This document discusses topical protection of teeth, specifically focusing on fluoride. It begins by categorizing traditional measures for topical tooth protection such as operative dentistry, prophylactic odontomy, and fissure eradication. It then discusses various fluoride applications and delivery methods including pit and fissure sealants, topical fluoride applications, and remineralization techniques using compounds like amorphous calcium phosphate. The document delves into the history, sources, metabolism, and mechanisms of action of fluoride, as well as methods of delivery including dentifrices, mouth rinses, gels, and other products. It also covers the toxicity of fluoride in both acute and chronic forms.

1. Topical protection of
teeth
‘Fluoride’

2. By
Mohamed G. Aboelsau’d
2

3. Topical tooth protection
• All measures to maintain an intact outer surface for the tooth
through treatment of that surface itself.
3

4. Traditional measures
• Operative dentistry:- “caries control” (traditional 6m recall).
• Prophylactic odontomy:- as soon as possible after eruption.
• Fissure eradication:- deep fissures are opened to wide
cleansable grooves.
• Prophylactic fissure filling:- = (prophylactic odontomy).
4

5. • Pit and fissure sealant:-
• Preventive resin restoration (PRR):-
• topical chemotherapy:- increase resistance of the exposed surface of the
tooth “ammoniacal silver nitrate”
• Topical Fluoride application:-
• Remineralization:- (ACP) (tetra calcium phosphate and dicalcium phosphate
anhydrate).
• Polymeric coatings:- thin polymeric coating
5

6. • Laser light:- (reducing the rate of demineralization, sealing pits and
fissures, increase F uptake, vaporizes caries and fuses sound enamel,
improve sealant retention.
• Augmenting host resistance:- “ Recombinant DNA technologies, small
peptides” to enhance saliva functions.
6

7. We can categorize those measures mentioned into:-
7
Biological measuresPhysical
measures
Chemical measuresMechanical measures
Polymeric coatingsLaser lightammoniacal silver
nitrate
Operative dentistry
Topical Fluoride
application
Prophylactic
odontomy
Augmenting host
resistance
ACPFissure eradication
tetra calcium
phosphate
Prophylactic fissure
filling
dicalcium phosphate
anhydrate
Pit and fissure sealant

8. Fluoride
• Introduction (element fluoride)
• History
• Source of fluoride
• Metabolism
• Mechanism of action
• Delivery methods
• toxicity
8

9. 9

10. 10
In elemental state is a pale yellow green gas
A member of halogen family.
The most reactive member

11. 11
As essential
nutrient.

12. 12
one of the 14 physiologically essential
trace elements required for the normal
growth and development.

13. 13

14. 1901
14

15. Colorado stain
15

16. mottled enamel
16

17. An endemicimperfectionoftheenameloftheteeth
heretoforeunknownintheliteraturesofdentistry".
17

18. • This assumption established when this condition observed in
Britton residents when changed water supply from shallow
wells to deep wells after 1898, people born before that had
normal appearance.
18

19. 19

20. 1931, H. Dean
1. High concentration of fluoride in water is directly related to
the severity of enamel mottling.
2. Enamel mottling was widespread in areas with water having
fluoride content of 3 ppm.
3. Mottling with discrete pitting of enamel was notice at
fluoride of 4 ppm.
4. Mottling was less in case f fluoride levels of 2.5:3 ppm with
dull chalky white appearances of teeth.
5. No mottling or any other enamel changes were observed inn
areas with water with 1 ppm fluoride concentration.
20

21. • Term (mottled enamel) gave away to more exact term
(dental fluorosis).
21

22. 1942.
• The important milestone discovery was made by Dean et al
that 1 ppm fluoride in drinking water obtain 60% reduction in
caries experience
22

23. 1945.
• The world's first artificial fluoridation plan was started at
Grand Rapids U.S.A.
23

24. 1969.
24
that 1 ppm fluoride in water was practical and
effective public health measure.

25. ** Sources of fluoride
25

26. 26

27. 27

28. Dried tea leaves contain 100:400 ppm depending on the brand.
F is rapidly released into tea fusion most of it within 5:10 min.
(ingestion of F by tea drinkers is in the range from 0.04 to
2.7mg/day.
Water, naturally or artificially fluoridated, is the most important
single source of fluoride.
28

29. 29

30. 30

31. absorption
• 1 liter of fluoridated water containing 1 ppm F consumed.
• 1/3 : 1/2 of F in food is assimilated
31

32. Passive transportation
32

33. • Solubility and degree of ionization of the compounds. (rate of
absorption is inversely related to gastric acidity).
• Other dietary constituents such as Ca which may form
insoluble salts with F.
33

34. • Blood plasma is considered the central compartment into
which fluoride must pass for its subsequent distribution and
elimination.
34

35. Fluoride metabolism
35

36. • F in plasma exists in:-
• *ionic "free" F. *non-ionic "bounded" F.
• Ionic F is the public health importance.
• Fluoride concentration in plasma in healthy fasting person
consuming 1ppm F, is 1µM "0.019 ppm" which increases with
age.
36

37. **pharmacokinetics**
• Initial increase: - absorption phase till plasma peak is reached
1µM "0.019ppm" absorption decreases.
• Rapid fall for 1hr:- distribution phase α phase from blood to
tissues.
• Slow decline: - elimination phase β phase, this decline
reflects the plasma half-life of F "4 : 10 hrs.".
37

38. 38

39. 39

40. • F is a mineralized tissue seeker. Approximately 99% of all F in
the human body found in calcified tissues.
• accretion: - where most of fluoride is buried within the
mineral crystallites during the period of crystal growth.
•
40

41. F in saliva—
• -From salivary glands "very low" 0.007: 0.05 ppm.
• -From fluoride containing materials.
• ** 10mg F will raise parotid gland F levels from 0.02 ppm to
0.28 ppm.
• ** 5min after APF treatment, saliva F will be approximately
100 ppm.
41

42. 42

43. • F in pulp— 100: 650 ppm.
• F in dentin--- 200: 300 ppm
• F in cementum --- 4.500 ppm
• Concentration of fluoride in cementum is higher than that of
any skeletal or dental tissues.
43

44. F in enamel
• ** Outer enamel containing F levels between 2.200: 3.200 ppm
• ** Acquisition of F by the enamel surface appears to continue at a
perceptible rate as long as the tissue remains porous.
• ** F interferes with the process of maturation, thus prolonging the
length of time during which the enamel is porous and therefore will
extend the period of rapid fluoride uptake.
• ** Fully mineralized enamel has a density of 2.98 gm/ml with a
porosity as low as 0.1% space by volume.
• ** Creation of porosity or destruction of the apatite lattice is
necessary to increase the concentration and depth intake, by high
level F "1.000: 10.000 ppm" &/or acidification.
44

45. F in plaque---
• 15: 65 ppm
The ionic F activity of neutral plaque is between 0.08: 0.8 ppm
and it is too low to inhibit the metabolism of plaque bacteria.
• **Plaque F acts as a reservoir for the ionized form, "As the pH
drops and favors remineralization and bacterial inhibition."
• ** When plaque is exposed to high concentration of F, CaF is
formed, slightly soluble in water, in buffers and in 0.5M
perchloric acid and complete dissolved in strong mineral acids.
45

46. Mechanism of action of
fluoride
• The exact mechanism of action is not completely understood.
1. Increase enamel resistance "reduce enamel solubility" by
formation of fluorapatite which is less soluble.
2. Increase rate of post-eruptive maturation, increase rate of
mineralization of hypo mineralized areas.
3. Remineralization of incipient lesions, growth of crystals
which become larger than those in either demineralized or
sound enamel.
4. The composition of remineralized enamel is different from
normal enamel and may vary according to conditions
employed to produce the remineralization.
46

47. "F pH effect"
5-Interference with micro-organisms,
high concentration of F is bactericidal.
low concentration of F is bacteriostatic.
Fluoride lodges in plaque and inhibits bacterial enzymes that
responsible for acid metabolism.
.1“enolase, bacterial phosphatases and cation transport”
47

48. 6-Modification of the tooth morphology. During tooth
development, fluoride makes the morphology of teeth with
more rounded and smaller cusps with shallow fissures and
grooves.
48

49. 49

50. Topicalfluoridecompoundsused in
preventivedentistry.
• Neutral sodium fluoride :- NaF 2%
• 20 g of NaF dissolved in 1000 ml of distilled water.
• Stored in plastic containers, F reacts with glass t form SiF
which reduce the availability of free active F.
50

51. Method of application
"knutson’s technique"
1. Treatments are given in a series of four appointments.
2. Initial appointment, prophylaxis by aqueous pumice and isolation
with cotton roll, then dry with air.
3. Cotton applicator is used t paint the dried teeth till all surfaces are
visibly wet, and then the solution is allowed to dry for 3 to 4 mins.
4. At 2nd, 3rd and 4th visits the procedure isn't preceded by prophylaxis
and is scheduled with intervals of one week.
5. The four visits technique is recommended for ages 3, 7, 11 and 13
years old.
51

52. Mechanism of action
Sodium fluoride
• reacts form with hydroxyapatite crystals to form calcium
fluoride. (thick ppt layer) (reservoir for F release)
• “chocking off effect”
• Fluoride released from CaF is then react with hydroxyapatite
crystals to form fluoridated hydroxyapatite.
52

53. Advantages of neutral NaF.
1. Storage stable.
2. Acceptable taste.
3. Non-irritant to the gingiva.
4. No discoloration.
5. Series f treatments repeated only at the general ages 3, 7,
11 and 13 years old rather than annual or semiannual
intervals. 53

54. Disadvantages.
• Major disadvantage is the 4 visit technique
54

55. Stannous fluoride 8% , 10% SnF2
• Technique of application "Müller's technique"
1. Pumice prophylaxis cleaning for 5: 10 sec.
2. Unwaxed dental floss is passed between the interproximal.
3. Teeth are isolated and air dried.
4. SnF2 is applied using the paint on technique and is kept for 4
mins.
5. Application is repeated semiannual.
55

56. Mechanism of action
Stannous fluoride
• in low conc. Gives tin hydroxyphosphate “metallic taste”.
• In high conc. Gives calcium tri-fluorostannate + tin tri
fluorophosphate. (stable and strong tooth surface)
• Calcium fluoride also is the end product of reaction (low and
high conc.) 56

57. Advantages of SnF2
• Using annual or semiannual usual patient recall system.
• Single visit application.
57

58. Disadvantages of SnF2
1. Not stable in aqueous solution
2. Unpleasant taste.
3. Reversible tissue irritation.
4. Tooth pigmentation of "hypo-calcified regions and margins
of restorations".
58

59. Acidulated phosphate fluoride APF
1.23%
• Introduced by Brudevold at 1960
• Dissolving 20 g of NaF in 1L of 0.1M phosphoric acid with 50%
hydrofluoric acid to adjust pH at 3.0 and F concentration at
1.23% "Brudevold's solution".
59

60. Technique of application.
1. For aqueous preparations of APF the paint on technique is
performed.
2. For gel preparations the tray technique is selected.
3. Recommended application is repeated annual or
semiannual.
60

61. Mechanism of action
APF
• Dehydration and shrinkage of the hydroxyapatite crystals
hydrolysis DCPD “highly reactive with F”
• Fluoride penetrates into the crystals more deeply.
61

62. Advantages of APF
1. Semiannual application per year is compatible with the
regular patient recall system.
2. Gel preparations can be self applied.
3. Deposits F more deeply and more concentrated.
4. Stable and don't need fresh preparation.
62

63. Disadvantages of APF
1. Practical difficulties due to repeated application for every 30
sec. to keep the teeth wet for 4 min.
2. Acidic, sour and bitter tastes.
3. Repeated or prolonged exposure of porcelain or composite
resin restorations to APF may cause loss of materials,
surface roughness and possible cosmetic changes.
63

64. 64

65. 65

66. 66

67. Delivery methods
1-self administrated
•Fluoride dentifrices
67

68. Dentifrices "1942"
1. NaF>>> 0.188: 0.254% with F conc. Of 650ppm.
2. SnF2 "1950, by Crest">>> not used today.
3. Monofluorophosphate>>> the most widely used today.
• Half the fluoride content to produce acute toxicity
compared with NaF.
• Doesn't stain the teeth.
• Mechanism of action is not absolutely established.
• 0.564: 0.88% with F conc. 800ppm. 68

69. 4-Amine fluoride >>>"GABA 1963"
• Insoluble metaphosphate.
• Less foam than monofluorophosphate.
• Superior properties (low rate enamel dissolution, increased F
uptake and more anti-glycolytic activity in plaque) compared
with NaF and monofluorophosphate.
69

70. Adverse effects
• When eaten by children, may experience the phenomenon of
PICA and acute F toxicity.
• Detergents and flavoring oils may irritate the stomach if
ingested in large amounts.
• The largest container of toothpaste "270 gm" (family size)
contain 270mg of F that still below the Certainly Lethal Dose
(CLD)"320 mg", but exceeds the Safely Tolerated Dose (STD)
"80 mg F"
70

71. Fluoride mouth rinses
71

72. Fluoride mouth rinses>>>"1946"
Become one of the most widely used caries preventive public
health methods.
NaF 0.2% with 900ppm/ week.
NaF 0.05% with 225ppm/day.
Swishing 10 ml for 60 sec.
72

73. Recommendations for fluoride
moth rinses.
1. Rinse and expectorate technique can be used in patients in
optimally fluoridated commuinties.
2. Teaspoonful of NaF 0.05% will deliver 1 mg of F if
swallowed.
3. Swish and swallow technique should be recommended if
Fluoride concentration is 0.3 ppm or less.
4. With special benefits for patient with increased high caries
risk "orthodontic patients and patients under radiotherapy".
73

74. •Fluoride gel
74

75. Fluoride foam
75

76. 76

77. Fluoride dental floss
77

78. Fluoride containing chewing gum
78

79. 79

80. 80

81. Video club
81

82. 82

83. 83

84. 84

85. Fluoride toxicity
(Double edged sword).
• Acute toxicity: - Single ingestion of large amount of fluoride.
• Nausea >> F combine with H+ in the gastric juice to form HF
acid "highly irritant to stomach"
• Abdominal cramps.
• Vomiting.
• Increased salivation.
• Dehydration and thirst. 85

86. • Fluoride causes death by blocking normal cell metabolism.
• Death usually happened in the first 2:3 hrs. due to either
cardiac failure or respiratory paralysis.
86

87. • Chronic toxicity: - long term ingestion of small
amounts of fluoride.
87

88. Dental ->> "Enamel fluorosis"
• Excessive intake of fluoride during tooth development.
• Fluorosis occurs symmetrically (premolars, 2nd molars,
maxillary incisors, canines, 1st molars and mandibular incisors).
88

89. Skeletal ->>
• Sever pain in backbones, joints and hips.
• Stiffness in joints and spine.
• Knock-knee syndrome.
• Pregnant and lactating mothers are the most effected groups.
• CaF2 is more toxic to fetus than NaF.
• May lead to blocking and calcification of blood vessels causing
cardiac problems.
89

90. 90

91. • Crippling fluorosis.
• Neurological manifestations are seen in very advanced cases.
•
• Consumption of 20: 80 mg of fluoride/ day for a period of 10:
20 years.
91

92. 92

93. 93

94. 94