topical fluorides in public health dentistry introduction mechanism of action fluoride delivery methods and examples in detail conclusion n reference

1. DEPARTMENT OF PUBLIC
HEALTH DENTISTRY
FATHIMA IKBAL K
FINAL YEAR (PART
I)
15DO33

3. CONTENTS
• INTRODUCTION
• FLUORIDE DELIVERY METHODS
• DIFFERENCE BETWEEN TOPICAL FLUORIDES AND SYSTEMIC FLUORIDES
• INDICATIONS
• RATIONALE FOR USING TOPICAL FLUORIDE AGENTS
• TYPES OF TOPICAL FLUORIDES
• 1.PROFESSIONALLY APPLIED
• 2.SELF APPLIED
• TOPICAL FLUORIDES IN PREVENTIVE DENTISTRY
• CONCLUSION
• REFERENCES

4. INTRODUCTION
• Fluorine is the member of the halogen family.
• It is the most electronegative element and
reactive of all the elements of the periodic table.
• The word fluorine is derived from the Greek
word “Fluore” meaning to flow.
• Its selective action on the hard tissues of the
body attributes significantly to prevention and
control of dental caries.

5. FLUORIDE DELIVERY METHODS
Fluorides can be delivered either as :
TOPICAL FLUORIDES
These are placed directly on the teeth.
Some preparations provide a high concentration
of fluoride over a short period of time. Other
preparations such as dentrifices provide
continuous low concentration of fluoride on the
teeth. Topical fluorides allow for the interaction
of fluoride with minerals in the teeth.

6. SYSTEMIC FLUORIDES
They circulate through the blood
stream and are incorporated into developing
teeth. They provide a low concentration of
fluoride over a long period of time.

7. DIFFERENCE BETWEEN SYSTEMIC FLUORIDES AND TOPICAL FLUORIDES
SYSTEMIC FLUORIDES TOPICAL FLUORIDES
Applied through systemic route during
development of dentition(pre-eruptive).
Applied topically after eruption of teeth
(post-eruptive).
Usually lower concentrations of fluorides
are used.
Normally high concentration of fluoride is
used.
Effects are there throughout life. Effects are only seen for shorter
durations.
It can lead to dental fluorosis. It does not lead to fluorosis.
Patient’s co-operation and compliance are
not required.
Patient’s co-operation and compliance are
absolutely necessary.
Cost effective and cheaper. Expensive
Self application is possible. Normally applied professionally. Or
sometimes can be used by patients
themselves. Eg: Dentrifices, mouth rinses.
Fluoride is incorporated during teeth
development stage.
Repeated application is required.

8. INDICATIONS OF TOPICAL FLUORIDES
 Caries active individuals.
 Children shortly after the period of teeth eruption.
 Those who are on medication which decrease the salivary
flow or who have received radiation to head and neck.
 After periodontal surgery when the roots of the tooth are
exposed.
 Patients with fixed or removable prosthesis after
placement or replacement of restorations.
 Mentally and physically challenged patients.
 Patients with an eating disorder or who are undergoing a
change in lifestyle which may affect their oral hygiene
habits.

9. RATIONALE FOR USING TOPICAL
FLUORIDES
i. To speed the rate and increase the
concentration of the fluoride acquisition
above the level which occurs naturally.
ii. The initial caries lesion characterised by a
white spot is porous and accumulates
fluoride at a much higher concentration
than the adjacent sound tooth enamel.

10. Topical fluorides are divided broadly
into 2 main categories:
TOPICAL FLUORIDES
PROFESSIONALLY APPLIED SELF APPLIED

11. PROFESSIONALLY APPLIED
Introduced by Bibby in 1942.
Dispensed by dental professionals in the dental
office and usually involve the use of high
fluoride concentration products ranging from
5000-19000 ppm which is equivalent to 5-9mg
F/ml.
The three agents currently in use are:
1) Neutral Sodium Fluoride (NaF)
2) Acidulated Phosphate Fluoride (APF)
3) Stannous Fluoride (SnF2)

12. FLUORIDE VEHICLES
AQUEOUS SOLUTIONS AND GELS
 The gel adheres to the teeth for a considerable amount of
time and eliminates the continuous wetting of the enamel
surfaces required when solutions are used.
 When gels are applies using trays, it is possible to treat
two or four quadrants simultaneously and saves time.
 Each application is loaded by using a thin layer (approx.
less than 0.5ml), the hazard of accidentally ingesting a
large quantity of fluoride is minimized.
 Thixotropic solutions are more stable at lower pH and do
not run off the tray as readily as conventional gels.

13. FLUORIDATED PROPHYLACTIC PASTES
 Surface enamel contains higher levels of fluoride
than the internal layers. Prophylaxis removes
this fluoride-rich layer. So if a prophylaxis pastes
containing fluoride is used, it can replenish the
lost fluoride and there is a small but significant
net gain in the concentration of fluoride.
 Even though fluoride pastes provide less
benefits than solutions or gels, it would seem
prudent to use a formulated paste rather than a
non-fluoridated paste.
 However, the paste should not be used as a
substitute for a regular topical application.

14. FOAMS
• Foam based agents were developed to
minimize the risk of fluoride over dosage as
well as to maintain the efficacy of topical
fluoride treatment.
• Advantages of foam based APF agents are:
1. It is much lighter than a conventional gel
and therefore only a small amount agent is
needed for topical application.(4gm of
gel/mouth while less than 1gm of
foam/mouth).
2. The surfactant in the foaming agent has a
cleansing action by lowering the surface
tension.

15. It may also facilitate the penetration of the
material into inter proximal surfaces where
its action is most needed.
3. Since APF foams does not require suctioning,
it offers advantages for home use as well as
treatment of young children and disabled
persons where saliva evacuation may not be
feasible.

16. FLUORIDE VARNISH
• It was first developed by Schimdt in Europe in 1964.
• Increasing the time of contact between enamel surface
and topical fluoride agents favours the deposition of
fluorapetite and fluorhydroxyapetite.
Technique Used:
1. After prophylaxis, the teeth are dried but not isolated
since varnish can stick to cotton.
2. 0.3-0.5ml of varnish is required to cover full dentition.
3. Application is done first on lower arch then upper, using
single tufted small brush, starting with the proximal
surfaces.
4. Patient is asked to sit with mouth open for 4 min to let it
set. The patient is asked not to rinse or drink for 1 hour.

17. DURAPHAT
 It is the first fluoride varnish developed in
Germany.
 It is a viscous yellow material containing
22,600 ppm fluoride as sodium fluoride in a
neutral colophonium base.
 It has shown 30%-40% caries reduction in
permanent dentition and 7%-44% reduction
in primary dentition.

18. FLUORPROTECTOR
 It is a clear polyurethane based product
containing 7000 ppm fluoride from
difluorosilane.
 It is dispensed in 1ml ampules and each
ampule containing 6.21mg of fluoride.

19. CAREX
 It is also a fluoride varnish containing low
fluoride concentration than Duraphat (1.8%
fluoride).
 It has the efficacy equal to that of Duraphat
as caries preventive agent.

20. TOPICAL FLUORIDES IN PREVENTIVE
DENTISTRY
NEUTRAL SODIUM FLUORIDE
STANNOUS FLUORIDE
ACIDULATED PHOSPHATE FLUORIDE
AMINE FLUORIDE

21. NEUTRAL SODIUM FLUORIDE (NaF2)
 Sodium fluoride was the first fluoride
compound for topical application.
 A minimum of 4 applications with a 2% sodium
fluoride solution gives caries reduction of 30%.
• PREPARATION:
• By dissolving 20gms of sodium fluoride
powder in 1 litre of distilled water in a plastic
bottle.

22. TECHNIQUE USED:
KNUTSON’S TECHNIQUE
 At the initial appointment the teeth are cleaned with
aqueous pumice slurry and then isolated with cotton
rolls and dried with compressed air.
 Using cotton tipped applicator sticks, 2% sodium
fluoride solution is painted on the air dried teeth so
that all tooth surfaces are visibly wet. The solution is
allowed to dry for 3-4 minutes.
 The procedure is repeated for each of the isolated
segments until the teeth are treated.
 A 2nd ,3rd and 4th fluoride application, each not
preceeded by a prophylaxis, is scheduled at intervals
of approx. 1 week.
 The four-visit procedure is recommended for 3, 7, 11
and 13 years, coinciding with the eruption of different
groups of primary and permanent teeth.

24. MECHANISM OF ACTION
NaF as Topical
Fluoride on Tooth
Surface
Reacts with
Hydroxyapatite
Crystals
Calcium Fluoride
(End Product)
“CHOCKING OFF
EFFECT”
CaF2
+ Hydroxyapatite
=Fluoroapatite
Increased
Concentration of
Fluoride on Enamel
Surface
Tooth Surface
Become Resistant
to Caries Attack

25. ADVANTAGES
 Relatively stable when kept in a plastic container and
no need to prepare a fresh solution for each patient.
 The taste is well acceptable to the patients.
 The solution is non- irritating to the patients.
 It does not cause discolouration of tooth structure.
 Once applied to the teeth, the solution is allowed to
dry for 3 minutes. And thus the clinician can pursue
multiple chair procedures.
 The series of treatment is repeated only 4 times in a
general range of 3 to 13,rather than annual or semi-
annual intervals.

26. DISADVANTAGES
 The major disadvantage of sodium fluoride is
that the patient must make four visits to the
dentist in a relatively short period of time.

27. STANNOUS FLUORIDE (SnF2)
Fluoride concentration- 19500 ppm
Stannous fluoride has been used at 8% and
10% concentrations.
PREPARATION:
To prepare 8% stannous fluoride solution, the
content of one capsule which is 0.8gms(‘0’
No. gelation capsule) is dissolved in 10ml of
distilled water in a plastic container.

28. TECHNIQUE USED:
MUHLER’S TECHNIQUE
 Each tooth surface is cleaned with pumice or any
other dental cleaning agent for 5-10 seconds.
 Unwaxed floss is passed between the inter-
proximal areas.
 Teeth are isolated and dried with air.
 SnF2 is applied using paint-on technique and the
solution is kept for 4 minutes.
 Repeat applications are made every 6 months or
more frequently if the patient is susceptible to
caries.

30. MECHANISM OF ACTION
SnF2 Applied On
Teeth Surface
Tinhydroxyapatite
(At Low
Concentrations)
Calcium
Trifluorostannate +
Tin tri-
Fluorophosphate
(At High
Concentrations)
CaF2 is formed as
end product at low
and high
concentrations
CaF2 reacts with
hydroxyapatite and
forms small amount
of fluorhydroxyapatite

31. ADVANTAGES
 Using 8% stannous fluoride solution at an
interval of 6 to 12 months, conforms to the
practicing dentist’s usual patient recall
system.
 Administrative difficulties, particularly in
Public Health Programs, created by the need
to arrange four appointments.

32. DISADVANTAGES
 In aqueous solution, the material is not
stable.
 8% solution is quite astringent and
disagreeable in taste.
 The solution occasionally causes reversible
tissue irritation manifested by gingival
blanching.
 It occasionally causes pigmentation of teeth
which has a characteristic light brown colour.

33. ACIDULATED PHOSPHATE FLUORIDE (APF)
APF introduced in 1960’s by Brudevold and is his
co-workers at the Forsyth Dental Centre, Boston,
Massachusetts.
Fluoride concentration- 12300 ppm
PREPARATION:
 An aq. solution of APF is prepared by dissolving
20 gms of sodium fluoride in 1 litre of 0.1 M
Phosphoric acid.
 50% hydrofluoric acid is added to this to adjust
the pH at 3 and fluoride ion concentration at
1.23% [Brudevold’s Solution].

34. For the preparation of Acidulated Phosphate
Fluoride gel, a gelling agent methylcellulose
and hydroxyethyl cellulose is added to the
solution and the pH is adjusted between 4-5.

35. TECHNIQUE OF APPLICATION
PAINT-ON TECHNIQUE/TRAY TECHNIQUE
 The patient should sit upright in the chair.
 Oral prophylaxis is done.
 The teeth to be treated are completely isolated
and dried with air.
 Clinical application of APF gels should be done
using trays that fit into the patient’s upper and
lower arches. A disposable foam-lined tray is
preferred.
 To reduce ingestion of fluoride, a minimum
amount of fluoride gel that will permit complete
coverage of the tooth surfaces should be
dispensed. Usually, the amount is less than 5 ml.

36.  After the trays have been properly positioned,
saliva ejector is used to evacuate the stimulated
saliva and excess fluoride.
 It is repeated every 15-30 seconds so as to keep
the teeth most with the fluoride solution
throughout the four minute period.
 The patient should be told not to swallow the
gel but to exert slight pressure using the cheeks
and tongue as well as light biting force in order
to cause the gel to flow interproximally. The
fluoride gel should be in the mouth for 4
minutes and then the remaining oral fluid must
be expectorated.
 The patient is instructed not to eat, drink or
rinse mouth for 30 minutes.

37. PAINT ON TECHNIQUE
TRAY TECHNIQUE

39. MECHANISM OF ACTION
Fluoride penetrates into the crystals more deeply through the openings caused by
shrinkage and forms Fluorapatite
Dicalcium Phosphate Dihydrate(DCPD)
-Highly Reactive
Formed immediately after APF is applied
Further Hydrolysis of Hydroxyapatite Crystals
Dehydration, Shrinkage of Hydroxyapatite Crystals
APF is applied on Teeth Surface

40. For the conversion of the whole DCPD
formed into fluorapatite, a deeper
penetration and continuous supply of
fluoride is required.
Because of this reason, APF is applied every
30 seconds and the teeth have to be kept wet
for 4 minutes.

41. ADVANTAGES
 Requires only two applications in a year and is
thus suited for most dental office routines.
 The gel preparation can be self applied and thus
the cost of application also gets reduced.
 It has the ability to deposit fluoride in enamel to
a deeper depth than a neutral sodium fluoride
or stannous fluoride.
 APF is stable and need not be freshly prepared
for each patient.

42. DISADAVANTAGES
 Practical difficulties like the teeth must be
kept wet for 4 minutes.
 It’s acidic, sour and bitter in taste.
 It cannot be stored in glass containers.
 Repeated and prolonged exposure of
porcelain or composite restorations to APF
can result in loss of materials, surface
roughening and possible cosmetic changes.

43. AMINE FLUORIDES
 They are cariostatic agents.
 Some of them surface acting agents i.e. they
have an affinity for enamel and thus will hold
the fluoride for longer time against the tooth.
 They also have anti-bacterial properties.
Reduced plaque formation and anti-glycotic
activity is also reported with these compounds.
 Amine fluorides have been tested with
dentrifices, mouth rinses and topical gels where
they are either brushed on teeth or applied with
a tray but is not known if they are superior to
the other currently available fluoride agents.

44. RECOMMENDEDGUIDELINES FOR PROFESSIONAL
APPLICATIONOF HIGH F- CONCENTRATIONPRODUCTS
1. Apply not more than 2 grams of gel/tray
(approximately 40% of tray capacity)
2. Use a saliva ejector during the 4 minute
application procedure and have the patient tilt
his head forward during the F- application.
3. Instruct patients to expectorate thoroughly for
from 30 seconds to 1 minute immediately
following the application procedure.
4. When one is utilizing custom-made trays, only
one from five to ten drops of product should be
dispensed per tray.

45. SELF APPLIED TOPICAL FLUORIDES
DENTRIFICES
MOUTHRINSES
FLUORIDE GELS

46. DENTRIFICES
 1942- First clinical trial by Bibby.
 Active agent was sodium fluoride which was
added to a conventional dentrifice containing
dicalcium phosphate as the abrasive.
 1954- Mulher et al reported a clinical trial that
tested stannous fluoride in a paste.
 1955- stannous fluoride dentrifice became the
first dentrifice recognized by the FDA as an
effective tooth decay preventive product.
 1964- first fluoride dentrifice accepted by ADA.

47. FIRST TOOTHPASTE ACCEPTED BY
ADA

48. FLUORIDE COMPOUNDS IN DENTRIFICES

49. ADVERSE EFECTS OF FLUORIDE
CONTAINING DENTRIFICES
Fluoride containing dentrifices can be acutely
toxic if swallowed in large amounts.

50. 15mg/kg body weight is the acute lethal
dose, 5mg/kg may be fatal to children.
• If only the substantial quantities of paste are
eaten by children, the experience a
phenomenon called pica, that the acute
toxicity of fluoride dentrifices must be
considered.

51. Nausea and vomiting.
Dental fluorosis.

52. FLUORIDE MOUTHRINSES
 Described first in 1946 by Bibby et al.
 In 1975, the council on dental therapeutics of
the ADA accepted neutral sodium fluoride
and acidulated phosphate fluoride mouth
rinses as effective caries preventive agent.
 Later, stannous fluoride mouth rinse was also
accepted by the American Dental
Association.

54. SODIUM FLUORIDE MOUTH
RINSES
 Usually formulated at concentrations of
either 0.2% for weekly use or 0.05% for daily
use.
 They are intended to be used by forcefully
swishing 10ml of liquid around the mouth for
60 seconds before expectorating it.

55. OTHER FLUORIDE MOUTH RINSES
 The anti-caries effect of stannous fluoride rinses
is roughly the same as that of sodium fluoride
rinse.
 The clinical trial of an amine fluoride showed no
superiority over a neutral sodium fluoride rinse
when used according to the same regimen.
 An ammonium fluoride mouth rinse was no
more effective than a sodium fluoride rinse
when both were used daily in acidulated form.

56. MECHANISM OF ACTION
 Fluoride changes the enamel structure of the
teeth from predominantly hydroxyapatite to
fluorapatite.
 Fluoride may act by inhibition of bacterial
metabolism and plaque acid formation.

57. ADVANTAGES OF DAILY RINSING
 If the patient misses several sessions, it is
probably less critical than if he was on a
weekly schedule.
 Advantage of the 0.05% sodium fluoride
concentration is that it can be used to
provide both a topical and systemic benefit
when indicated for the individual patient.

58. RECOMMENDATIONS FOR
FLUORIDE MOUTHRINSES
 The rinse and expectorate technique can be
used for patients in fluoride deficient
communities or for those in optimally
fluoridated communities.
 In patients with increased caries risk e.g.,
those undergoing orthodontic treatment or
radiotherapy.

59. FLUORIDE GELS
 Fluoride gels products include neutral sodium
fluoride and acidulated phosphate fluoride with
a fluoride concentration of 5000 ppm and
stannous fluoride with a concentration of 1000
ppm.
 The gels are either applied in trays or brushed
on teeth.
 Professionally applied- given twice a year .
 Self applied- once a day or more.
 Home fluoride gels are not recommended for
children below 6 years and younger.

61. LIMITATIONS
 They voilate the principle of delivering low
concentration of fluoride at regular intervals.
 Toxic hazard.
 Tedious to use on daily basis.

62. CONCLUSION
Fluoridation is universally accepted by the
dentists and other medical professionals as
being useful in preventing tooth decay.
They can be used in areas where there are no
central water supplies, where the fluoride
concentration of well water is low.

63. REFERENCES
Essentials Of Public Health Dentistry- Soben
Peter
Topical Fluorides- Amrit Tiwari
Dental Care For Children- Anil Kohli
Carranza Clinical Periodontology, (12th
Edition)

64. THANK YOU