
Summary of Anti-Caries Activity of Fluoride. 39
Mechanism of action of fluorides in caries reduction  Increase in enamel resistance or decrease in solubility  Increased rate of posteruptive maturation  Remineralisation of incipient lesions  Inhibition of demineralisation  Interference with plaque microorganisms  Modification of tooth morphology 40
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ADA recommended fluoride supplementation schedule 42
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New recommended schedule for fluoride supplements 44 Guideline on Fluoride Therapy, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY REFERENCE MANUAL V 37 / NO 6 15 / 16
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 Levy (2003) stated: There continues to be controversy concerning the use of dietary fluoride supplements, and now they are not generally recommended.  ADA convention in 2010 latest recommendations. 48
Fluoride delivery methods 49 Systemic Topical Dietary fluoride supplements Water fluoridation School water fluoridation Milk fluoridation Salt fluorudation Sugar fluoridation Professionally applied Self applied Solutions Gels varnishes Dentrifices Rinses Gels Toothpicks Floss Chewing gums
Topical vs systemic fluorides  Original belief  Fluoride that is swallowed topical effect on erupted teeth (before swallowed, as well as a topical effect due to increasing salivary and gingival crevicular fluoride levels).  Elevated plasma fluoride levels  outer surface of fully mineralized, but unerupted teeth topically.  Topical fluoride that is swallowed  systemic effect. 50
Systemic fluorides  Low concentration of fluoride to teeth for a long period  Circulates through blood stream and is incorporated into the developing teeth. After teeth erupt fluoride contacts teeth directly through salivary secretions.  Common form of systemic fluorides is fluoridation. 51
Sources of fluoride  Ground water  Plants  Tea  97 ppm  Some fishes  Potatoes  6.4 ppm 52
What is water fluoridation..????  Water fluoridation is the adjustment of the natural fluoride concentration of fluoride-deficient water to the level recommended for optimal dental health.  Based on extensive research, the United States Public Health Service (USPHS) established the optimum concentration for fluoride in the water in the United States in the range of 0.7 to 1.2 parts per million.  This range effectively reduces dental decay while minimizing the occurrence of dental fluorosis.  The optimum level is dependent on the annual average of the maximum daily air temperature in the geographic area.  One milligram per liter (mg/L) of fluoride in water is identical to one part per million (ppm).  At 1 ppm, one part of fluoride is diluted in a million parts of water. 53
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HISTORY OF WATER FLUORIDATION. The first water fluoridation programme was started in the year 1945 in the four cities in USA. GRANDS RAPIDS- MUSKEG ON STUDY NEWBURG H- KINGSTON STUDY EVANSTO N- OAK PARK STUDY BRANTFOR D-SARNIA- STARTFOR D STUDY TIEL – CULEMBORG STUDY 55
GRAND RAPIDS- MUSKEGON STUDY  On January 25 th ,1945 ,sodium fluoride was added to GRAND RAPIDS water supply. Muskegon town was kept as a control.  After 6 ½ years in July ,1951 the caries experience of 6 and 15 years old children residents of Grand Rapids was half that of Muskegon . ( reported by - Arnold et al,1953).  So impressive was the efficacy of fluoridation that the city officials of Muskegon also decided to fluoridate their own water supply also. 56
NEWBURGH –KINGSTON STUDY  On may 2nd 1945 , sodium fluoride was added to drinking water of Newburgh on the Hudson river .  Kingston town was kept as a control.  After 10 years of fluoridation Et Al (1956) reported that the DMF rate had fallen from 23.5 % to 13.9 %, confirming the caries inhibitory property of 1 ppm fluoride in drinking water. 57
THE BRANTFORD- SARNIA-STARTFORD FLUORIDATION CARIES STUDY  In Canada, a project was undertaken in Brantford, Ontario, where fluoride was added to water supply in June 1945.  The community of Sarnia was established as the control town.  In addition ,the community of Stratford, where fluoride was naturally present in drinking water at level of 1.3 ppm was used as an auxiliary control.  After 17 years of fluoridation in Brantford, caries experience was similar to that occurring in the natural fluoride area of Stratford and was 55 % lower than in the control town of Sarnia ( REPORTED BY – BROWN AND POPLOVE,1965) 58
TIEL – CULEMBORG STUDY  In March 1953 the drinking water in Tiel was fluoridated to a level of 1.1 ppm.  Culemborg with water fluoride level of 0.1 ppm was the control.  After 13 years of fluoridation, the number of anatomical sites of teeth affected by dental caries was 58 % lower in Tiel than in Culemborg. 59
Recommendations by AAPD 1. There is confirmation from evidence-based reviews that fluoride use for the prevention and control of caries is both safe and highly effective in reducing dental caries prevalence. 2. There is evidence from randomized clinical trials and evidence- based reviews that fluoride dietary supple- ments are effective in reducing dental caries and should be considered for children at caries risk who drink fluoride-deficient (less than 0.6 ppm) water. 60
Sample collection for fluoride estimation  Fluoride electrode coupled with standard pH meter  Scot-Sanchis method Compounds used for water fluoridation  Fluorspar  Sodium fluoride  Sodium silicofluoride  Aluminium silicofluoride  Hydrofluorosilicic acid Equipment for water fluoridation  Saturator system  Dryfeeder system  Solution feeder system 61
MATERIALS USED IN WATER FLUORIDATION  Three types of fluoride equipments 1. Dry feeder 2. Solution feeder 3. Saturation methods  Dry compound such as ammonium silico fluoride, fluorspar, sodium silico fluoride.  Solution of hydrofluoro sillicic acid. Fluoride is added to 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. 62
 SATURATOR SYSTEM  DRY FEEDER SYSTEM  SOLUTION FEEDER SYSTEM 63
 Principle: 4% saturated solution of NaF is produced and injected at the desired concentration at the water distribution source with the aid of a pump  High hard water level used  Suitable for small towns 64
 Principle: NaF in the form of powder is introduced into a dissolving basin with the aid of an automatic mechanism to ensure maintanence of the correct supply of F according to the amount of water to be delivered  Handling of F, obstruction of pipes  Medium sized town 65
 Principle: Volumetric pump permitting the addition of a given quantity of hydrofluorosilicic acid in proportion to the amount of water treated  Construction using polyvinyl chloride  medium sized and large town 66
 Maintenance and control  Control at water treatment plants  Control of the quality of analysis  Control of the quality of water in network  Control of the quality of the F used 67
SYSTEM PROCEDURE FACTORS LIMITING USAGE RECOMMENDATION SATURATOR SYSTEM 4 % saturated solution of NaF is produced and injected at the desired concentration in the water distribution source with aid of a pump. Need to clean gravel bed used for filtration. Suitable for medium sized towns requiring less than 3.8 million lit/day DRY FEEDER NaF or silicofluoride in the form of powder is introduced into a dissolving basin. Care in handling fluoride, obstruction of pipes and compacting of fluoride while storage. Suitable for medium sized towns requiring 3.8 million lit/day to 19 million lit/day. 68
SOLUTION FEEDER Volumetric pump permitting the addition of a given quantity of hydrofluosilicic acid in proportion to the amount of water treat the equipment must be resistant to attack by hydrofluosilicic acid, necessitating construction in polyvinyl chlorides or another plastic. Suitable for medium sized and large towns with a capacity of more than 7.6 million lit/day 69
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).  Fluoride concentration  4.5 times the optimal concentration for a community in the same geographic area  Currently recommended level: 4.5-6.3 ppm  In the early 1980s, a total of 13 states had initiated school water fluoridation in 470 schools serving 170,000 children . 70
 Recent studies  this effect might no longer be as pronounced  Operating and maintaining small fluoridation systems (i.e., those serving <500 persons)  practical & logistical difficulties  higher than recommended fluoride concentrations in the school drinking water, but no lasting effects among children have been observed.  In schools that enroll preschoolers in day care programs, children aged <6 years  > adequate fluoride. 71
SCHOOL WATER FLUORIDATION  School water fluoridation is one of the possible areas to be explored. This programme helps in limiting caries in school children who are the prime concern.  It is the suitable alternative where water fluoridation is not feasible.  The amount of fluoride added In school drinking water should be greater than normal because children have to stay in the school for a short period of time and to compensate for holidays and vacations. HISTORY  This procedure was first started in 1954 in St. Thomas V.S Virgin islands by US public health service division. . 72
 The current recommended regimen for school water fluoridation is adding 4.5 times more fluoride .  There has been around 25 to 40 % decrease in dental caries with this program.  Simple fluoridators particularly that employ the venturi system are most suitable ,because they require almost no maintenance and can be utilized effectively in small instalments of small or medium sized schools. ADVANTAGES  good results in reducing caries.  Minimal equipment .  Not expensive. 73
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. 74
FDA fluoride requirements for bottled water 75
The declining benefit of water fluoridation  The magnitude of the benefit of fluoridated water declined in the 1970s and 1980s (Ripa 1993)  worldwide trend of declining dental decay rates, even in non-fluoridated areas (Diesendorf 1986; Brathall et al. 1996; de Liefde 1998)  making it difficult to measure the efficacy of water fluoridation. 76
 Factors responsible for the worldwide decline in dental caries  General, widespread use of fluoridated toothpaste (Brathall et al. 1996)  improved diets  changes in oral flora  improved dental materials and therapies  improved dental hygiene 77
Does water fluoridation simply delay dental decay?  Diesendorf (1986)  delay in caries increment in fluoridated areas.  Prior to the introduction of fluorides for caries prevention, the mean age of tooth eruption rates were constant (Limeback 1999)  Since the introduction of fluorides, delay in tooth eruption  0.7 years (Virtanen et al. 1994) & 2 years (Campagna et al. 1995).  Fluoride incorporation in the primary dentition and in the alveolar bone  generalized delay in tooth eruption.  Delay of tooth eruption of 1.0 or 1.5 years 20% or 33.3% apparent difference in dental decay rates resp. 78
Will decay rates rise if fluoridation is halted?  Kobayashi et al. 1992; Seppä et al. 1998; Künzel and Fischer 2000: failed to find a lasting difference in dental decay rates when fluoridation is halted  Halo effect  Decline of caries in non-fluoridated communities (Ripa 1993; Lewis and Banting 1994).  The benefits of water fluoridation, which are less and less clinically significant these days, have to be weighed against the side effects. (Excess fluoride from all sources) 79
FEASIBILILITY IN INDIA  Based on the current knowledge of increasing prevalence of dental caries, developing economy of our country, dentist population ratio of 1:80,000 and lack of preventive awareness of oral diseases , communal water fluoridation appears to be the most effective, practical and economical public health measure for prevention of dental caries as this method extends its benefits to all the residents of the community without necessitating any conscious effort on the part of the residents. 80
 But the only short coming is that it can be implemented only in the areas which have central pipe water supply system.  Currently, most of the cities and towns in India covering 30% of the population have piped water supply.  An effort should be made with the concerned authorities to institute water fluoridation at least in these areas ( hope I.D.A.takes it up). 81
Salt fluoridation  Salt fluoridation programs  Bolivia, Equador, Columbia, Peru, Jamaica, Costa Rica, Mexico, Uruguay, Venezuela, Switzerland, Germany, and France ; Switzerland started the practice in 1955 (Marthaler 2005)  Salt is usually fluoridated at 250 ppm (250 mg F/kg salt, or 0.25 mg/gm salt).  Table salt in the kitchen 1 to 4 g of the daily salt intake  1 mg of fluoride a day at a salt intake of 4 grams a day. 82
Stephen et al. 1999: 350 mg fluoride/kg salt did not produce dental fluorosis but failed to show significant reduction in caries after 11.5 years On a theoretical basis (Hedman et al. 2006), ingestion of meals prepared with fluoridated salt  Increases salivary fluoride levels  Protection against caries Disadvantages  fluoridated salt consumption is lowest in early years of life and high salt intake can lead to hypertension. 83
FEASIBILITY IN INDIA  Salt fluoridation appears to be a viable and feasible method of fluoride ingestion systemically because its distribution can be easily monitored as the supply can be effectively controlled especially for those areas which do not need supplemental fluorides i.e., endemic fluoride belts.  Moreover ,individual monitoring is not required as the levels are so adjusted so as to provide optimum levels of fluoride keeping in view the fact that on an average an individual consumes 5-8 gms of salt per day. 84
 Also salt is freely available and is used on a large scale all over the country by majority of the population of various ethnic and regional groups.  Regarding the acceptability of the population it shall be readily accepted as the addition of fluoride to salt does not alter its colour as in case of salt iodization. 85
LIMITATIONS  There may be large variations in salt intake in different groups of people .fluoridated salt consumption is lowest when the need for fluorides is greatest – in early years of life.  Increasing consumption of processed foods .if the processors do not use fluoridated salt.  Difficulties arise when there are multiple drinking water sources which have a naturally optimal or excessive fluoride concentration. 86
4. It requires refined salt produced with modern technology and a high level of technical expertise. 5. The current view data high salt intake may contribute to hypertension. 87
Milk fluoridation  First advocated by Ziegler in 1956.  Cochrane collaboration review by Yeung et al. 2005  only two intervention studies showed a reduction in dental decay when milk was fortified with fluoride and fed to children on a daily basis.  Maslak et al. (2004)  2.5 ppm fluoride & Stephen (1984)  6 ppm. (in 5 years, 31.2% reduction in DMFT) The children generally consumed one typical serving (200 mL) of the beverage (test and control milk). 88
 A high concentration of fluoride is needed for two reasons: (1) the children did not drink the beverage throughout the day and (2) calcium in the milk complexes with fluoride, which would reduce its availability for topical benefits.  5-15 ppm of fluoride in the milk  significant caries reduction of 40-50%.  Fluoridated milk  permanently low level of ionized fluoride within the oral cavity promoting remineralisation (topical effect) 89
FEASIBILITY IN INDIA 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 anti cariogenic action,  Though theoretically milk fluoridation is advantageous, in addition being the staple food for children and its consumption can be confined to groups who need it most, that practically speaking that this scheme /method does not seem to be viable and feasible because of : 90
a) In INDIA, majority of children population living in rural and urban areas cannot afford milk daily. a) Central milk supply system does not exist in India a) Variation of intake and quantity of milk is another which cannot be controlled since it depends upon the socio-economic and ethnic factors. 91
Flour and sugar fluoridation  Flour fluoridation was advocated in Denmark  Similar advantages as salt fluoridation, but not tested clinically  Wei, 1988  sugar fluoridation  both culprit & cure  First achieved in Finland (10mg/kg) 92
FLUORIDE COMPOUND USED  Most commonly used is sodium fluoride .  Other compounds used are acidulated phosphate fluoride, potassium fluoride or calcium fluoride.  Supplements contain measured amount of fluorides, 0.25 mg , 0.5 mg, 1.0 mg.  They should be taken on daily basis according to the prescribed dosage schedule.  The council of DENTAL THERAPRUTICS OF AMERICAN DENTAL ASSOCIATION recommends the dosage schedule for dietry fluoride supplements as shown in the table : 93
 Correct dosage is based on the concentration of fluoride in drinking water, age and weight of the child and other available fluoride.  Not more than 1 milligram of fluoride should be ingested each day from all available systemic sources. 94
Fluoride supplements  First introduced in late 1940s in children of non fluoridated areas. Common supplements used are:  Fluoride drops with/without vitamins (0.125,0.25 & 0.5 mg)  Fluoride tablets with/without vitamins (0.25,0.5 & 1mg)  Lozenges (0.25,0.5 & 1mg)  Oral rinse supplements (swish and swallow) (1mg, 5ml)  Considered for children at high caries risk who drink fluoride- deficient (< 0.6 ppm F) water. 95
 Determination of dietary fluoride  Sources of dietary fluoride  drinking water from home, day care, and school; beverages such as soda, juice, and infant formula; prepared food; and toothpaste.  Infant formulas, esp., powdered formulas reconstituted with fluoridated water  increased risk of fluorosis.  Infants may be particularly susceptible because of the large consumption of such liquid in the first year of life, while the body weight is relatively low. 96
 Commonly used compounds NaF & APF  Supplements  systemic & topical benefits for both primary & permanent teeth.  Bibby et al. 1955  fluoride lozenges that were sucked and swallowed were better than fluoride ‘pills’ that were swallowed right away 97
 Feltman and Kosel (1961)  ingestion of fluoride tablet by pregnant mothers  placenta, reaches developing fetus and benefits offspring; fluoride delays tooth eruption  some benefit.  Fluoride drop prescription  incorrect instruction following  incorrect dosages, complicated schedules, esp., when there were children of different ages in the household  poor compliance. 98
99
100
Percentage of caries reduction with different methods 101
102
Endemic areas for Fluoride / Fluorosis in Andhra Pradesh & Telangana Krishna Medak Karimnagar Kurnool Nalgonda Prakasam Chittoor Guntur Khammam Mahbubnagar Nellore 103
104
Conclusion In public health and clinical practice it is recommended that: • Fluoridation should continue and extend into the fluoridation of community drinking water. • Counsel parents and caregivers regarding use of fluoride toothpaste by young children, especially those < 2 years of age. • Target mouth-rinsing to persons at high risk. • Judiciously prescribe fluoride supplements. • Apply high-concentration fluoride products to persons at high risk for dental caries. 105
For purpose of self-care, it is recommended that patients: • Be aware of the fluoride concentration in the primary source of drinking water • Use small amounts of fluoride frequently. • Supervise use of fluoride toothpaste among children < 6 years of age. • Consider additional measures for persons at high risk for dental caries. • If the primary drinking water contains > 2 ppm fluoride, then use an alternative source of water for children ≤ 8 years of age. 106
References  Limeback H. Comprehensive Preventive Dentistry. Wiley Blackwell publishers. Limeback H and Robinson C. Fluoride therapy. Chapter 16, 251-82  Peter S. Essentials of preventive and community dentistry. 3rd edition, Arya (Medi) publishers. Peter S. Fluorides in preventive dentistry. Chapter 6, 270-355  Tandon S. Textbook of pedodontics. 2nd edition, Paras publishers. Tandon S, Gupta K. Chapter 11, 265-92  AAPD Guideline on Fluoride Therapy. Reference manual 36:14/15  Koplan JP. Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States. 2001;50 RR-14 107
 Guidelines on the use of fluoride in children: an EAPD policy document. Eur Arch Paediatr Dent 2009;10:129-35  Jones S, Burt BA, Peterson PE, Lennon MA. The effective use of fluorides in public health. Bulletin of WHO 2005;83:670-6  Everett ET. Fluoride’s effects on the formation of teeth and bones, and the influence of genetics. J Dent Res 2011;90:552-60  Lewis CW. Fluoride and Dental Caries Prevention in Children. Pediatrics in Review 2014;35;3-15  Fluoride in drinking water: A Scientific Review of EPA’s Standards, National Academies Press Washington DC. Chapter 4. 85-106.  Adair SM. Evidence-based Use of Fluoride in Contemporary Pediatric Dental Practice. Pediatr Dent 2006 ; 28:133-42 108
 Oganessian E., Lenčová E., Broukal Z. Is Systemic Fluoride Supplementation for Dental Caries Prevention in Children Still Justifiable? Prague Medical Report 2007 ;108:306–14  Burt BA. The Changing Patterns of Systemic Fluoride Intake. J Dent Res ;71:1228-37  de Souza CFM, Lima Júnior JF, Soraya PM, Adriano F, Sampaio FC. Systemic Methods of Fluoride and the Risk for Dental Fluorosis. Oral Health Care – Prosthodontics, Periodontology, Biology, Research and Systemic Conditions. 357-72  Hellwig AE , Lennon M. Systemic versus Topical Fluoride. Caries Res 2004;38:258–62 109
 Sikora M, Kwiatkowska B, Chulbek D. Fluoride content in superficial enamel layers of human tooth from archaeological excavations. Fluoride 2014;47:341-8  Saxena S, Sahay A, Goel P. Effect of fluoride exposure on the intelligence of school children in Madhya Pradesh, India. J Neurosci Rural Pract 2012;3:144-9. Neurotoxicity of fluoride. Abstracts, Fluoride 2014;47:92  Broadbent JM, Moffitt TE, Thomson WM, Ramrakha S, Poulto R. Community water fluoridation and Intelligence Quotient . Poster vii-145, 26th Annual convention of the association for psychological science;2014, San Francisco. Neurotoxicity of fluoride. Abstracts, Fluoride 2014;272-6 110
 Susheela AK. Dental fluorosis and its extended effects. Indian J Pediatr 2013;80:715-7. extended effects, beyond dental fluorosis, of fluoride poisoning in children. Fluoride 2014;47:272-6  Dobaradaran S, Nabipour I, Mahvi AH, keshtkar M, Elmi F, Amanollahzade F, khorsand M. Fluoride removal from aqueous solutions using Shrimp shell waste as a cheap bioadsorbent. Fluoride 2014;47:253-7 111

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SYSTEMIC FLUORIDES

  • 1.
  • 2.
  • 3.
  • 4.
  • 5.
  • 6.
    Systemic fluorides 6 Presentedby: Suhail, 2nd year postgraduate.
  • 7.
     History offluorides  Fluoride metabolism  Fluoride concentration in enamel, dentin & cementum  Mechanism of action of fluorides in caries reduction  Topical vs systemic fluorides  Systemic fluorides  Water fluoridation  Salt fluoridation  Milk fluoridation  Sugar & flour fluoridation  Fluoride supplements 7
  • 8.
    Fluoride  Latin word‘fluore’ to flow  Pale, yellow-green gas  Fluoride is a ubiquitous mineral.  Trace element & halogen  Atomic weight  19 & atomic number 9  Combined forms fluorspar(48.5%), fluorapatite & cryolite. 8
  • 9.
    Fluorine is anelement of many mosts: most reactive of all of the elements the most powerful oxidizing agent most electronegative. compounds it forms--some of the most stable and inert substances known to man 9
  • 10.
    Distributed widely in: Fluoridein Air- HF , carbon tetrafluoride (CF4), hexafluoroethane (C2F6) and silicon tetrafluoride Dust of f2 containing soils, gaseous industrial, coal smoke, and volcanic emulsion. Levels of air borne- Aluminum factories: 5micro grams/ m3 Fluoride in plants- Roots form soil and Leaves form air Camellia sinensis –acidic soils, Indian Tea leaves – 70 to 375 ppm Vegetables- factories- 10ppm Fruits and vegetables- 0.2 to 0.5 microgram/gram wet wt. grown near aluminums In India, the natural level of fluoride in ground water varies from very low levels to over 4 ppm. The fluoride level of the oceans ranges from 1.2 to 1.4 ppm. 10
  • 11.
     Fluoride inanimal products-  Mutton and pork -0.3ppm  Higher in Chicken- contamination bone and cartilage fragments  Fish products- up to 20ppm  Dried sea foods also fluoride rich 84.5ppm (South East Asia)  Fluoride in beverages-  Ranges from 0.05 to 1.05 ppm  Fluoride content in alcoholic beverages generally reflects that of water used. 11
  • 12.
    Total daily intakeof fluoride Fluoride from Air  Minimal Fluoride from Water  Most important single source of fluoride  Dependent on fluoride concentration and amount  Fluctuation –climatic and geographical areas Fluoride from food  0.3 to 0.6 mg/day  Fluoride intake 6months of life- bottle/breast fed  Breast fed infant receives 0.003 to 0.004mg/day- formula fed infants (1.2ppm) fluoride intake increased 50 times 12
  • 13.
     Excessive consumptionof tea and sea foods- increased flr  National Research Council 1980 – safe and adequate 1.5 to 4.0 mg/day in adults 0.05 to 0.07 mg/day in children for optimal dental health 13 Total daily intake of fluoride
  • 14.
    Fluoride metabolism Any increaseof fluoride in the cell can cause interference with cellular function. In the neutral pH environment of the cytoplasm, HF dissociates into protons and fluoride ions. HF being neutral can readily penetrate gut epithelial cell walls and enter the cell cytoplasm. Because of high dissociation constant (Ka) of −3.189, 99.9% fluoride ions will be protonated by HCl in the stomach to produce HF. It then enters the GI system where it is absorbed and metabolized. Fluoride from systemic administration (supplements, milk, water, and salt) enters the oral cavity where it provides topical benefits before it is swallowed. 14
  • 15.
     90% ofthe absorbed fluoride  serum where it is quickly distributed and diluted (clearance depends on pH balance) (Whitford 1990)  Serum fluoride levels seldom exceed 0.06 ppm but are more typically in the 0.01- ppm range (Sowers et al. 2005)  Fluoride concentration of saliva, sweat and breast milk is less than the serum  these biological fluids would not be efficient for eliminating fluoride (besides, nearly all of the saliva is re-ingested). 15
  • 16.
    As the serumcirculates, about 50% is sequestered into the mineral phases of developing teeth and bones (1000 ppm) A small amount of fluoride is excreted in feces (Whitford 1990). Remaining fluoride is freely filtered in the kidneys(5ppm), stored in the bladder, and excreted. 16
  • 17.
    Fate of 1mg of fluoride ingested 17 Breast milk
  • 18.
    Fluoride metabolism &Bioavailability  Therapeutic action and safety of fluoride – kinetic process Mechanism and site of absorption:-  Water soluble fluorides- NaF, HF, H2SiF6, Na2PO3F and StF  Less soluble fluorides- CaF2 , Ca10(PO4)6F2  Passive in nature  Rapid absorption stomach- nonionic diffusion of HF  PH of gastric fluid-free F in the form of HF  With milk, F bioavailability decreased..  Formation of low soluble calcium fluoride  Binding to casein and colloidal calcium phosphate  Clotting of milk (acidity)-physical barrier over mucosal surfaces 18
  • 19.
    Fluoride metabolism &Bioavailability…  Absorption from solid foods is less compare to liquid  80% of ingested is absorbed From fluoride preparation and dental materials:-  Dentifrices- less  Alginate (4450 to 24,240 ppm)- systemic absorption peak in 30 min Single impression Zelgan- 119ng/ml in plasma level Double impression -200ng/ml 150 ng/ml from 3mg F in aqueous solution  Fluoridated anesthesia- halothane, methoxyfluorane, Enflurane -630ng/ml 19
  • 20.
    Physiologic Distribution offluoride Fluoride in Blood:-  Blood plasma is most reliable indicator  ¾ in plasma and ¼ in RBC  Fluoride exists in both forms -bounded from -ionic form- varies concentration F in drinking water  Increase in plasma F with age and in presence of renal failure Drinking water 0.25 or 1.25 ppm –plasma level 0.01 or 0.025ppm Increased reactive sites and voids in old bone is more saturated and filled with F than young bone 20
  • 21.
    Effects on Hematopoieticcells  Effects vary depending upon fluoride dose, duration of exposure, and species, and include anemia and leukopenia (Mehdi et al., 1978; Eren et al., 2005).  Bone marrow cells  CFU (pluripotent characteristics) multiple hematopoietic lineages (e.g., granulocytic, monocytic, and erythroid) or one hematopoietic lineage.  Potential shift in differentiation of BM progenitor cells away from monocytic lineage may affect osteoclast formation. 21
  • 22.
    Fluoride in softtissue:-  Tissue/ plasma ratio = 0.4 to 1  Ectopic calcification loci- F accumulation in Aorta, tendon, cartilage and placenta 22Physiologic Distribution of fluoride
  • 23.
    Effects on kidney Fluoride is normally cleared from the blood by deposition in bone, excretion in urine- unable to find toxic effect on kidney endemic fluorosis.  Patients with chronic renal failure- dialysed with fluoridated have additional load of fluoride So fluoride free water is used for kidney dialysis 23
  • 24.
    Fluoride in hardtissue Bone:-  Total amount-2.6mg  Most of F in the body retained in the skeleton-vary according to the renal clearance  F enter in mineralized tissue-replacing 0H-, C03 2- and HC03 -  Remodeling bones deposit more fluoride than older people  Fluoride deposition is a reversible process 24
  • 25.
    Actions on Bone Physicochemicalinteraction of fluoride with the bone mineral matrix (Grynpas, 1990; Grynpas and Rey, 1992; Pak et al., 1995; Chachra et al., 1999). Carbonated hydroxylapatite  carbonated fluorapatite Reduction in mechanical strength properties Alters bone crystal structure Delays mineralization 25
  • 26.
    Teeth:-  Deposition occursin successive stages. Initial deposition – organic and mineral phases are laid down Pre-eruptive maturation phase-before eruption Post eruptive maturation and aging period  Dentine contains 4 times more than enamel  Fluoride concentration not uniform  Fluoride concentration –initial stages is higher than on completion ( mineralization process- release of F to the bathing fluid)  Primary teeth less fluoride concentration than permanent teeth Fluoride in hard tissue… 26
  • 27.
    Actions on Ameloblasts Ameloblastsin the maturational phase  chronic fluoride exposure (DenBesten and Thariani, 1992) Transitional and early- secretory ameloblasts  acute fluoride toxicity (Lyaruu et al., 2006). 27
  • 28.
    Fluoride in hardtissue…  Fluoride concentration in the outer enamel (2micrometer)- 1700ppm-non fluoridated areas (0.1ppm) 2200 to 3200ppm- optimally fluoridated areas (1ppm) 4800ppm- 5 to 7ppm  Depth 5 micrometer- Permanentteeth Primaryteeth Non-fluoridated areas Fluoridated areas 1100ppm 2200ppm 670ppm 950ppm 28
  • 29.
    Fluoride in hardtissue…  F concentration in newly erupted teeth- higher in in incisal than cervical margin  Diffusion of F in enamel NaF and monoflurophosphate(100pmm)- 10-9cm2/sec  Speed at which F penetrates in enamel- 38 micrometer/ hour (186micrometer/ day) 29
  • 30.
    Fluoride in hardtissue… Concentration in dentin:- more than enamel-apatite crystals are smaller -surface area and capacity to take is much larger In permanent teeth: Highest near the pulpal surface low in secondary dentin In primary teeth complicated –physiologic resorption occurs towards pulpal side greatest rise and fall – Pulpal surface of multirooted teeth 30
  • 31.
    Fluoride in hardtissue… Fluoride concentration in Cementum:-  Higher than any skeleton or dental tissue  Tissue is very thin  Near the tissue surface- accessible to fluoride present in blood  Increases with age 31
  • 32.
    Excretion of fluoride 3main avenues are urine, feces and perspiration Via kidneys:-  40 t0 50% of single dose excreted in urine during 24 hours  Factors influencing are  Previous exposure to fluoride  Age  Urinary flow  Urine PH  Kidney status  Glomerular filtration –tubular reabsorption in the form of HF- greater the acidic urine 32
  • 33.
    Excretion of fluoride… PH- < 5.6: Excreted fraction of filtered fluoride <5% Reabsorbtion-95%  Above 5.6: increased fraction of F excretion In acute poisoning: increased PH urine alkalizing agents enhance the elimination of F 33
  • 34.
    Via the Gut:- Undissolved and not absorbed excreted unchanged in feces  10% of total fluoride intake is excreted in feces Via sweat:-  Varying proportions of absorbed fluoride may lost from the body in perspiration  Under normal conditions of F intake-concentration of Fin sweating range of 0.07 to 0.5ppm 34 Excretion of fluoride…
  • 35.
    Via saliva:-  Lessthan 1% of absorbed from saliva was recovered from saliva  0.01 to 0.05ppm Via breast milk:-  0.01 to 0.05ppm  Selective in taking up fluoride- no evidence of transfer of F from plasma to milk  Cow’s milk higher F content than human milk 35 Excretion of fluoride…
  • 36.
    Placental transfer offluoride  Fluoride in primary teeth and bones: placental transfer  Placenta does not selectively inhibit fluoride transfer  Higher the fluoride ingestion: partial barrier may exist 36
  • 37.
    Mechanism of actionof fluoride in caries reduction.  Increased enamel resistance (or) reduction in enamel solubility  Increased rate of post eruptive maturation  Remineralization of incipient lesions  Interference with plaque microorganisms  Modification in tooth morphology 37
  • 38.
    How does fluoridehelp prevent dental decay?  Systemic fluorides are those ingested into the body.  During tooth formation, ingested fluorides become incorporated into tooth structures.  Fluorides ingested regularly during the time when teeth are developing (preeruptively) are deposited throughout the entire tooth surface and provide longer-lasting protection than those applied topically.  Systemic fluorides can also give topical protection because ingested fluoride is present in saliva, which continually bathes the teeth providing a reservoir of fluoride that can be incorporated into the tooth surface to prevent decay.  Fluoride also becomes incorporated into dental plaque and facilitates further remineralization. 38
  • 39.
  • 40.
    Mechanism of actionof fluorides in caries reduction  Increase in enamel resistance or decrease in solubility  Increased rate of posteruptive maturation  Remineralisation of incipient lesions  Inhibition of demineralisation  Interference with plaque microorganisms  Modification of tooth morphology 40
  • 41.
  • 42.
  • 43.
  • 44.
    New recommended schedulefor fluoride supplements 44 Guideline on Fluoride Therapy, AMERICAN ACADEMY OF PEDIATRIC DENTISTRY REFERENCE MANUAL V 37 / NO 6 15 / 16
  • 45.
  • 46.
  • 47.
  • 48.
     Levy (2003)stated: There continues to be controversy concerning the use of dietary fluoride supplements, and now they are not generally recommended.  ADA convention in 2010 latest recommendations. 48
  • 49.
    Fluoride delivery methods49 Systemic Topical Dietary fluoride supplements Water fluoridation School water fluoridation Milk fluoridation Salt fluorudation Sugar fluoridation Professionally applied Self applied Solutions Gels varnishes Dentrifices Rinses Gels Toothpicks Floss Chewing gums
  • 50.
    Topical vs systemicfluorides  Original belief  Fluoride that is swallowed topical effect on erupted teeth (before swallowed, as well as a topical effect due to increasing salivary and gingival crevicular fluoride levels).  Elevated plasma fluoride levels  outer surface of fully mineralized, but unerupted teeth topically.  Topical fluoride that is swallowed  systemic effect. 50
  • 51.
    Systemic fluorides  Lowconcentration of fluoride to teeth for a long period  Circulates through blood stream and is incorporated into the developing teeth. After teeth erupt fluoride contacts teeth directly through salivary secretions.  Common form of systemic fluorides is fluoridation. 51
  • 52.
    Sources of fluoride Ground water  Plants  Tea  97 ppm  Some fishes  Potatoes  6.4 ppm 52
  • 53.
    What is waterfluoridation..????  Water fluoridation is the adjustment of the natural fluoride concentration of fluoride-deficient water to the level recommended for optimal dental health.  Based on extensive research, the United States Public Health Service (USPHS) established the optimum concentration for fluoride in the water in the United States in the range of 0.7 to 1.2 parts per million.  This range effectively reduces dental decay while minimizing the occurrence of dental fluorosis.  The optimum level is dependent on the annual average of the maximum daily air temperature in the geographic area.  One milligram per liter (mg/L) of fluoride in water is identical to one part per million (ppm).  At 1 ppm, one part of fluoride is diluted in a million parts of water. 53
  • 54.
  • 55.
    HISTORY OF WATER FLUORIDATION. Thefirst water fluoridation programme was started in the year 1945 in the four cities in USA. GRANDS RAPIDS- MUSKEG ON STUDY NEWBURG H- KINGSTON STUDY EVANSTO N- OAK PARK STUDY BRANTFOR D-SARNIA- STARTFOR D STUDY TIEL – CULEMBORG STUDY 55
  • 56.
    GRAND RAPIDS- MUSKEGONSTUDY  On January 25 th ,1945 ,sodium fluoride was added to GRAND RAPIDS water supply. Muskegon town was kept as a control.  After 6 ½ years in July ,1951 the caries experience of 6 and 15 years old children residents of Grand Rapids was half that of Muskegon . ( reported by - Arnold et al,1953).  So impressive was the efficacy of fluoridation that the city officials of Muskegon also decided to fluoridate their own water supply also. 56
  • 57.
    NEWBURGH –KINGSTON STUDY On may 2nd 1945 , sodium fluoride was added to drinking water of Newburgh on the Hudson river .  Kingston town was kept as a control.  After 10 years of fluoridation Et Al (1956) reported that the DMF rate had fallen from 23.5 % to 13.9 %, confirming the caries inhibitory property of 1 ppm fluoride in drinking water. 57
  • 58.
    THE BRANTFORD- SARNIA-STARTFORD FLUORIDATIONCARIES STUDY  In Canada, a project was undertaken in Brantford, Ontario, where fluoride was added to water supply in June 1945.  The community of Sarnia was established as the control town.  In addition ,the community of Stratford, where fluoride was naturally present in drinking water at level of 1.3 ppm was used as an auxiliary control.  After 17 years of fluoridation in Brantford, caries experience was similar to that occurring in the natural fluoride area of Stratford and was 55 % lower than in the control town of Sarnia ( REPORTED BY – BROWN AND POPLOVE,1965) 58
  • 59.
    TIEL – CULEMBORGSTUDY  In March 1953 the drinking water in Tiel was fluoridated to a level of 1.1 ppm.  Culemborg with water fluoride level of 0.1 ppm was the control.  After 13 years of fluoridation, the number of anatomical sites of teeth affected by dental caries was 58 % lower in Tiel than in Culemborg. 59
  • 60.
    Recommendations by AAPD 1.There is confirmation from evidence-based reviews that fluoride use for the prevention and control of caries is both safe and highly effective in reducing dental caries prevalence. 2. There is evidence from randomized clinical trials and evidence- based reviews that fluoride dietary supple- ments are effective in reducing dental caries and should be considered for children at caries risk who drink fluoride-deficient (less than 0.6 ppm) water. 60
  • 61.
    Sample collection forfluoride estimation  Fluoride electrode coupled with standard pH meter  Scot-Sanchis method Compounds used for water fluoridation  Fluorspar  Sodium fluoride  Sodium silicofluoride  Aluminium silicofluoride  Hydrofluorosilicic acid Equipment for water fluoridation  Saturator system  Dryfeeder system  Solution feeder system 61
  • 62.
    MATERIALS USED INWATER FLUORIDATION  Three types of fluoride equipments 1. Dry feeder 2. Solution feeder 3. Saturation methods  Dry compound such as ammonium silico fluoride, fluorspar, sodium silico fluoride.  Solution of hydrofluoro sillicic acid. Fluoride is added to 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. 62
  • 63.
     SATURATOR SYSTEM DRY FEEDER SYSTEM  SOLUTION FEEDER SYSTEM 63
  • 64.
     Principle: 4% saturatedsolution of NaF is produced and injected at the desired concentration at the water distribution source with the aid of a pump  High hard water level used  Suitable for small towns 64
  • 65.
     Principle: NaF inthe form of powder is introduced into a dissolving basin with the aid of an automatic mechanism to ensure maintanence of the correct supply of F according to the amount of water to be delivered  Handling of F, obstruction of pipes  Medium sized town 65
  • 66.
     Principle: Volumetric pumppermitting the addition of a given quantity of hydrofluorosilicic acid in proportion to the amount of water treated  Construction using polyvinyl chloride  medium sized and large town 66
  • 67.
     Maintenance andcontrol  Control at water treatment plants  Control of the quality of analysis  Control of the quality of water in network  Control of the quality of the F used 67
  • 68.
    SYSTEM PROCEDURE FACTORS LIMITINGUSAGE RECOMMENDATION SATURATOR SYSTEM 4 % saturated solution of NaF is produced and injected at the desired concentration in the water distribution source with aid of a pump. Need to clean gravel bed used for filtration. Suitable for medium sized towns requiring less than 3.8 million lit/day DRY FEEDER NaF or silicofluoride in the form of powder is introduced into a dissolving basin. Care in handling fluoride, obstruction of pipes and compacting of fluoride while storage. Suitable for medium sized towns requiring 3.8 million lit/day to 19 million lit/day. 68
  • 69.
    SOLUTION FEEDER Volumetric pump permitting the additionof a given quantity of hydrofluosilicic acid in proportion to the amount of water treat the equipment must be resistant to attack by hydrofluosilicic acid, necessitating construction in polyvinyl chlorides or another plastic. Suitable for medium sized and large towns with a capacity of more than 7.6 million lit/day 69
  • 70.
    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).  Fluoride concentration  4.5 times the optimal concentration for a community in the same geographic area  Currently recommended level: 4.5-6.3 ppm  In the early 1980s, a total of 13 states had initiated school water fluoridation in 470 schools serving 170,000 children . 70
  • 71.
     Recent studies this effect might no longer be as pronounced  Operating and maintaining small fluoridation systems (i.e., those serving <500 persons)  practical & logistical difficulties  higher than recommended fluoride concentrations in the school drinking water, but no lasting effects among children have been observed.  In schools that enroll preschoolers in day care programs, children aged <6 years  > adequate fluoride. 71
  • 72.
    SCHOOL WATER FLUORIDATION School water fluoridation is one of the possible areas to be explored. This programme helps in limiting caries in school children who are the prime concern.  It is the suitable alternative where water fluoridation is not feasible.  The amount of fluoride added In school drinking water should be greater than normal because children have to stay in the school for a short period of time and to compensate for holidays and vacations. HISTORY  This procedure was first started in 1954 in St. Thomas V.S Virgin islands by US public health service division. . 72
  • 73.
     The currentrecommended regimen for school water fluoridation is adding 4.5 times more fluoride .  There has been around 25 to 40 % decrease in dental caries with this program.  Simple fluoridators particularly that employ the venturi system are most suitable ,because they require almost no maintenance and can be utilized effectively in small instalments of small or medium sized schools. ADVANTAGES  good results in reducing caries.  Minimal equipment .  Not expensive. 73
  • 74.
    DISADVANTAGES  Children donot 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. 74
  • 75.
    FDA fluoride requirementsfor bottled water 75
  • 76.
    The declining benefitof water fluoridation  The magnitude of the benefit of fluoridated water declined in the 1970s and 1980s (Ripa 1993)  worldwide trend of declining dental decay rates, even in non-fluoridated areas (Diesendorf 1986; Brathall et al. 1996; de Liefde 1998)  making it difficult to measure the efficacy of water fluoridation. 76
  • 77.
     Factors responsiblefor the worldwide decline in dental caries  General, widespread use of fluoridated toothpaste (Brathall et al. 1996)  improved diets  changes in oral flora  improved dental materials and therapies  improved dental hygiene 77
  • 78.
    Does water fluoridationsimply delay dental decay?  Diesendorf (1986)  delay in caries increment in fluoridated areas.  Prior to the introduction of fluorides for caries prevention, the mean age of tooth eruption rates were constant (Limeback 1999)  Since the introduction of fluorides, delay in tooth eruption  0.7 years (Virtanen et al. 1994) & 2 years (Campagna et al. 1995).  Fluoride incorporation in the primary dentition and in the alveolar bone  generalized delay in tooth eruption.  Delay of tooth eruption of 1.0 or 1.5 years 20% or 33.3% apparent difference in dental decay rates resp. 78
  • 79.
    Will decay ratesrise if fluoridation is halted?  Kobayashi et al. 1992; Seppä et al. 1998; Künzel and Fischer 2000: failed to find a lasting difference in dental decay rates when fluoridation is halted  Halo effect  Decline of caries in non-fluoridated communities (Ripa 1993; Lewis and Banting 1994).  The benefits of water fluoridation, which are less and less clinically significant these days, have to be weighed against the side effects. (Excess fluoride from all sources) 79
  • 80.
    FEASIBILILITY IN INDIA Based on the current knowledge of increasing prevalence of dental caries, developing economy of our country, dentist population ratio of 1:80,000 and lack of preventive awareness of oral diseases , communal water fluoridation appears to be the most effective, practical and economical public health measure for prevention of dental caries as this method extends its benefits to all the residents of the community without necessitating any conscious effort on the part of the residents. 80
  • 81.
     But theonly short coming is that it can be implemented only in the areas which have central pipe water supply system.  Currently, most of the cities and towns in India covering 30% of the population have piped water supply.  An effort should be made with the concerned authorities to institute water fluoridation at least in these areas ( hope I.D.A.takes it up). 81
  • 82.
    Salt fluoridation  Saltfluoridation programs  Bolivia, Equador, Columbia, Peru, Jamaica, Costa Rica, Mexico, Uruguay, Venezuela, Switzerland, Germany, and France ; Switzerland started the practice in 1955 (Marthaler 2005)  Salt is usually fluoridated at 250 ppm (250 mg F/kg salt, or 0.25 mg/gm salt).  Table salt in the kitchen 1 to 4 g of the daily salt intake  1 mg of fluoride a day at a salt intake of 4 grams a day. 82
  • 83.
    Stephen et al.1999: 350 mg fluoride/kg salt did not produce dental fluorosis but failed to show significant reduction in caries after 11.5 years On a theoretical basis (Hedman et al. 2006), ingestion of meals prepared with fluoridated salt  Increases salivary fluoride levels  Protection against caries Disadvantages  fluoridated salt consumption is lowest in early years of life and high salt intake can lead to hypertension. 83
  • 84.
    FEASIBILITY IN INDIA Salt fluoridation appears to be a viable and feasible method of fluoride ingestion systemically because its distribution can be easily monitored as the supply can be effectively controlled especially for those areas which do not need supplemental fluorides i.e., endemic fluoride belts.  Moreover ,individual monitoring is not required as the levels are so adjusted so as to provide optimum levels of fluoride keeping in view the fact that on an average an individual consumes 5-8 gms of salt per day. 84
  • 85.
     Also saltis freely available and is used on a large scale all over the country by majority of the population of various ethnic and regional groups.  Regarding the acceptability of the population it shall be readily accepted as the addition of fluoride to salt does not alter its colour as in case of salt iodization. 85
  • 86.
    LIMITATIONS  There maybe large variations in salt intake in different groups of people .fluoridated salt consumption is lowest when the need for fluorides is greatest – in early years of life.  Increasing consumption of processed foods .if the processors do not use fluoridated salt.  Difficulties arise when there are multiple drinking water sources which have a naturally optimal or excessive fluoride concentration. 86
  • 87.
    4. It requiresrefined salt produced with modern technology and a high level of technical expertise. 5. The current view data high salt intake may contribute to hypertension. 87
  • 88.
    Milk fluoridation  Firstadvocated by Ziegler in 1956.  Cochrane collaboration review by Yeung et al. 2005  only two intervention studies showed a reduction in dental decay when milk was fortified with fluoride and fed to children on a daily basis.  Maslak et al. (2004)  2.5 ppm fluoride & Stephen (1984)  6 ppm. (in 5 years, 31.2% reduction in DMFT) The children generally consumed one typical serving (200 mL) of the beverage (test and control milk). 88
  • 89.
     A highconcentration of fluoride is needed for two reasons: (1) the children did not drink the beverage throughout the day and (2) calcium in the milk complexes with fluoride, which would reduce its availability for topical benefits.  5-15 ppm of fluoride in the milk  significant caries reduction of 40-50%.  Fluoridated milk  permanently low level of ionized fluoride within the oral cavity promoting remineralisation (topical effect) 89
  • 90.
    FEASIBILITY IN INDIA Inspite of the controversy concerning the binding and complexing of fluoride with calcium and protein of the milk and thus making it unavailable for its anti cariogenic action,  Though theoretically milk fluoridation is advantageous, in addition being the staple food for children and its consumption can be confined to groups who need it most, that practically speaking that this scheme /method does not seem to be viable and feasible because of : 90
  • 91.
    a) In INDIA,majority of children population living in rural and urban areas cannot afford milk daily. a) Central milk supply system does not exist in India a) Variation of intake and quantity of milk is another which cannot be controlled since it depends upon the socio-economic and ethnic factors. 91
  • 92.
    Flour and sugarfluoridation  Flour fluoridation was advocated in Denmark  Similar advantages as salt fluoridation, but not tested clinically  Wei, 1988  sugar fluoridation  both culprit & cure  First achieved in Finland (10mg/kg) 92
  • 93.
    FLUORIDE COMPOUND USED Most commonly used is sodium fluoride .  Other compounds used are acidulated phosphate fluoride, potassium fluoride or calcium fluoride.  Supplements contain measured amount of fluorides, 0.25 mg , 0.5 mg, 1.0 mg.  They should be taken on daily basis according to the prescribed dosage schedule.  The council of DENTAL THERAPRUTICS OF AMERICAN DENTAL ASSOCIATION recommends the dosage schedule for dietry fluoride supplements as shown in the table : 93
  • 94.
     Correct dosageis based on the concentration of fluoride in drinking water, age and weight of the child and other available fluoride.  Not more than 1 milligram of fluoride should be ingested each day from all available systemic sources. 94
  • 95.
    Fluoride supplements  Firstintroduced in late 1940s in children of non fluoridated areas. Common supplements used are:  Fluoride drops with/without vitamins (0.125,0.25 & 0.5 mg)  Fluoride tablets with/without vitamins (0.25,0.5 & 1mg)  Lozenges (0.25,0.5 & 1mg)  Oral rinse supplements (swish and swallow) (1mg, 5ml)  Considered for children at high caries risk who drink fluoride- deficient (< 0.6 ppm F) water. 95
  • 96.
     Determination ofdietary fluoride  Sources of dietary fluoride  drinking water from home, day care, and school; beverages such as soda, juice, and infant formula; prepared food; and toothpaste.  Infant formulas, esp., powdered formulas reconstituted with fluoridated water  increased risk of fluorosis.  Infants may be particularly susceptible because of the large consumption of such liquid in the first year of life, while the body weight is relatively low. 96
  • 97.
     Commonly usedcompounds NaF & APF  Supplements  systemic & topical benefits for both primary & permanent teeth.  Bibby et al. 1955  fluoride lozenges that were sucked and swallowed were better than fluoride ‘pills’ that were swallowed right away 97
  • 98.
     Feltman andKosel (1961)  ingestion of fluoride tablet by pregnant mothers  placenta, reaches developing fetus and benefits offspring; fluoride delays tooth eruption  some benefit.  Fluoride drop prescription  incorrect instruction following  incorrect dosages, complicated schedules, esp., when there were children of different ages in the household  poor compliance. 98
  • 99.
  • 100.
  • 101.
    Percentage of cariesreduction with different methods 101
  • 102.
  • 103.
    Endemic areas forFluoride / Fluorosis in Andhra Pradesh & Telangana Krishna Medak Karimnagar Kurnool Nalgonda Prakasam Chittoor Guntur Khammam Mahbubnagar Nellore 103
  • 104.
  • 105.
    Conclusion In public healthand clinical practice it is recommended that: • Fluoridation should continue and extend into the fluoridation of community drinking water. • Counsel parents and caregivers regarding use of fluoride toothpaste by young children, especially those < 2 years of age. • Target mouth-rinsing to persons at high risk. • Judiciously prescribe fluoride supplements. • Apply high-concentration fluoride products to persons at high risk for dental caries. 105
  • 106.
    For purpose ofself-care, it is recommended that patients: • Be aware of the fluoride concentration in the primary source of drinking water • Use small amounts of fluoride frequently. • Supervise use of fluoride toothpaste among children < 6 years of age. • Consider additional measures for persons at high risk for dental caries. • If the primary drinking water contains > 2 ppm fluoride, then use an alternative source of water for children ≤ 8 years of age. 106
  • 107.
    References  Limeback H.Comprehensive Preventive Dentistry. Wiley Blackwell publishers. Limeback H and Robinson C. Fluoride therapy. Chapter 16, 251-82  Peter S. Essentials of preventive and community dentistry. 3rd edition, Arya (Medi) publishers. Peter S. Fluorides in preventive dentistry. Chapter 6, 270-355  Tandon S. Textbook of pedodontics. 2nd edition, Paras publishers. Tandon S, Gupta K. Chapter 11, 265-92  AAPD Guideline on Fluoride Therapy. Reference manual 36:14/15  Koplan JP. Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States. 2001;50 RR-14 107
  • 108.
     Guidelines onthe use of fluoride in children: an EAPD policy document. Eur Arch Paediatr Dent 2009;10:129-35  Jones S, Burt BA, Peterson PE, Lennon MA. The effective use of fluorides in public health. Bulletin of WHO 2005;83:670-6  Everett ET. Fluoride’s effects on the formation of teeth and bones, and the influence of genetics. J Dent Res 2011;90:552-60  Lewis CW. Fluoride and Dental Caries Prevention in Children. Pediatrics in Review 2014;35;3-15  Fluoride in drinking water: A Scientific Review of EPA’s Standards, National Academies Press Washington DC. Chapter 4. 85-106.  Adair SM. Evidence-based Use of Fluoride in Contemporary Pediatric Dental Practice. Pediatr Dent 2006 ; 28:133-42 108
  • 109.
     Oganessian E.,Lenčová E., Broukal Z. Is Systemic Fluoride Supplementation for Dental Caries Prevention in Children Still Justifiable? Prague Medical Report 2007 ;108:306–14  Burt BA. The Changing Patterns of Systemic Fluoride Intake. J Dent Res ;71:1228-37  de Souza CFM, Lima Júnior JF, Soraya PM, Adriano F, Sampaio FC. Systemic Methods of Fluoride and the Risk for Dental Fluorosis. Oral Health Care – Prosthodontics, Periodontology, Biology, Research and Systemic Conditions. 357-72  Hellwig AE , Lennon M. Systemic versus Topical Fluoride. Caries Res 2004;38:258–62 109
  • 110.
     Sikora M,Kwiatkowska B, Chulbek D. Fluoride content in superficial enamel layers of human tooth from archaeological excavations. Fluoride 2014;47:341-8  Saxena S, Sahay A, Goel P. Effect of fluoride exposure on the intelligence of school children in Madhya Pradesh, India. J Neurosci Rural Pract 2012;3:144-9. Neurotoxicity of fluoride. Abstracts, Fluoride 2014;47:92  Broadbent JM, Moffitt TE, Thomson WM, Ramrakha S, Poulto R. Community water fluoridation and Intelligence Quotient . Poster vii-145, 26th Annual convention of the association for psychological science;2014, San Francisco. Neurotoxicity of fluoride. Abstracts, Fluoride 2014;272-6 110
  • 111.
     Susheela AK.Dental fluorosis and its extended effects. Indian J Pediatr 2013;80:715-7. extended effects, beyond dental fluorosis, of fluoride poisoning in children. Fluoride 2014;47:272-6  Dobaradaran S, Nabipour I, Mahvi AH, keshtkar M, Elmi F, Amanollahzade F, khorsand M. Fluoride removal from aqueous solutions using Shrimp shell waste as a cheap bioadsorbent. Fluoride 2014;47:253-7 111

Editor's Notes

  • #3 Frderick mckay 1901 – Colorado springs usa. – patients had stains. He called it mottled enamel. Letters to Colorado springs dental society. – little help. 1905 Moved to st.louis – ortho – no pts were affected. Came back to Colorado. – 1908. meeting at boulder. Met gv black in 1909- shocked. No literature. Mckay with Isaac and fleming – 2945 children – 87% - affectd. Gv black published article, 1916 – mckay nd gv black – study across 22 communities – britton – deep well water, Churchill – fluoride in water. After 30 yrs. Dean – shoe leather survey - 5824 children across 22 cities of usa. 1942 – caries reduction. 1945 – fluoride water plant. – grand rapids. 1969 – who 1 ppm.
  • #9 It is found in all soil, bodies of water, plants, and animals and, as such, is a normal constituent of all diets…….It is derived from a ………………..and rarely found in elemental state…………….. It may occur in
  • #16 Thus, at any given time each tissue contains fluoride. The fluoride concentration of saliva (Oliveby et al. 1989; Oliveby et al. 1990; Whitford et al. 1990), sweat (0.067-0.5 ppm) (WHO Expert Committee on Oral Health Status and Fluoride Use 1994) and breast milk (0.4 ml) (Ekstrand et al. 1981) is less than the serum,
  • #17 The kidneys and bladder may contain up to 5 ppm of fluoride, but bone can accumulate fluoride throughout life where levels under normal conditions can exceed 1,000 ppm primarily in tissue surfaces.
  • #22  give rise to mixed colonies containing………..are committed, giving rise to cells from
  • #26 Fluoride’s actions on bone appear to be mediated at several levels. ….Fluorapatite is more stable and resistant to acid dissolution than is hydroxyapatite (Grynpas and Cheng, 1988). In vitro fluoridation of bone
  • #28 Ameloblasts in the maturational phase appear to be the cellular target of chronic fluoride exposure (DenBesten and Thariani, 1992), whereas acute fluoride toxicity targets the transitional and early-secretory ameloblasts (Lyaruu et al., 2006).
  • #40 Fluoride prevents demineralization. Fluoride enhances remineralization. Fluoride alters the action of plaque bacteria. Fluoride aids in posteruptive maturation of enamel. Fluoride reduces enamel solubility.
  • #46 The recommendations were developed by an expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs (CSA). The panel addressed the following questions: when and for whom should fluoride supplements be prescribed, and what should be the recommended dosage schedule for dietary fluoride supplements? The panel concluded that dietary fluoride supplements should be prescribed only for children who are at risk of developing caries and whose primary source of drinking water is deficient in fluoride.
  • #49 reviewed the various problems associated with continued use of fluoride supplements and Nevertheless,
  • #51 The original belief was that fluoride’s primary action was to inhibit dental caries when incorporated into developing dental enamel (ie, the systemic route), but the fluoride concentration in sound enamel does not fully explain the marked reduction in dental caries.
  • #71 where fluoridating a community’s drinking water was not feasible……… Studies of the effects of school water fluoridation in the …….. Because children are at school only part of each weekday, a fluoride concentration of 4.5 times the optimal concentration for a community in the same geographic area was recommended to compensate for the more limited consumption of fluoridated water.
  • #72 Several concerns regarding school water fluoridation exist.
  • #77 The dental decay rates in the 1950s and 1960s were considerably high and a major health problem. Using decayed, missing, and filled teeth (DMFT) as the accepted measure of disease incidence, water fluoridation trials showed that adding fluoride to the drinking water at about 1.0 ppm lowered decay rates by as much as 50% to 60% (McDonagh et al. 2000; Young 2008).
  • #79 First…………. which must be resorbed prior to the eruption of the permanent teeth is believed to be the cause of this generalized delay in tooth eruption.
  • #80 Fluoridated water is used in the manufacturing of beverages and foods that are consumed in nonfluoridated areas (the ‘halo’ effect). This, in part, explains why it is so difficult to show a difference in caries prevalence rates between fluoridated and non- fluoridated communities.
  • #83 The countries that have embarked on …….The main evidence provided has been an observation of before and after caries rates in countries where fluoridated salt was introduced………. when the need for fluorides is greatest
  • #84 The evidence that fluoridated salt is actually effective is weak. when the
  • #89 No correction was made for delay in tooth eruption.
  • #96 In those individuals not accessible to community water supplies, dietary fluoride supplements can be given.
  • #97 before prescribing supplements can help reduce intake of excess fluoride. However, a recent evidence-based review suggests that reducing fluoride intake from reconstituted infant formula alone will not eliminate the risk of fluorosis development. Fluorosis is associated with cumulative fluoride intake during enamel development, with the severity dependent on the dose, duration, and timing of intake.