Topical Fluorides.pptx

Topical Fluoride
Presented by – Dr PARIKSHIT SHIVAJIRAO KADAM

• Introduction
• History of fluoride
• Metabolism of fluoride
• Mechanism of action of fluoride in caries prevention
• Fluoride delivery methods
• Professionally applied topical fluoride –
Neutral sodium fluoride
Stannous fluoride
Acidulated phosphate fluoride solution/gels
Varnish
Contents
2

• Self applied topical fluorides –
Dentifrices
Mouth rinses
Fluoride gels
Fluoride tablets
• Fluoride update
• Conclusion
• References
3

• The greatest contribution of last century to the improvement of oral health is discovery
and utilization of fluoride as a caries preventive measure which continues to be
cornerstone of caries prevention program (Murray 1991)
• Extensive research has been carried out about the utility of this salt in variety of ways to
draw maximum systemic and topical benefits of its cariostatic properties
• Predominant effect of fluoride is topical, which occurs mainly through promotion of
remineralisation of early caries lesions and by reducing sound tooth enamel
demineralization (Featherstone 1988)
Introduction
4
Fluoride In Dentistry,1st edition,1988, Ekstrand J, Fejerskov O, Silverstone LM

• Fluoride - Latin word Fluore - to flow
• Atomic weight -19
• Atomic no – 9
• Fluoride never found in elemental form
• Fluoride is reduced form of fluorine
5

Atmosphere
Hydrosphere
Lithosphere
Fluoride In The Environment
6

• Absorption
• Transportation
• Soft Tissue Distribution
• Excretion
• Distribution of Fluoride in the Body –
plasma – 0.7-2.4 µm
kidney – 4.16 ppm
Bone – 99%
Enamel – 2200-3200 ppm
Dentin – 200 -300 ppm
Cementum – 4500 ppm
Metabolism Of Fluoride
7
Essentials of preventive and community dentistry, 3rd edition, 2006, Peter S

• Increase enamel resistance/reduction in enamel solubility
• Increased rate of posteruptive maturation
• Remineralisation of incipient lesions
• Interference with plaque micro-organism
• Modification in tooth morphology
Mechanism of action of fluorides in caries reduction
8

History Of Fluorides
Dr McKay State
Dental Association
in Boulder, found
that condition
extended to other
towns also
1908 1912
McKay and Black
conducted a
survey over
unknown factor in
water may cause
mottled enamel
1916
inhabitants of
Oakley switched
their water supply
from deep wells to
shallow water
supply
1925
Dr. Fredrick McKay
of Colorado
observed ‘Colorado
stains’
1901
Dr McKay & Dr
JM Eager
reported high
proportion of
Italian residents
in Naples had
brown stains on
their teeth

Dean conducted the
famous ‘Shoe
Leather Survey’
classification of
mottling and an
index
1934 1945
Water fluoridation
started in the US
1950s
WHO & Pan
American Health
Organization
endorsed the
practice of water
fluoridation
1964
Churchill developed
a method for
determining conc of
fluoride in drinking
water
1931
First community
level water
fluoridation
program started
in Grand Rapids,
USA
Fluorides and dental caries, 1st edition, 1986, journal of Indian Dental association, Tiwari A

11
• Shoe Leather Survey –
• Fluoride concentration in drinking water, mottled enamel and dental caries
• Aim – to find out the minimal threshold of fluoride
• Observations -
• He also reported that the incidence of caries in these teeth was less as compared to
nonfluoridated teeth
Water concentration Signs
4 ppm or more discrete pitting
3 ppm or more Widespread Mottling
2 to 3 ppm dull chalky appearance
1 ppm or less No mottling

History Of Topical Fluorides
Biby conducted 1st
clinical study using
0.1% aqueous NaF .
45% reduction in
caries seen
1941 1942
Buonocore &
Bibby concluded
that lead fluoride
was more
effective than
NaF
1945
Muhler & Van Huysen
carried out in vitro
studies of similar
nature
1947
1st topical fluoride
compound NaF was
introduced. Biby &
Knutson initiated
studies using this
agent
1940
Knutson began a
series of clinical
trials & Knutson
technique was
introduced i.e. 4
treatments at
weekly intervals

Muhler, Boyd and
Van Huysen found
that SnF was 3
times more
effective than NaF
1950
Crest markets
first Therapeutic
Dentifrice with
SnF2
1955 1957
Scott using
electron
microscope found
out that Stannous
ion forms a
coating on
enamel surface
1960
APF was introduced
by Brudevold & co-
workers
1960
Gish, Howell &
Muhler showed
56% lower caries
increment with
SnF2

Mercer and
Muhler found 51%
reduction in DMFS
using SnF
1961
the first clinical
trial of APF was
started by
Wellock &
Brudevold
1961 1964
Szwejdar Tossy
& Below first
published clinical
trial of APF gels
1967
Heuser & Schmidt
first used fluoride
lacquer, Duraphat.
1968
First ADA seal for
Crest (first fluoride
dentifrice )

Englander et al
found an 80%
reduction in caries
by daily use of
0.5% fluoride as
APF gel.
1969
Colgate with
MFP was
approved
1969 1970
Horowitz &
Doyle carried out
largest APF study
1971
Ingraham and
Williams,
concluded that APF
gels showed more
caries reduction
than solution.

Fluoride Delivery Methods
16
Fluoride
Topical fluorides
Professionally applied
Self applied
Systemic fluoride
1.Water fluoridation
2.Salt fluoridation
3.Milk fluoridation
4. Fluoride tablets,
drops

1. According to chemical nature of material used -
• Sodium fluoride
• Stannous fluoride
• Acidulated phosphate fluoride
• Sodium monofluorophosphate
• Amine fluoride.
• Hexa fluoro zerconate
Professionally applied fluorides
17

2. According to the vehicle used -
• Pastes (> 1000ppm F)
• Solutions
• Gels
• Thixotropic solution
• Foams
• Varnishes
18

3. According to the method of application -
• Paint –on technique
• Tray technique
• Spray application ( De Paola -1967)
• Single application of rinses
• Sequential fluoride rinses
19

20
Techniques Of Professional Applied Topical Fluorides Application
• Tray technique
• Paint-on technique
• Englander’s technique
• Swejda & Knutson’s technique
• Knutson & Feldman’s technique
• Mercer & Muhler’s technique
• Dubbing & Muhler’s technique
• Muhler’s single application technique

Professionally Applied Topical Fluorides
21
• Neutral sodium fluoride
• Stannous fluoride
• Acidulated phosphate fluoride solution/gels
• Varnish

Recommendations To Reduce Ingestion During Professionally Applied
Fluoride
22
• Limit the amount of gel to no more than 2ml or 40% of the tray capacity.
• Limit the amount of gel in custom trays to 5 to 10 drops.
• Seat patient in the upright position with head titled forward.
• Use suction throughout fluoride treatment.
• Never leave child patient unattended.

• 1st topically applied F compound
• 1940- Bibby, knutson and co workers of United States Public Health Service
Sodium Fluoride
23

•Milestone studies - Bibby in 1941 and Knutson (1942, 1947, 1948 varied in
concentration of fluoride and number of application)
•In 1941, 1st clinical study of NaF was carried out by Bibby using 0.1% NaF solution,
began the era of topical fluorides
•Knutson and Armstrong (1942) - gave 8-15 applications of NaF in the 1st year of 3 years
study, percentage reduction was found to be 39.8% after 1st year, 41.4% after 2 years &
36.7% after 3 years.
History
24

• Knutson et al (1947) - in three groups of 7-15 yrs children gave 2,4,6 applications /
year result after 2 yrs showed …..9.3%, 20.1%, 21% caries reduction
• Galagan & knutson (1947) - in three groups of 7-15 yrs children gave 2,4,6
applications / year result after 1 yrs showed …..21%, 40.7%, 41% caries reduction
• Knutson & feldman (1948) – recommended tech of 4 applications in a year at weekly
interval
• Studies followed by Knutson tech showed….DMFS reduction 23.6% (Howell-1955),
20% (Torell & Ericsson -1965), 11% (cons et al – 1970), 34% (Swejda -1971)
25

• Dissolving 20 grams of NaF powder in 1 liter of distilled water
• Store fluoride in plastic bottles
• pH of 7
Method of preparation of 2% NaF
Dentistry for child and adolescent, 10th edition, 2016, Dean JA, Jones JE

Cleaning & polishing of teeth
Isolation
Application of 2 % NaF for 4 mins
Instructions to patient
2nd, 3rd, 4th application at 3,7,11,13 age
Method Of Application – Knutson Technique

CaF₂ reacts with hydroxyapetite crystals
To form fluoridated hydoxyapatite
Choking effect
When NaF applied topically
It reacts with hydoxyapatite
To form CaF₂
Mechanism Of Action

10Ca (PO4) 6 (OH)2 + 20 F 10 CaF₂ + 6 PO + 2 OH
Hydoxyapatite
CaF2 + 2 Ca₅ (PO4) 3 OH 2 Ca₅(PO4)₃F + Ca (OH)₂
Fluoridated
Hydoxyapatite

1. Chemically stable
2. Acceptable test
3. Nonirritating to gingival tissue
4. Does not discolour to teeth
5. Cheap and inexpensive
1. Patient has to make 4 visits in
short time
2.Follow up is difficult
ADVANTAGES
DISADVANTAGES

• Muhler and his associates - Indiana university
• SnF₂ became the 2nd topical fluoride agents to gain wide acceptance
• Early experiments ……..Enamel surface treated with SnF₂ was less acid soluble than
treated with other F compounds like NaF
• Later experiments …….under certain conditions NaF may be superior to SnF₂
• Although, 10% SnF₂ - 2.5 % F – adults
8% SnF₂ – 2 % F – children
Stannous Fluoride
31
No evidence of clinical difference
Pediatric dentistry, 3rd edition, 2018, Tondon S

Muhler,
• Freshly prepared before each use
•‘O’ gelatin capsules - 0.8 g powdered SnF₂
• Just before application - dissolved in 10 ml of distilled water in a plastic container
Method of preparation of stannous fluoride

Prophylaxis – isolation
either quadrant or half of mouth at a time
Freshly prepared SnF₂ applied, teeth kept 4 min wet
Application – once/ year
Method Of Application

Muhlers single application technique:
Thorough prophylaxis including interproximal stripping…. Teeth are isolated dried with
air… kept moist for 4 mins. Repeat application made at every 6 months
Mercer and Muhlers technique
Same as that of muhlers technique except that teeth are kept moist for 30 secs instead of 4
min.
34

Dubbing and Muhlers technique:
Prophylaxis with stannous fluoride paste ….Application of stannous fluoride
solution for 4 mins. Unwaxed silk floss is used for interproximal surfaces
Englader Technique:
Solution or gel is applied in a special mouthpieces made from polyvinyl sheets.
Application made for 3 mins 3 times a week in schools.
35

In addition products formed are-tin Hydroxyphsphate, ca tri-fluorostannate,
ca F
stannous F reacts with HA forms new product- tin tri fluoro phosphate
Mechanism Of Action

Low conc.-
Ca₅(PO4)₃OH + 2 SnF₂ 2 CaF₂ + Sn₂(OH) PO₄ + Ca₃(PO4)₂
Hydoxyapatite tin
hydroxyphsphate
High conc -
Ca₅(PO4)₃OH + 16SnF₂ 2 CaF₂ + 2 Sn₃F₃PO₄ + Sn₂(OH) PO₄ + 4 CaF2 (SnF3) 2
Hydoxyapatite tin tri -
fluorophospahte
2 Ca₅(PO4)₃OH + CaF₂ 2 Ca₅(PO4)₃F + Ca (OH)₂
ca
tri-fluorostannate
tin
hydroxyphsphate

1. highly effective on semiannual
application
2. effective against radiation
caries
1. Should be prepared freshly
2. Low pH
3. Metallic test
4. Gingival irritation
5. Discolouration of teeth
6. Staining on margins of restoration
ADVANTAGES
DISADVANTAGES

• Shannon…..developed gel
(0.4% - SnF₂ in a methyl cellulose & glycerin base
Flavored -cinnamon or grape
stability - 15 months
• However for the Fluoride to be released, the gel should be
diluted while application
• Effective with a synthetic saliva gel in reducing caries in post –
irradiation cancer patients.
Stannous Fluoride Gel
39

• Nevitte et al (1955)…… 44.4% reduction with SnF2 & 35.9% with NaF
• Howell & Muhler (1956) …..1st clinical Utilization 2% SnF2 was carried at & studied the relative
efficacy of four applications of 2% SnF2 & 2% NaF & reported 83% & 23.6% reduction in
caries rate respectively
• Gish & Muhler in (1957)……… tried single annual application of 8% SnF2 & compared it with
Knutson’s Technique of NaF application & reported SnF2 to be 21% more effective than NaF
after first year, 32% & 35% after 2nd & 3rd year
• Muhler (1962) also tried 10% SnF2 solution topically on permanent teeth & obtained 24%
reduction in DMFT increment after one year thus showing no additional advantages
History
40

• Houwink et al (1974) in their longest clinical trial extending over a period of 9 years &
utilizing 8% SnF2 in 22 pairs of mono Zygomatic twins showed 37% caries reduction.
• Muhler et al (1947) observed that enamel powders treated with stannous fluoride solution
greatly reduced the rate of acid dissolution.
• Muhler et al (1950) in vitro study found SnF2 to be three times more effective than NaF.
• Muhler (1968) reported that when SnF2 reacts with hydroxy apatite in addition to fluoride,
the tin of SF2 also reacts with enamel & a new crystalline product.
41

• (Andres et al., 1974) and in vitro (Tinanoff et al., 1983)…..SnF2 was significantly
more effects against oral microorganism than has NaF
•Furthermore, SnF2 has also been noted to inhibit S. mutans selectively which is
associated with dental caries (Svanberg and Westergren, 1983) & Tinanoff et al., 1983
42
Studies on ....Antibacterial determinants of stannous fluoride

• Baig A A et al......compared the ability of two active ingredients – NaF and SnF₂- to
inhibit hydroxyapatite dissolution in buffered acidic media
• Both F sources provided protection against acid dissolution
• But SnF2 - treated HAP was significantly more acid-resistant than the NaF treated
mineral.
• reduction in HAP dissolution was 47.7% for NaF and 75.7% for the SnF2 -treated
apatite.
43
Baig AA, Faller RV, Yan J, Ji N, Lawless M, Eversole SL.. Protective effects of SnF2 ..Mineral solubilisation studies on
powdered apatite. Int Dent J. 2014 Mar;64 Suppl 1:4-10

The idea of Acidulated Phosphate Fluoride as a topical agent in the prevention of dental
caries emerged with the in vitro-investigation of Bibby in 1947
who reported that -
As the pH of the NaF solution was lowered, fluoride was absorbed into enamel more
effectively.
Inherent limitations - lowering of pH of NaF solution will cause decalcification and
demineralization of the enamel thus obviating the fluoride effect
Acidulated Phosphate Fluoride
44

• In 1960’s – Brudevold and his co-workers at Forsyth Dental Centre
• Development was based on slightly demineralised enamel acquired more F than
unaffected enamel
• Muhler and co-workers : prepared APF using SnF₂ but this preparation was never
marketed
• Currently available APF contains NaF as active ingredient
45

• Brudevold’s solution -
• Dissolving 20 g of NaF in 1 liter of 0.1M phosphoric acid
• 50 % HF acid added - pH at 3.0 and F concentrations at 1.23%
• APF gel - Methylcellulose or Hydroxyethyl cellulose, pH : 4 to 5
Method of preparation of 1.23% APF

Oral Prophylaxis – isolation
application of gel –
Place enough gel to fill 1/3rd of tray
Semi-annual application
Method Of Application

DCPD highly reactive with fluoride – fluoroapitite
Hydrolysis - dicalcium phosphate dehydrate (DCPD)
When APF is applied on teeth - dehydration and shrinkage of
hydroxyapatite crystals
Mechanism Of Action

Ca₅(PO₄)₃OH + 4 H 5Ca + 3HPO₄ + H₂O
Ca + HPO₄ Ca. HPO₄.2H₂O
5 Ca.HPO ₄.2 H₂O + F Ca₅(PO₄)₃ 3F + 2 HPO₄ + 3 H + 2 H₂O
Dicalcium phosphate
dihydrate
Fluorapatite

50
APF Gel APF Solution
Application using tray technique Application using paint on technique
Costly Cheap
Readily available (imported in India) Prepared easily
Self application is possible Applied by dentist or auxillary staff
Table : comparison of APF Gel and APF Solution

1. Acceptable test
2. No stating
3. No gingival irritation
4. Stable with long shelf life
5. Cheap
1. Teeth have to be kept 4 min wet
2. Acidic, sour & bitter taste
3. Not stored in glass container
4. Cosmetic changes in Restorations
ADVANTAGES
DISADVANTAGES

• Wellock & Brudevold (1963)…. 1st clinical trial was started in 1961 & after 2years children in
the study group had approximately 66 percent fewer carious surfaces than children in the control
group.
• Parmeijer et al (1963) …….in a study of 77 children aged 4 – 10 years of age, compared the
effectiveness of NaF with APF. it was therefore concluded that APF was 50 percent more
effective than neutral NaF as a caries preventive agent
• Horowitz & Doyle (1971)- The largest APF study so far carried out
After 3 years a total of 681 Hawaiian children aged 10 –12 years had taken part continuously in
the study. The greatest reduction in caries increment was obtained with the APF solutions rather
than the APF gels.
Various studies
52

• Brudevold et al (1963) - studied the effect of prolonged exposure of enamel to sodium
fluoride in acid sodium phosphate solutions. They concluded that the fluoride concentration in
enamel increased with decrease in the pH of the solution.
• Melberg (1966) - reported that after 10-minute exposure of a cut tooth section to an acid
phosphate Fluoride solution there was a high fluoride concentration in the inner surfaces of
enamel.
• Aasenden & Brudevold (1968) - reported that the tooth enamel acquired larger amounts of
Fluoride with deeper penetration when pre – treated with dilute phosphoric acid before being
exposed to fluoride Solution
53

54
Characteristic NaF SnF₂ APF
% F 2% 8% 1.23%
ppm fluoride 9200 19500 12300
Frequency of
application
4 visits at weekly
interval 3,7,11,13
1 or 2 1or 2
Taste Bland Dis agreeable Acidic
Stability Stable unstable Stable in plastic
container
Tooth pigmentation No Yes No
Gingival irritation No Occasional No
Caries reduction 29% 30% 28%
pH 7 2.1-2.3 3
Table : Comparison of topical fluoride agents

• Thixotropic solution: -
• Viscous solution
• High viscosity under storage and became fluid under conditions of high stress or
shearing force
• Why NaF once applied and is left to dry for 4 mins -
• Why APF is applied continuously for 4 mins-
for conversion of whole DCPD into FAP, deeper penetration and continuous supply of
F is required
ADD ON
55

• Shoe Leather Survey –
Shoe leather survey was conducted among 21 cities in 10 states of USA during this
survey Trendley Dean visited each and every house in that particular community.
usually any door to door or house to house survey is called as shoe leather survey.
56

• Increase enamel resistance/reduction in enamel solubility
• Increased rate of post-eruptive maturation
• Remineralisation of incipient lesions
• Interference with plaque micro-organism
• Fluoride as inhibitors if demineralisation
• Modification in tooth morphology
Mechanism of Action
57

• Increase enamel resistance/reduction in enamel solubility-
Formation of fluorapatite
• Increased rate of post-eruptive maturation –
Newly erupted teeth often have hypo -mineralised area which are prone to dental
caries
Involves deposition of mineral and organic material from saliva into hypo -
mineralised area
58

• Remineralisation of incipient lesions –
• Deposition of minerals into previously damaged areas – results in reduced enamel
solubility( growth of crystals which became larger than those either in demineralised
or sound enamel)
• Most effective remineralising solution contains F and Ca /P ions
• Interference with plaque micro-organism –
inhibit bacterial enzymatic process involved in carbohydrate metabolism
F interferes with oral bacteria in two ways
High conc – F is bactericidal ( how F helps to reduce plaque)
Low conc – F is bacteriostatic ( prevents growth of bacteria )

• Fluoride as inhibitors in demineralisation –
Experiment - artificial white spot lesions are made ..by immersing enamel into under
saturated, acidified solution of pH 4-6 & higher dissolution rate was observed
When F was added to this solution, F reduced rate of demineralisation
• Modification in tooth morphology –
Direct relationship between amount of F ingested during tooth development and
incidence of caries
Some report suggest that – diameters and cusp depths are smaller if F is present during
tooth development

• 1962 - U.S. Public Health Service recommended that optimum fluoride concentration in water
should vary depending on climatic temperature.
• 1969 - WHO reported that water fluoridation programs were under way in more than 30 countries,
serving over 120 million people
• Twenty-Second World Health Assembly issued a statement recommending member states to,
where practical, introduce water
• Fluoridation-
• Early 1970s Widespread marketing and use of fluoride-containing toothpastes
• 1975 : 28th World Health Assembly endorsed water fluoridation and other methods of delivering
fluoride
61
History

• 1977 - European Commission suggested an upper limit of 1,500 ppm F for toothpastes sold over
the counter.
• 1981 - A total of 210 million people worldwide received water fluoridation according to a 1986
WHO report
• 1983 - First indication of an increase in the prevalence and severity of dental fluorosis in the
United States.
• 1983 - Five hundred schools in 13 U.S. states operated school water fluoridation schemes.
• 1983 - Fluoridated salt was available in 23 Swiss cantons and used voluntarily by 70% of the
population.
• 1993 - First reports that there could be several risk factors for dental fluorosis. 62

• 2007 – 16th World Health Assembly issued statement urging member states to consider introducing
water fluoridation or other fluoride-based policies, including salt, milk, and affordable fluoride-
containing toothpaste.
• 2007 - Canada and Ireland lowered the recommended optimum fluoride concentration in drinking
water from 1 to 0.7 ppm.
• 2009 - European Union regulations approved addition of fluoride to foods.
• 2011 - U.S. Public Health Service recommended lowering optimum water fluoride concentrations.
• 2012 - Reported that 370 million people in 27 countries receive fluoridated water.
• 2013 - Reported that over 100 million people use fluoridated salt in Latin America.
• 2016 -Reported that over 1.5 million children receive fluoridated milk in school worldwide 63

• Silver : 24-27%
• Ammonia : 7.5-11 %
• Fluoride :5-6% (44800ppm)
• pH - 10
• Mechanism of action :
physical barrier forms- resultant product are : silver phosphate (reservoir for P ion)
calcium F ( regulate pH & F supply)
Silver ions in demineralised area reduced by environmental oxygen & turns lesion black
SDF as topical fluoride
64

Shah et al (2014).......to compare the efficacy of SDF as a topical fluoride agent in vivo
with Fluoride Varnish and Acidulated phosphate fluoride (APF) Gel.........concluded
that application of SDF on enamel significantly increases fluoride content in enamel as
compared to Fluoride Varnish and APF Gel and can be used effectively as topical
fluoride agent.
65
Shah, et al.: Efficacy of silver diamine fluoride as topical fluoride agent. Journal of Pediatric Dentistry / Jan-
Apr 2014 / Vol 2 | Issue 1

Fluoride Varnish
“ A Milestone Discovery In The Prevention Of Dental Caries ”
66

• With all currently used fluoride 2/3rd of F is lost within days
• Increasing contact time of enamel surface to F solution it favours more deposition
of bound fluorapatite and fluorohydroxyapatite
• Richardson applied water proof coating on teeth after F application .........more F
uptake by enamel
• So that, F compound directly incorporated into varnish like compound
67

68
• 1st F varnish ...Germany
• NF in varnish form containing 22.6 mg F/mL (2.26%) suspended in an alcoholic
solution of natural organic varnishes
• active fluoride available - 22,600 ppm
• Available in bottles of 30 mL suspension containing 50 mg NaF/mg.
• Neutral pH
DURAPHAT

• DURAPHAT
built of reservoir of fluoride ions
F slowly releasing and continuously reacting with HA crystals
formation of fluorapatite
10Ca₅ (PO₄) 3OH + 10 F = 6 Ca₅(PO₄) 3F + 2CaF₂ + 6 Ca₃₃ (PO₄) 2 + 10 OH
Low concentrations :
2Ca₅(PO₄) 3OH + 2CaF₂ = 2Ca₅(PO₄) 3F + Ca(OH)₂
Mechanism Of Action
69

• Heuser and Schmidt (1968).........1st clinical trial to see efficacy of Duraphat. one
application of Duraphat on 224 children 13-14 yrs....showed 30% DMFT reduction
over 15 months
• Majority of clinical trials conducted to see efficacy of Duraphat during early 1970’s
reported effectiveness between 30-45%............
• 45% DMFS reduction after 23 months (Maiwald & Geiger 1973)
• 43% DMFS reduction after 3 yrs (Hetzer & Imisch 1973)
• 40% DMFS reduction after 3 yrs (Maiwald &, HJ 1974)
• 36.6% DMFS reduction after 3 yrs (Murray et al 1979)
• 44% DMFS reduction after 2 yrs (Holm 1979)
70

• Koch & Peterson (1975) ..........found duraphat more effective which showed 75%
DMFS reduction after semi-annual application in 1 yr study
• Similar effect shown by Tewari A et al (1984)...........73% DMFS reduction in 1.5 yrs
study
• Holm et al (1984) ........found 56% DMFS reduction after 2 yrs
71

72
• Colourless, polyurethane lacquer
• Dissolved in chloroform & dispensed in 1 mL ampules ( 1 ampule – 6.21mg F)
• F compound - difluorosilane
• F content - 0.7 % by weight
• Active fluoride available - 7000 ppm
FLUOR PROTECTOR

• FLUORPROTECTOR –
Fluoride deposited is more
Less ability to inhibit caries
Silane fluoride + water = hydrofluoric acid (HF)
Fluorosilanes also enhance retention and penetration of fluoride in enamel by
utilizing enamel network as
73

• Mechanism Of Action-
• Silane fluoride of fluorprotector reacts with water to produce HF - which penetrates
into enamel more readily than fluoride (Arends & Schuthof 1975)
• Fluorosilanes also enhance retention and penetration of fluoride in enamel by utilizing
enamel network. (Koritzer & Levy 1979)
• These observations support the fact that the fluoride deposited in enamel is more in
case of fluorprotector as compared to Duraphat.
R-SiF2 OH + H2O = R-Si (OH)3 + 2 HF
74

• Groeneveld & co workers (1982) ............. no difference in caries incidence after
annual application of fluorprotector after 3 yrs
• Lissa Seppa (1982) ........compared fluorprotector with duraphat.........showed caries was
significantly reduced by 66% with duraphat & 40% by fluorprotector
• Lissa Seppa et al (1982)........in study on 13-15 yrs children after 5 semi-annual
applications.........DMFS reduction of 1.3 in duraphat gr and 0.5 in fluorprotector gr
• Seppa et al (1982).........After 3 yrs of semi-annual applications using half mouth as a
control.......duraphat proved superior to fluorprotector in children residing in an
optimally Fluoridated community (DMFS reduction with duraphat 30%, fluorprotector
–non significant
75

• Inspite of lower F content of fluorprotector , amount of F introduced by fluorprotector
is considerably greater than introduced by Duraphat ( Edenholm 1977, Retief 1980,
Seppa et al 1982, Dijkman 1983, Tveit 1980)
• Lissa seppa (1982)........ six months after 5 semi-annual application of fluorprotector
and duraphat in 13-15 yrs children found 3364 ppm in duraphat gr, 4179 in
fluorprotector, 2036 ppm incontrol gr
• Seppa et al (1982) .......study done on 13-15 yrs children residing in community with
fluoridated water after 5 semi-annual applications of fluorprotector and duraphat
found 1601 ppm in duraphat gr and 2181 ppm in fluorprotector gr .
76

77
Ekstrand et al (1980) ........... investigated plasma F levels in 4 children after oral
application of duraphat. A total 0.11-0.15ml duraphat applied in younger children
supplying F dose of 2.3-3 mg and in older children 0.25 ml varnsih contatning 5-5.2 mg
F was applied. Highest plasma F varied between 60-120mgf/ml within 2 hrs of
application
Seppa et al (1983) ............ plasma F levels after 2 hrs were found to be 0.180µg/ml
after duraphat application and 0.140 µg/ml after fluorprotector application

After prophylaxis, teeth are dried
No isolation is required
Total 0.3-0.5ml of varnish is required to cover full
dentition
After application patient is made to sit for 4 mins before
spiting
Instruction to patient are given
Technique of Varnish Application
78

• Necessary to evaluate the risk of possible side effects by examining plasma levels
• The recommended dose –
0.5 mL duraphat for single application - 11.3 mg F
0.5 mL of fluorprotector - 3.1 mg F
• Highest plasma fluoride concentration 60 -120 mg/mL and was seen within 2 hours of
application
• These values are far below the toxic doses and hence adjudged to be safe.
Safety Aspect of Fluoride Varnish
79

Self Applied Topical Fluorides
80
• Dentifrices
• Mouth rinses
• Fluoride gels

Fluoride Dentifrices
“A Milestone Discovery In The Prevention Of Dental Caries”
81

• 1st clinical trial – Bibby (1942)
Active NaF added in Dicalcium phosphate- not statistically significant
• Muhler et al (1954)-
Stannous F with new Ca pyrophospahte abrasive system - statistically significant
• Torell and Ericson (1965) –
Sodium monofluorophosphate added to toothpaste - statistically significant
82
Early clinical trials of Fluoride Dentifrices

• First era :
Torell and Ericson 1965 ( using sodium bicarbonate)........ Brudevold et al 1966
(using di calcium phosphate dihydrate).......Peterson et al 1968(using insoluble
sodium metaphospahet).....reported reduction of dental caries from 6% - 20%
• Second Era :
Zacherl 1968, Reed et al 1970, Weisenstein 1972( using calcium pyrophosphate)
and Koch 1970 ( using plastic abrasives) reported 28-48% reduction of dental caries
83

• Cosmetic dentifrices and therapeutic dentifrices -
• Physico-mechanical functions :
• Chemical functions :
84
Functions of Fluoride Dentifrices

• Abrasive or polishing agent, detergent, binders, flavouring agents
• Abrasives – Ca pyrophosphate, Na metaphosphate, silica gels
• Humectants – to prevents loss of water
glycerol, sorbitol, propylene glycol
• Binders /thickening agents – hydrophilic substances
seaweed colloids (extract of irish moss or Na alginate , synthetic cellulose )
85
Composition of Dentifrices

• Surface active agents – sodium lauryl sulphate, N – lauryl sarcosinate, sodium alkyl
sulfoacetate
• Flavouring agents –
• Sweeteners –saccharin 0.1%
86

• Sodium fluoride dentifrices
1st F compound added as active ingredient
Bibby 1945, Muhler 1955 : 0.22% Naf was ineffective in reducing caries
FDA (1973) approved NaF dentifrice.... formulated with Ca pyrophosphate abrasive system
FDA proposed rules for NaF dentifirces – 0.188 - 0.254 % (650ppm)
87
Fluoride Compounds In Dentifrices

• Stannous fluoride dentifrices -
In 1955 -
0.4% SnF₂ added in Ca pyrophosphate abrasive system
Incompatibility
Inadequacies in design and conduction of trial
pH - 4.8
88

With SnF₂, dentifrice containing calcium pyrophosphate as abrasive % reduction
reported 9 % Mergele 1964, 21% Muhler 1962, 3% Muhler & Radhike 1957, 54%
Bixler et al 1966
However, both SnF₂ & NaF not widely used today ........because of lack of
compatibility with abrasive, staining of composite restoration
89

• Monofluorophosphate –
Used since 1969
• Advantages -
• Neutral pH (6.5)
• Greater stability to oxidation and hydrolysis
• Longer shelf life
• Increased availability of fluoride
• No staining of teeth
90

• Dentifrices containing MFP at conc of 0.76%,0.1% with sodium metaphosphate as
abrasive, have led to variable reductions in caries from 17 % (unsupervised brushing
in areas of optimal F) to 34 % for supervised brushing in nonfluoridated areas) Finn
& Jamison 1963, Naylor & Emslie 1967, Zachrel 1972
• Caries reduction were greatest in proximal surfaces and newly erupted teeth
( Andlaw & Tucker 1975)
• Less expensive abrasives Al oxide used to eliminate Po₃F²⁻ to inhibit uptake of F by
enamel........using these abrasive 2% NaMFP dentifrices, Hargreaves & Chester
1973, Lind et al 1974 over period of 3 yrs reported 30% caries reduction
91

92
P
MFP
Ingram et al 1972
Mechanism of action
Erricsson 1963
MFP deposited in lattice
F release
replaces OH
Fluorapatite
Gron et al 1971
Release of F by hydrolysis
F + HAP
FA

• Amine fluoride dentifrices -
• 1st tested for cariostatic potential (Zurich, switzerland)
• Amine fluoride emlex – 1st marketed in switzerland 1963
• Marketed only in Europe
• Foam less than MFP
• Organic F shows antibacteial and antisolubility properties superior to inorganic F
(Muhlemaum 1957, Marthaler 1961)
93

• Fluoride tooth paste – 800 to 1000 ppm F
• Free available F - 500 to 600 ppm i.e. 30 mg F in tube of 50 mg
• Safety Tolerated Dose : 8-16 mg F/ kg body weight
• Certainly Lethal Dose : 32-64 mg F/ kg body weight OR 5000 -10000 mg of NaF
94
Safety Of Fluoride Dentifrices

Age (years) Weight (lbs) CLD (mg) STD (mg)
2 22 320 80
4 29 422 106
6 37 538 135
8 45 65 164
10 53 771 193
12 64 931 233
14 83 1206 301
16 92 1338 334
18 95 1382 346
95
Table : CLD & STD of F for children of various ages

Age (years) Toothpaste indicated
< 4 years Not recommended
4 – 6 years Once/day with F toothpaste
Other two times without toothpaste
6 – 10 years 2 times/ day with F toothpaste
Once without F toothpaste
> 10 years 3 times/ day with F toothpaste
96
Table : Recommendation for use of F Toothpaste

Fluoride Mouth Rinses
97
“An Effective And Economical Measure For Dental
Caries Prevention At Community Level”

• Frequent use of low conc. of F is more cariostatic than less frequent use of higher
conc.of F for topical application
• Topical effect of fluoridated water is best of providing frequent local applications
• Where water fluoridation is not possible, F mouth rinses (0.05% NaF daily) have been
found effective tool
• Use of fluoride mouth rinses 1st described – Bibby et al (1946)
• 1975 – council on dental therapeutic of the ADA accepted NaF & APF mouth rinses
• Later Stannous F was accepted by ADA
98

• Sodium Fluoride Mouth Rinses :
• 0.2% (900ppm) for weekly use or 0.05% (225ppm) for daily use
• Forcefully swishing 10ml for 60 sec
Preparation –
• Daily - 200 mg NaF tablet (10mg F + rest is lactose) + 5 teaspoon water
• Weekly – 2gm NaF powder + 1 lit water
99

• Acidified Sodium Fluoride Mouthrinses :
• Bibby and co workers 1st to clinically evaluate Acidified Sodium Fluoride rinses
• 0.01% NaF (45ppm) at pH 4
• But results were negative ....later higher conc were used
• Stannous Fluoride Mouthrinses
100

• Mechanism Of Action Of Fluoride Mouth Rinses :
101
• Fluoride changes structure of enamel
• Fluoride may act by inhibition bacterial metabolism and plaque acid formation

Mouth rinsing in different clinical situations
102
Effectiveness on –
• Primary Dentition
• Different Tooth Surfaces
• Newly Erupted Permanent Tooth
• Adult Caries ( ADA – daily use F rinses along with semi annual application of F )
• In Low And High Prevalence of caries

103
• Torrel & Ericcsson 1965 – studied caries preventive effect of mouth rinsing with
0.2% (fortnightly) and 0.05% Naf (daily) solution. .....at end of 2 yrs......daily rinsing
was found to be significantly more effective than fortnightly rinsing which had
resulted 21% reduction over control gr
• Studies conducted using NaF and APF mouth washes .....percentage reduction in
DMFS from 16-54% ...............Koch 1967 reported 23% reduction using 0.5% NaF
biweekly.....Horowitz et al 1971 reported 44% reduction with weekly rinsing of 0.2%
NaF..........Heiftz et al 1973 reported 44% reduction with weekly rinsing of NaF 0.3%
........Ripa et al 1983 reported 44% reduction with weekly rinsing of 0.2% NaF

104
• % caries reduction with daily use of APF ranges from 23% Laswell et al
1975......30% Aasenden et al 1972
•Weekly rinsing with 3000 ppm in APF led to caries reduction of 27% Heifitz et al
1973.....and .....1000 ppm to 46% Laswell et al 1975
•Neither APF rinses nor acidulated gels have been found to be more cariostatic than
neutral NaF (Aasenden et al 1972, Heifitz et al 1973)

• In addition to professional gels for office...self applied gels for home are also
available
• NaF and APF (5000 ppm)
• Stannous fluoride (1000 ppm)
• Either applied in trays or brushed on teeth
• Advantage : home use of F gel – many more applications can be done
• Use –
• Home F gels not recommended - below 6 years
Fluoride Gels
105

“A Dual Approach In Prevention Of
Dental Caries”
Fluoride Tablets
106

• F mouth rinses - economical and effective cariostatic measure
• Difficulty of preparation and transportation
• F tablets found to be easiest vehicle for mouth rinse preparation
• Dual role of tablet – preparation of mouth rinse and chewing
• Started before 2 yrs of age and continued for about 3-4 years
107

Age
Natural F content (ppm) in drinking water
0-0.3 0.3-0.7 > 0.7
0.25-2 yrs 0.25 0.0 0
2-3 yrs 0.5 0.25 0
3-13 yrs 1.0 0.5 0
108
Table : Recommended daily dosages of F supplements in mg/day

• Hoskova 1968 .....deft reduction of 93% when F tablets were started prenatally and 54%
when F tablets were given since birth
• Kailis et al 1968..... deft reduction of 82% and 56% respectively
• Prichard 1969 .....40% deft reduction , 6-8 yrs after ingestion of F tablets since birth
• Henon 1971 ....... 78% deft reduction , 3 yrs after ingestion of F tablets since birth
• Studies done to see cariostatic effectiveness of F tablets started 3 yrs of age showed less % of
caries reduction in range of 0-38% .......0% Kamocka et al 1964.....20% Pollak 1960....38%
leonhart 1965.....11% stolte 1968........22% Kraemer 1971
Studies
109

• Intra oral fluoride releasing device
• Use of fluoride complexer
• Use of fluoride containing polyelectrolytes
• Surface active agents on F-enamel interaction
• Self gelling liquid F
• Additive protective effects of combination of F and chlorine exidine
Fluoride update
110

• Cowsar et al (1976)
• A membrane-controlled reservoir-type and has an inner core of HEMA / MMA
copolymer (50:50 mixture), containing a precise amount of NaF
• This core is surrounded by a 30:70 HEMA/MMA copolymer membrane which
controls the rate of fluoride release from the device
• 8mm length, 3 mm width, 2 mm thickness.........attached to buccal surfcae of the 1st
permanent molar
• Depending upon F in inner core , F release can be 0.02-1 mgF/day for 180 days
Intra oral fluoride releasing device
111

• As F is capable of forming strong F complexers with polyvalent metals
• Aluminium, titanium
• Treatment of enamel for 1 min with 0.5 M aluminium nitrate, then 3 mins with APF
solution and washed – 1800 ppm F in outer layer
Use of fluoride complexer
112

Bartels et al 1982 studied.......... enamel fluoride uptake at various depths from F
containing polyelectrolyte i.e. Poly-(4-vinyl pyridine).....it was observed there was
considerable deposition of 45000 ppm of F on and just below toothsurface.
Polyelectrolyte (higher molecular wt F) are superior to low molecular wt F ( NaF, APF,
SnF₂) due to following reasons –
1) Polyamine F affect essential surface properties of HA/enamel ( surface charge &
wettability) [Bartels et al 1981]
Use of fluoride containing polyelectrolytes
113

2) Thick layer at enamel interface & prevents from being exposed [Morrissey 1977]
F content after polyelectrolyte application - 45000 ppm
F content of pure FA – 37000 ppm
3) In aqueous solution, polyelectrolyte F have low activity coefficient. Therefore initial
absorption of macromolecules on enamel surface is accompanied by adsorption of F
counter ions
114

• Affects wettability i.e. Lowering surface tension of F solution leading to increased
spread and penetration into tooth surface
• Initial screening investigation – caslavaska & Gron (1981-83)
• Cetylpyridinium chloride, decyl-beta-D-glucopyranodise, zwittergent-316, lodyne
S-110 : more F penetration
Role of surface active agents on F-enamel interaction
115

• Mechanism of action SAA :
1) Lodyne S-110, Cetylpyridinium chloride –
wetting of enamel surface – quicker formation of thin barrier of CaF₂ - reduces
further dissolution of enamel – more formation of fluorapatite
2) cationic zonyl FSC, non ionic zonyl FSN - chemically inhert – provides greater
mobility of solution within enamel pores
116

• Second screening investigation –
• 1% SAA added to F solution to study effect of reduced tension on formation of FA
117
SAA (1%) FA (ppm) at 10µm enamel depth
None 350
Cetylpyridinium chloride 450
Zonyl FSP 460
decyl-beta-D-glucopyranodise 460
Zonyl FSC 480
NCS 505
Triton-X-100 515
Zonyl FSN 635
Lodyne S-110 700
Zwittergent -310 725

• Caslvaska & Gron (1984) –
tetraethoxysilane, water, surfactants, electrolytes
cross linked polymer and ethanol
Self gelling liquid F
118

• Fluoride –
• Inhibits glycolysis by acting on enolase – acid production
• Inhibit sugar transport in bacteria by reducing PEP in PEP-PTS sugar transport
system (Hemilton -1977)
• Chlorhexidine - inhibits PEP-PTS sugar transport system
• F and Chlorhexidine – inhibit carbohydrate metabolism at different sites
Additive protective effects of combination of F and
chlorhexidine
119

• Acute toxicity - rapid excessive ingestion of F at one time
speed & severity of responses are dependant on amount of F
weight & age of individual
adverse effect – nausea, vomiting abdominal cramps, diarrhoea,
dehydration, thrust, after 2 hrs fatality is possible ( by blocking
normal cellular metabolism)
• Chronic toxicity – long term ingestion of small amount of
dental fluorosis, skeletal fluorosis
Toxicity of Fluoride
120

Safety Aspect Of Fluoride
In Caries Prevention
121

• Recommended optimum levels of F for drinking water (WHO,1963) - 1 ppm
• Average daily intake intake from all sources (Longwell,1957)
Adult : 2-2.2 mg
Children (5-14) : 1.2 mg
• Which leads to plasma F levels within range of 0.019-0.038 ppm OR 19-38 mg F/ml of
plasma
• Acute lethal dose : 32-64 mg/kg
• Safety tolerated dose : 8-16 mg/kg
122

123
F in drinking water Effects
0.7-1.2 ppm Depending upon temperature of area Prevent dental caries
No dental/skeletal fluorosis
1.5-3 ppm Consumed over period of 5-10 yrs Dental fluorosis
( milder form ,with lower range)
4-8 ppm Consumed over period of 5-10 yrs Dental fluorosis -Severe form
skeletal fluorosis - milder form
8 or > 8 ppm Consumed over period of 5-10 yrs Dental fluorosis -Severe form
skeletal fluorosis - Severe form
Table - Commonly recognised effect of F ingestion through water

Agent Frequency F conc Vol required for 1
application
Total amount of F
(mg)
2% NaF Series of 4 applications
or 2/year
0.91% 2.5 22.8
APF 1or2/year 1.23% 2.5 30.75
8% SnF₂ 1or2/year 1.95% 2.5 46.75
Duraphat 1or2/year 2.26% 0.5 11.3
Fluor protector 1or2/year 0.7% 0.5 3.5
124
Table 1: Professionally administered topical fluoride

Agent Frequency F Conc volume required
(ml)
Total fluoride (mg)
0.05 % NaF Daily (home) 0.023% 5-7 1.15-1.61
0.2% NaF Fortnightly
(school based)
0.09% 5-7 4.5-6.3
0.02% APF Daily (home) 0.02% 5-7 1-.4
0.2% APF Fortnightly
(school based)
0.2% 5-7 10-14
125
Table 2 : Amount of total F (mg) in fluoride mouth rinses

III) Fluoride gels :
F conc : 0.4 - 1.23 %
Frequency – 2-4 times/year
3-5 ml gel : 60 mg F
IV) Dentifrices –
full ribbon of toothpaste over tooth brush – 1 gm of toothpaste , 0.75 mg of F
126

Author & year Aim Methodology Results Conclusion
Mainwaring PJ,
Naylor M
(1978)
to compare the
caries inhibiting
effect of the
unsupervised home
use of a sodium-
monofluorophosph
ate-calcium-
carbonate-
based toothpaste
formulation and an
acidulated
phospho-fluoride
(APF) gel
professionally
applied semi-
annually, used
singly and together
The study was of 3 years’
duration, involving 1,718
boys and girls aged 11–12
years at the time of the initial
examinations, living in two
sectors, London and the Isle
of Wight. There were five
treatment groups: control
group – non-fluoride paste
and non-fluoride gel; paste A
group -fluoride paste A and
non-fluoride gel; paste B
group – fluoride paste B and
non-fluoride gel; gel group –
non-fluoride paste and APF
gel, and paste A/gel group –
fluoride paste A and APF gel
after 3 years, there were
statistically significant
reductions in caries
increments when the test and
control groups were
compared. However, the
unsupervised use of sodium
monofluorophosphate
dentifrice was as effective in
reducing caries as twice
annual, professionally
applied, treatments of APF
gel. Further, the reductions in
caries obtained by the
combined use of fluoride
dentifrice and gel
applications were not
significantly greater than the
use of fluoride dentifrice or
gel applications alone.
sodium
monofluorophosphate
Was effective in
reducing caries.

Stanley B,
Rhea M,
Albert K
(1980)
to compare the
cariostatic effect
of weekly use of
a 0.2~ NaF rinse
with daily use of
a 0.05~ NaF
rinse in a public
health program
Participants in grades 5-7 (ages 10-
12) in public and parochial schools
were randomly assigned to the
weekly F rinse, daily F rinse or
control group that rinsed weekly
with a placebo solution (0.1 ~
NaC1
). Findings reported after two
years showed anticaries
effects for both F rinse
regimens, but no statistically
siguificant difference
between them. Year one to
year two increments showed
that subjects in the weekly
and daily F rinse groups had
1.61 and 1.18 mean DMFS
compared with 2.01 DMFS
for children in the control
group or 19.9~ and 41.3~g
fewer new carious surfaces,
respectively
findings of this study
pertain to the use of
fluoride mouthrinses
in a public health
program and should
not be generalized to
private practice.

Axelsson P,
Paulander J,
Nordkvist K,
Karlsson R
(1987)
to evaluate the
separate effect of
fluoride
dentifrice,
fiuoride
mouthrinsing
and fluoride
varnish on
approximal
dental caries.
All 252 13-14-yr-old children at an
elementary school were selected at
random and divided among four groups
for a 3-yr longitudinal study. Group 1
received a lluoride dentifrice for home
care and a fluoride mouthrinse once a
week. Group 2 received a fluoride
dentifrice for home care and a placebo
mouthrinse once a week. Group 3
received a fluoride dentifrice for home
care and a iluoride varnish onee every 3
months. Group 4 received a placebo
dentifrice for hoine care and a fluoride
rinse once a week.
The difference between
Groups 1 and 3 is
(P = 0,05). In the
present study the caries
progression was lowest
in Group 3, which
received fluoride-
varnish treatment four
times a year in addition
to the daily use of a
fluoride dentifrice
Fluoride rinsing did
not give any
additional effect
compared with
placebo-rinsing when
a dentifrice was used
for home care,
Fluonde varnish gave
a significant caries
reduction compared
with lluoride rinsing^

Tewari A,
Chawla HS,
Utreja A
(1991)
to evaluate the
effect of
topical
application of
NaF, APF and
Duraphat
The study was conducted on
1251, 6-12-year-old children,
Gr I – NaF, Gr II- APF, gr III –
Duraphat....they were assessed
for 2.5 yrs for percentage of
caries reduction of each group
percentage caries reduction with
sodium fluoride to be in the range
of 20-24 percent on base line teeth
and 30-33 percent on teeth erupted
during study, showing more effect
on newly erupted teeth. In APF
group, the caries reduction was 32-
37 percent, in the DMFT and
DMFS-slightly more on teeth
erupted during study than on
baseline teeth. The dental caries
reduction with Duraphat (NaF
varnish) was in the range of 70-75
percent-slightly more on newly
erupted teeth
Duraphat was found
more effective as
compared with NaF,
APF. Duraphat
showed the greatest
public health
potential.

Janna T,
Frank C
(2001)
to evaluate the
effect of fluoride
varnish on enamel
caries progression
in the primary
dentition
One hundred forty-two children
in Head Start schools (3 to 5
years old) were randomized into
the varnish and control groups.
Children in the varnish group
received fluoride varnish
(Duraphat, Colgate-Palmolive
Co.) at baseline and after four
months, and children in the
control group received no
professional fluoride
applications. Two calibrated
examiners performed the
examinations at baseline and at
nine months.
The mean decayed surfaces, or
ds, value in the varnish group
was significantly lower after
nine months than it was at
baseline (P < .0001). When
enamel lesions were included
in the data analysis (along
with dentinal lesions), the
decayed with initial enamel
lesions, missing and filled
surfaces, or dEmfs, values;
decayed with initial enamel
lesions, missing and filled
teeth, or dEmft, values; and
decayed surfaces with initial
enamel lesions, or dEs, values
were significantly lower in the
varnish group after nine
months than they were at
baseline (P < .0001).
fluoride varnish
applications may be
an effective measure
in reversing active
pit-and-fissure
enamel lesions in the
primary dentition

Jiang H,
BaoJun T,
MinQuan D
(2005)
to evaluate the effect
of 6-monthly
professional
application of APF
foam on caries
reduction in permanent
first molars in 6–7-
year-old children over
24 months, and to
compare the caries-
preventive effect
between APF foam and
APF gel.
In a randomised
controlled trial, 661
children aged 6–7-years-
old were randomly
divided into three groups
on a school class basis.
The foam group and the
gel group received 6-
monthly APF foam and
APF gel application,
respectively, and the
control group did not
receive any treatment.
The mean caries increment of
smooth surfaces of permanent
first molars in the foam group
was 0.16 while that of the control
group was 0.27, resulting in 41%
caries reduction (P-value=0.02),
but there was no statistically
significant difference between the
foam group and the gel group (P-
value=0.10). No difference was
found on the mean caries
increment of pit and fissure
surfaces or all surfaces among the
three groups (ANOVA, P-
value=0.89).
Six-monthly
professional
application of APF
foam could
effectively reduce the
incidence of dental
caries in smooth
surfaces of
permanent first
molars in 6–7-year-
old children, which
was similar to APF
gel

Vorakul C,
Vanitchanon C,
(2009)
To compare the
effectiveness of
self-applied
fluoride (5000
ppm NaF gel,
1000 ppm SnF2
gel, 226 ppm NaF
rinse) and
professional-
applied
fluoride(resin-
modified glass
ionomer cement;
ProSeal) on
remineralization
of artificial
incipient carious
lesion on
proximal
surfaces.
Two volunteers wore
palatal appliances attached
with six slabs of artificial
proximal lesion, applied
with one of the 4 materials
on one side of the appliance
comparing to intraoral
control on the contralateral
side. Every volunteer was
randomly assigned to each
of the 4 materials. All self-
applied fluoride products
were applied by the
volunteers, while ProSeal
was applied by a dentist
before their attachment.
The fluoride dentifrice was
used for 3 minutes twice a
day. The palatal appliance
was dipped in 20% w/w
sucrose solution for 5
The fluoride products
yielded less lesion area
compared to control
(p<0.01) in descending
order: NaF rinse,
ProSeal, SnF2 gel, and
NaF gel; however, there
were no statistically
significant differences
among the first 3
products.
Both self-applied and
professional-applied fluoride
were effective in reduction of
the proximal carious lesion
area, as follows: NaF gel-
7.19%, SnF2 gel-21.52%,
NaF rinse-23.52%, and
ProSeal-21.89%, in addition
to 27.85% reduction from the
use of fluoride dentifrice
alone2009)

Suwansingha
O,
Rirattanapong
P,
(2015)
to measure the
effectiveness of
fluoride varnish
as a public health
intervention to
prevent caries on
partially erupted
first and second
permanent
molars among 6-
11 year old
children at high
risk for caries.
In a six-month clinical trial, 105
children were randomly divided
into a fluoride varnish
(Duraphat®) group (117
molars) or a control group (117
molars). The chisquare test used
to compare caries occurrence in
each group with a 95% level of
confidence (p
Four teeth (3%) had enamel
caries (100% with a score of 1).
In the control group, 84% were
sound teeth, 19 teeth (16%) had
enamel caries (79% with a score
of 1 and 21% with a score of 2).
No dentinal caries was found in
either group. There was a
significant difference in the
caries occurrence between the 2
groups
Fluoride varnish
significantly reduced
carious lesions in
partially erupted
molars at six months
among high caries
risk children.

Khattak MF,
Conry J
(2015)
to evaluate the
short and long-
term
effectiveness of
fluoride varnish
and compare it
with the two
most commonly
used topical
fluorides, i.e.,
fluoride gel and
foam. A second
purpose of the
study was to
compare the
effectiveness of
these
preparations on
primary and
permanent teeth
Enamel slabs with a thickness
of 500 microns were obtained
from caries free primary molars
and premolars.They were
divided into four groups:
control, foam (F), gel (G) and
varnish (V). Fluorides were
applied to the enamel slabs
according to the manufacturer’s
instructions and were placed in
a 5.1 pH acidic gel for one
week.The amount of
demineralization from the
enamel was measured by
calculating the amount of light
reflected from these surfaces.
The results showed no
difference (with
Bonferroni correction)
in the effectiveness of
different fluoride
preparations over the
short-term (Week I
comparison; p-values: F
vs. G 0.079, F vs. V
0.030, G vs. V 0.44).
However, the long-term
protection provided by
fluoride varnish was far
more than fluoride gel
and foam (Week II
comparison; p-values: F
vs. G 9X10-5 , F vs. V
7X10-8, G vs. V 1X10-
4).
fluoride varnish is beneficial
for use with white spot
lesions, newly erupted
permanent teeth and early
decalcification in primary
dentition

Twetman S,
Agouropoulos A,
Pandis N,
Kavvadia K ,
Papagiannoulis L
(2016)
To evaluate
the effect of
biannual
fluoride
varnish
applications
in preschool
children as an
adjunct to
school-based
oral health
promotion
and
supervised
tooth
brushing with
1000 ppm
fluoride
toothpaste.
424 preschool children, 2–5
year of age, from 10 different
pre schools in Athens were
invited to this double-blind
randomized controlled trial and
328 children completed the 2-
year programme. All children
received oral health education
with hygiene instructions twice
yearly and attended supervised
tooth brushing once daily. The
test group was treated with
fluoride varnish (0.9%
diflurosilane) biannually while
the control group had placebo
applications. The primary
endpoints were caries
prevalence and increment;
secondary outcomes were
gingival health, mutans
streptococci growth and salivary
The groups were balanced at
baseline and no significant
differences in caries prevalence
or increment were displayed
between the groups after 1 and 2
years, respectively. There was a
reduced number of new pre-
cavitated enamel lesions during
the second year of the study
(p = 0.05) but the decrease was
not statistically significant. The
secondary endpoints were
unaffected by the varnish
treatments.
Under the present
conditions, biannual
fluoride varnish
applications in
preschool children
did not show
significant caries-
preventive benefits
when provided as an
adjunct to school-
based supervised
tooth brushing with
1000 ppm fluoride
toothpaste.

Kapoor A,
Indushekar
KR,
Saraf BG,
Sheoran N,
Sardana D
(2016)
to evaluate and
compare the
remineralization
potential of three
commercially
available Indian
pediatric
dentifrices with
different
compositions on
artificially
induced carious
lesions in
vitro through
(SEM).
The present in vitro study was conducted
on 45 sound extracted primary molar
surfaces divided into three groups (15
each).
1) Sodium fluoride 0.24% (0.15% w/v
fluoride ion) 1000 ppm.
2) Sodium fluoride 500 ppm.
3) 498 ppm sodium MFP and xylitol.
Artificial demineralization was carried
out, followed by remineralization
using dentifrice slurry as per the
group allocation. All the samples
were studied for remineralization
using SEM and the results
statistically compared.
All three dentifrices
tested showed
remineralization;
although insignificantly
different from each
other but significantly
higher compared to the
demineralizing surface
One can use pediatric
dentifrices for
preventing dental
caries and
decelerating lesion
progression with an
added advantage of
lower fluoride
toxicity risk

Malhotra R,
Singla S,
Shashikiran ND
(2017)
to evaluate and
compare
antimicrobial
efficacy of
commercially
available
child's dental
formulas in
reduced
concentrations
containing
different forms
of fluoride
against Strepto
coccus
mutans activit
y.
selected dentifrices were prepared in
dilutions of 1:1, 1:2, 1:4, 1:8, and 1:16
using sterile pyrogen-free distilled water.
Various dilutions of the selected
toothpaste slurries were incubated in the
agar plate containing pure strains of
S. mutans, and antimicrobial activity of
each was assessed by measuring the
diameter of zones of inhibition (in mm).
Agar well plate diffusion method and
minimum inhibitory concentration
(MIC) determination were the methods
used in this study. The inhibitory circle
of each dentifrice was measured and
MIC was achieved by considering the
value of diameter of the circle.
even at a lower
concentration of
fluoride, inhibition
halos were obtained
for all the
formulations at
different dilutions.
the kid's formulations
having lower fluoride
concentration show
antimicrobial activity
even after dilutions.
Thus, commercially, the
fluoride concentrations
can be further lowered
down in the dentifrices,
thereby reducing the risk
associated with fluoride

Parkinson CR,
Hara AT,
Nehme M,
Lippert F,
Zero DT
(2017)
To investigate
potential anti-
caries efficacy of
a 220 ppm
fluoride
mouthrinse.
articipants brushed twice
daily for 14 days with
either a 1150 ppm
fluoride or a fluoride-free
placebo dentifrice and
either rinsed once daily
with the 220 ppm
fluoride mouthrinse or
not. Following each
treatment period, percent
surface microhardness
recovery (%SMHR) and
enamel fluoride uptake
(EFU) were assessed
participants completed the study.
Compared with the placebo
dentifrice/no rinse treatment, the
fluoride-containing regimens
demonstrated greater enamel
remineralisation (%SMHR) and
fluoridation (EFU): fluoride
dentifrice/fluoride rinse (%SMHR
difference: 21.55, EFU difference 8.35,
fluoride dentifrice/no rinse: 19.48,
6.47, placebo dentifrice/fluoride rinse:
16.76 ,5.87 .(all P < .0001). There
were no significant differences
in%SMHR between fluoride regimens.
fluoride mouthrinse
is effective in
promoting enamel
caries lesion
remineralisation

Patil SK,
Fatangare M,
Jadhav RG, et
al
(2017)
to evaluate the
efficacy of
intensive
application of
sodium fluoride
varnish in
reducing caries
incidence among
children aged 6
to 7 years.
The study was a randomized
controlled trial conducted
among 6- to 7-year-old children
of Sangamner, Maharashtra,
India. Nearly 200 randomly
selected children were
randomized into two groups:
Control group and intervention
(varnish) group. Dental
examination to record the caries
experiences was conducted at
baseline and at 1-year follow-
up. The fluoride varnish was
applied for three times in a
week for a period of 1 year.
Out of 200 participants, there
were 3 dropouts for control
group and 4 for intervention
group. Nearly 55% study
participants were males and
remaining were females. There
was a statistically significant
difference between the baseline
and follow-up caries levels in
varnish group for deciduous
dentition. Mean caries reduction
in this study was 26%.
After 1 year of study,
we found significant
caries reversal in
deciduous dentition
among the 6- to 7-
year-olds after
intensive fluoride
application. Such a
regimen can be
advocated to
encourage the
practitioners and the
caregivers alike for
early caries
prevention

Rabab I,
Waleed G
(2019)
to evaluate the
effect of different
fluoride
varnishes forms
on the level of
fluoride ions in
saliva and their
antibacterial
action on
streptococcus
mutans.
: Seventy five school children of
age 12-15 years were selected
fulfilling inclusion and
exclusion criteria and divided
into three groups: Group I
(Duraphat varnish); Group II
(Bifluorid 10) ; Group III (MI
varnish). Salivary samples were
collected and fluoride ions were
recorded at baseline, one, two,
24,48 hours after applications.
Salivary streptococcus mutans
(CFUs X 10 6 ) was assessed at
baseline and after one, two,
three, and four weeks of
applications.
Statistical significant
higher mean values of
fluoride ions Group II
(Bifluorid 10); Group
III (MI varnish) after
one, two, 24, 48 hours
of applications.
Statistical significant
reduction was detected
in the streptococcus
mutans level with the
three used varnishes
with different levels.
After 48hrs of fluoride
varnishes application, (MI
varnish) fluoride varnish with
CPP-ACP was superior to
other varnishes to maintain
high level of salivary fluoride
ions.

Bijle M.N,
Abdalla M,
Ashraf U,
Ekambaram M,
Yiu CK
(2020)
to examine the
acid-resistance
potential of
enamel carious
lesions treated
with arginine
(Arg)-sodium
fluoride (NaF)
varnishes
using nano-
mechanical
testing and
chemical
mapping
L-arginine (at 1%, 2%,
& 4%) was incorporated
in 5% NaF varnish. The
experimental/control
groups were: 1% Arg-
NaF, 2% Arg- NaF, 4%
Arg-NaF, NaF, and no
treatment. Enamel
specimen blocks were
subjected to incipient
carious lesion formation.
After treatment, the
specimens underwent
chemical pH-cycling for
8-days and acid
challenge for 2 h. The
specimens were
characterised for (SNH)
and calcium/phosphate
content of the treated
lesions to determine
The SNH for 2%/4% Arg-NaF
demonstrated a higher resistance to
acid challenge with significantly
higher SNH recovery than NaF
varnish (p<0.05). The ESR
potential of 2%/4% Arg-NaF
varnish was significantly higher
than NaF varnish (p<0.05). The
XRD crystalline phases
demonstrated that 2%/4% Arg-NaF
had intense hydroxyapatite peaks
discerning its increased potential to
resist demineralization than NaF
varnish.
1. Incorporating 2%/4%
L-arginine in a 5% NaF
varnish enhanced the
acid-resistance potential
of NaF varnish. 2. Lower
concentration (1% w/v)
of L-arginine in 5% NaF
varnish had a similar
acid-resistance potential
as NaF varnish.

Hobbs M,
MarekL,
Clarke R
et al.(2020)
To Investigate
the prevalence
of non-fluoride
toothpaste use
in adults and
children
individual-level self-
reported data were
sourced from the New
Zealand Health Survey
(2017/18). Both child (n
= 4,723) and adult (n =
13,869) data were used.
Data included
sociodemographic (for
example, age),
socioeconomic (for
example, area-level
deprivation) and dental-
related (for example,
type of toothpaste used)
variables.
highest prevalence of non-fluoride
toothpaste use for children and
adults was in the moderate to least
deprived areas, while the lowest
prevalence was in the most
deprived areas. When
disaggregated by ethnicity, the
Asian population had the highest
prevalence of non-fluoride
toothpaste use for both adults and
children compared to Māori,
Pacific and European/Other. There
was little difference in prevalence
by rural/urban classification;
however, prevalence varied
geographically across the study
area.
6.8% of adults and 6.4%
of children use non-
fluoride toothpaste.

Reddy D,
Selvan A,
Paul ST, et al
(2021)
to evaluate and
compare the
antimicrobial
efficacy of
low-fluoride
and fluoride-
free dentifrices
against Strepto
coccus
mutans.
The antimicrobial efficacy of
four commercially available
low-fluoride child formula
dentifrices and four fluoride-
free dentifrices against S.
mutans was determined using
the agar diffusion test. Fifty
microliters of various
dilutions (1:1, 1:2, 1:4) of
each dentifrice were
inoculated on the assigned
plates under aseptic
conditions. Saline was taken
as negative control and 0.2%
chlorhexidine was considered
as a positive control. The
plates were incubated at 37°C
for 24 hours and the zone of
inhibition around the wells
was measured.
All the tested low-fluoride
dentifrices showed varying
degrees of antimicrobial
activity against S. mutans with
F2 (Pediflor®) and F4
(Cheerio™) showing greater
zones of inhibition when
compared to F1
(Colgate®kids) and F3
(Kidodent). When the mean
zones of inhibition produced
by non-fluoridated dentifrices
were compared with that of
fluoridated dentifrices, no
difference was noted between
NF1, NF3, NF4, and F2, F4.
The antibacterial activity of F1
and F3 was significantly lower
when compared to others.
However, no antibacterial
Both low-fluoride and
fluoride-free
formulations tested in the
study exhibited
antimicrobial activity
against S. mutans. In very
young children where the
risk of fluorosis is of
concern, fluoride-free
formulations can be
considered as safe
alternatives to fluoride
formulation

Kasemkhun P,
Rirattanapong
P
(2021)
to evaluate the
remineralizing
effect among
various non-
fluoridated
toothpastes on
artificial caries
in primary teeth.
Fifty sound primary incisor teeth were
embedded in self-curing acrylic resin
and immersed in demineralizing solution
for 4 days forming artificial caries. All
teeth were divided into five groups (10
teeth/group): Group I deionized water
(control); Group II 1000 ppm F
(Kodomo®); Group III non-fluoridated
toothpaste containing calcium
glycerophosphate and calcium lactate
(Dokbuaku®); Group IV casein
phosphopeptides-amorphous calcium
phosphate (CPP-ACP) paste (GC Tooth
Mousse®), and Group V non-fluoridated
toothpaste containing
nanohydroxyapatite (NHA) (Apagard®).
The SMH values of test
groups were
significantly higher than
those of the control
group (p = 0.00). The
%SMHR was -
5.72±7.03% in the
control group, Group II
was significantly higher
than Group III but there
were no significant
differences among
Groups II, IV, and V
(p > 0.05).
Non-fluoridated
toothpastes
containing CPP-ACP
or NHA for young
children had efficacy
in remineralizing
effect on primary
teeth comparable
with 1000 ppm
fluoridated
toothpaste.

• Role of fluoride in preventive dentistry is very important as it has a long history
of effective decline in caries occurrence when used wisely either systemically or
topically
Conclusion
147

• Fluoride In Dentistry,1st edition,1988, Ekstrand J, Fejerskov O, Silverstone LM
• Dentistry for child and adolescent, 10th edition, 2016, Dean JA, Jones JE
• Fluorides and dental caries, 1st edition, 1986, journal of Indian Dental association, Tiwari A
• Essentials of preventive and community dentistry, 3rd edition, 2006, Peter S
• Pediatric dentistry, 3rd edition, 2018, Tondon S
References
148

• Renuka P, Pushpanjali K. Review on Defluoridation Techniques of Water. The Int J of Engin
and Sci. 2013;2(3):86-94.
• Nawalakhe WG, Paramasivam R. Defluoridation of potable water by Nalgonda technique.
Curr Sci. 1993;65
• Pessan JP, Al-Ibrahim NS, Buzalaf MAR, Toumba JK. Slow-release fluoride devices: a
literature review. J Appl Oral Sci. 2008;16(4):238-44
149

• Hobbs, M., Marek, L., Clarke, R. et al. Investigating the prevalence of non-fluoride
toothpaste use in adults and children using nationally representative data from New Zealand:
a cross-sectional study. Br Dent J 228, 269–276 (2020).
• Reddy D, Selvan A, Paul ST, et al. Antimicrobial Efficacy of Commercially Available Low-
fluoride and Fluoride-free Dentifrices for Children. Int J Clin Pediatr Dent 2021;14(2):183-
186.
• Malhotra R, Singla S, Shashikiran ND. Comparison ofAntimicrobial Activity of Child
Formula Dentifrices at different Concentrations: An in vitro Study. Int J Clin Pediatr Dent
2017;10(2):131-135.
• Kapoor A, Indushekar KR, Saraf BG, Sheoran N, Sardana D. Comparative Evaluation of
Remineralizing Potential of Three Pediatric Dentifrices. Int J Clin Pediatr Dent
2016;9(3):186-191.
150

• Kasemkhun P, Rirattanapong P. The Efficacy of Non-fluoridated Toothpastes on Artificial
Enamel Caries in Primary Teeth: An In Vitro Study. J Int Soc Prev Community Dent. 2021 Jul
3;11(4):397-401
• Parkinson CR, Hara AT, Nehme M, Lippert F, Zero DT. A randomised clinical evaluation of a
fluoride mouthrinse and dentifrice in an in situ caries model. J Dent. 2018 Mar;70:59-66.
• Patil SK, Fatangare M, Jadhav RG, et al. Caries Preventive Effect of Sodium Fluoride Varnish
on Deciduous Dentition: A Clinical Trial. The Journal of Contemporary Dental Practice. 2017
Dec;18(12):1190-1193.
• Rabab I Salama et.al. Comparing the Effect of Three Different Fluoride Varnishes on Salivary
Fluoride Ions and Streptococcus Mutants' Levels: Clinical Trial, International Journal of Health
Sciences & Research (www.ijhsr.org) 280 Vol.9; Issue: 12; December 2019
151

• Axelsson P, Paulander J, Nordkvist K, Karlsson R: Effect of liuoride containing dentifrice,
mouthrinsing, and varnish on approximal dental caries in a 3-year clinical trial. Community Dent
Oral Epidemiol 1987; 15: 177-80,
152

Topical Fluorides.pptx

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Topical Fluorides.pptx

Similar to Topical Fluorides.pptx (20)

More from Parikshit Kadam

More from Parikshit Kadam (13)

Recently uploaded

Recently uploaded (20)

Topical Fluorides.pptx