caries

1. COURSE # AND TITLE: PEDS 538, Pediatric Dentistry
SESSION # AND TOPIC: # 9 Prevention of Dental Caries-Fluoride
DURATION: Equivalent to 1 hour
FACULTY: Dr. Glenn Minah
GENERAL GOALS: Become familiar with various soft tissue
abnormalities and diseases found in children
SPECIFIC OBJECTIVES: The student should be able to:
1. State goals of fluoride therapy.
2. Understand how optimal benefits of non-
professional administration of fluoride can be
accomplished.
3. Describe rationale and clinical
recommendations for professionally applied
topical gels, fluoride varnish and home rinses
and gels.
SESSION PLAN

2. SPECIFIC OBJECTIVES: The student should be able to:
4. Describe optimal use of fluoride dentifrice.
5. Know when intensive fluoride therapy is required and
what type should be administered.
METHODOLOGY: Web Lecture
ASSIGNMENT: McDonald RE, Avery DR. Dentistry for the Child
and Adolescent. Mosby, St. Louis, 7th ed. 2000.
Chapter 10, p. 209
EVALUATION: Written exam. Questions will be from the text portion of
this presentation.
SESSION PLAN
TEXT

3. A. Goals of fluoride administration
B. Non-professional fluoride administration
1. Systemic
2. Topical gels
3. Rinses
4. Dentifrice
C. Professional administration
1. Topical
2. Varnish
SESSION OUTLINE

4. Goals of Fluoride (F) Administration
1) Do not harm the patient. 2) Prevent decay on intact dental surfaces. 3) Arrest
active decay. 4) Remineralize decalcified tooth surfaces.
TEXT

5. GOALS OF FLUORIDE (F) ADMINISTRATION
Do no harm
Prevent decay on in tact
dental surfaces
F
F
Arrest active decay
Remineralize
decalcified teeth
1.
2.
3.
4.
F
Fluorosis or
toxicity

6. Do not harm the patient
Probable toxic dose (PTD): The PTD is 5 mg F/kg body weight. For a 20
kg 5 to 6 year old this would be 100 mg and for a 10 kg 2 year old, 50 mg.
F content of dental products or treatments may exceed these values for
young children. For example, a gel tray containing 5 ml of APF contains
61.5mg F (F is absorbed more quickly when in acidic form.), 100ml of 0.2
or 0.4% F mouthrinse contains 91 or 97mg F and a tube of fluoridated
toothpaste contains as much as 230mg F. Sub-lethal toxic symptoms are
manifested quickly after the dose and consists of vomiting, excessive
salivation, tearing and mucous discharge, cold wet skin and convulsions
with higher doses. Counter measures which should be administered
immediately are emetics, 1% calcium chloride, calcium gluconate or milk.
(Calcium reacts with F in the GI tract and prevents its absorption. The
most serious consequences of F toxicity stem from reactions of cationic
electrolytes with systemic F.)
1.
TEXT

7. POTENTIAL HARM
5 mg F / kg body
weight
20 kg 6 year old,
PTD= 100 mg F
10 kg 2 year old
PTD = 50 mg F
230 mg F/
tube
toothpaste
ACT
91-97 mg
F/
container
of F
mouthrinse
Symptoms:
1. Vomiting
2. Excess salivary
and mucous
discharge
3. Cold wet skin
4. Convulsion at
higher dose
Probable toxic dose:
Topical F,
12,300 ppm
F pH= 3.5
61.5
mg F/
5 ml

8. F
Ca
F
Ca
Counter Measures:
1. Emetics
2. 1% calcium
chloride
3. Calcium
gluconate
4. milk
Divalent
cations like Ca
cause
precipitation,
of F and
prevent
absorbtion in
the intestine.
F Ca
F
Ca
F Ca
FCa
F
Ca
F
Ca
A serious systemic
consequence is
binding of F to Ca
which needed for
heart function.
POTENTIAL HARM
F Ca
FCa
F
Ca
F
Ca

9. Fluorosis: Fluorosis occurs when teeth are developing. The most
critical ages are from 0 to 6 years. After 8 years, risk of fluorosis is
essentially past. During the critical ages F intake in excess of
0.1mg/kg body weight/day can lead to fluorosis. This is roughly
1mg/day for a 1 to 2 year old or 1.5 to 2 mg for a 5 year old.
Remember that all forms of F intake comprise the daily
consumption. This includes water intake (up to 1.5mg/day), foods
(0.3 to 1.0mg) and especially significant in young children,
swallowed toothpaste. Children under 2 years swallow 50% of
toothpaste during tooth brushing and at 5years, 25%, both of
which may amount to 1mg F/day.
Do Not Harm the Patient
2.
TEXT

10. 10
9
8
7
6
5
4
3
2
FLUOROSIS
0.0 0.5 1.0 2.0 3.0 4.0
DMFT
PPM F IN DRINKING WATER
slight
severe
moderate
mild
F in excess of 0.1mg/ kg body
weight = fluorosis
POTENTIAL HARM

11. FLUOROSIS
F
F
Excess F affects
mineralization of
developing teeth
Up to age 6 is the critical age for
fluorosis. After age 8, risk is past.
Enamel prism

12. FLUOROSIS
F in excess of 0.1mg/ kg body
weight = fluorosis
Maxium safe
dose for a 5 year
old = 2 mg F /
day
Maxium safe
dose for a 2 year
old = 1 mg F /
day
1 2 3 4 mg F
supplements toothpaste
fluids food
DW Banting
JADA
123:86,1991
Daily F intake of a 20 kg
4 year olds with
different water F
0.5 ppm
water F
1.2 ppm
water F

13. FLUOROSIS
Children under 2
years swallow 50%
of toothpaste
5 year olds swallow
25% of toothpaste
Toothpaste = 1 mg
F / gram (1000
ppmF)
1 to 3 grams
“pea” size amount (0.5g) is
recommenred for fluorosis
susceptible children.

14. moderate
severe
mild
pitting

15. Prevention of Caries
Deposition of fluorapatite (FHA) in sound tooth structure: Caries
protection results from FHA being more acid resistant than pure
hydroxyapatite (HA). Deposition takes place when F replaces hydroxyl
groups in HA. This can occur pre- or post-eruption at neutral pH, or
post-eruptively at neutral or acidic pH. At low pH, HA dissolves, then
re-precipitates as new crystals which are larger and more acid-resistant
due to higher FHA and lower magnesium and carbonate content.
Deposition of FHA is accomplished both by systemic intake of F during
tooth development, and topical F administration after eruption.
Professional topical F treatments with concentrated acidulated phosphate
fluoride (APF) gels (2.72% APF gel contains 12,300 ppm F), is the most
efficient way to accomplish this, especially when applied to newly
erupted teeth (i.e., age 2 for primary molars; age 6 to 8 for permanent
first molars and anterior teeth; age 11 to 14 for permanent premolars and
second molars).
1.
TEXT

16. MECHANISMS OF F PROTECTION
F F F F F F
F F F F F
F
Saliva (S)
Plaque (P)
Tooth (T)
DEPOSITION
Increase FHA
levels maximally in
intact dental surfaces.
Theory:
Topical F is
the best
method for
deposition.

17. F
F
F
F
F
F
F
F
Ca
PO4
PO4
Ca
Neutral pH
remineralization
DEPOSITION OF F
F
F
FHA
FHA
FHA
HA
pH 5.0
Ca
P
FHA is more acid resistant than
HA
H+
H+
CO3
Mg
H+
H+
Mg and
CO3 do
not
repreci-
pitate

18. F
F
F
F
This has better F uptake due
to more porosity
DEPOSITION OF F
Best F uptake is late pre-
eruption and early post-
eruption
F
F
F
F
F
F
FF
F
F
F
F
Mature
enamel
Surface
build-up
of F
F
F
F
Enamel
fluid
Young enamel
Drinking
water
Permanent
teeth
Primary
teeth
F 3000 900
No F 2000 600
Maximal F levels of in outer 5 microns

19. 3000
2000
1000
PPM Fluoride
outer 2 microns = 6000
ppm fluoride (max.
uptake)
Fluoride uptake is higher in a
decalcified area
F
5 um
DEPOSITION OF F
CaCa CaCaCa
F F
F
As fluoride reacts strongly
with calcium it does not
penetrate far into the tooth.
3000 ppm F
1500 ppm F

20. F
DEPOSITION OF F:
Maxium uptake
can not be
exceeded.
(3000 to 4000
ppm F in outer
5 um)
The F-rich surface can be
abraded away.

21. TOPICAL F STUDIES
Averill JADA 74:990,1987
DePaola JADA 87:155,1973
Downer BritDJ 141:242,1978
Horowitz JDent Child 27:157,1980
Muhler JDent Child 27:1571980
Szwejda JPub Health Dent
32:110,1972
NaF
APF
APF
SnF2
SnF2
APF
Caries reduction
100%
Newly erupted
teeth
Previously erupted teeth

22. Bioavailability of F: A second theory of caries prevention asserts that
F in the vicinity of carious activity (in enamel fluid) prevents
dissolution of HA crystals. Although this mechanism requires only
low levels of F (less than 100ppm to as low as 1ppm), F must be
present when the acid challenge takes place and therefore must be
supplied continually. Examples of topical applications which ensure
bioavailability are fluoridated drinking water and fluoridated
dentifrices. A major source of bioavailable F is residual F in plaque
and pellicle. F in plaque minerals such as CaF2 or calculus or in
protein complexes is released during bacterial acid production.
Prevention of Caries
2.
TEXT

23. BIOAVAILABILITY
F
F
S
P
T F
ACID
SUGAR
Provide continual low level
of F to enamel fluid. The
benefit occurs at the time of
decalcification.
Theory:
MECHANISMS OF F PROTECTION
Water fluoridation
is an example of a
source.

24. BIOAVAILABILITY OF F
SUGAR
Low level of F F
S
H+
H+
H+
H+
F
F
F
F
S
S
saliva
Plaque and
enamel
fluid
plaque
Intact HA
crystals
H+
FDecalcifying
HA crystals
J Arends. JDR
69(SI):601,1990
Decalcification of enamel
crystals:

25. F Stable FHA
F Loosely bound
or adsorbed F
F
F
F
F
F
F F
F
F
F
FF
ACID
Protection
from
dissolution
F from plaque
fluid
H+
H+
BIOAVAILABILITY OF F
F
F
Loosely-bound F
will eventually
become stable
FHA.
J Arends. JDR
69(SI):601,1990

26. F
F
F F
F
F
F
F
Protection only
where is
F
H+
H+
H+
H+
H+
BIOAVAILABILITY OF F
F
Ca
PO4
PO4
Ca
FHA with no
Incomplete
protection
F
H+
H+
H+
H+
H+
F
J Arends. JDR
69(SI):601,1990

27. BIOAVAILABILITY OF F
F
F
F
H+
H+
MS
Effect on bacteria:
H+
H+
F
F
F
F
S
SH+
F
H+
H+
The presence of
fluoride at the time of
glycolytic activity will also
inhibit of plaque
acidogenesis.

28. SOURCES OF BIOAVAILABLE F
1. saliva
0.08
0.02
ppm F in saliva
after drinking
1 3 5 h
F F F F
S
P
T
4. RESIDUAL F
ACT
2.
Fluoridated
water
3. Home care products
Calcium
Fluoride
F F F F F
Topical F
CaF2 precipitates in plaque during
topical F treatment

29. FHA
No FHA
No FHA
F F
10 ppm F
added to
drinking
water
LESIONS (mean)
MS
8
30
5
DEPOSITION
BIOAVAILABILITY
Larson RH. Caries
Res 10:321, 1976
sugar
BIOAVAILABILITY VERSUS DEPOSITION OF F
Rodent studies:
plus

30. 0
1
2
3
4
5
0.05 0.1 1 5
calcium loss
F ppm in solution
pH
BIOAVAILABILITY OF F
pH 5.0
HA
calcium
phosphate
JM Ten Cate.
JDR
69(SI):614,1990
Research evidence:
F
F
Add F:

31. Summary of preventive F procedures and recommendations: The older view
of caries prevention was that FHA deposition in non-carious dental surfaces
should be maximized by systemic F administration during tooth
development, and post-eruptively by topical F treatments. It was believed
that increased FHA provided increased protection against caries. Although
implementation of high FHA deposition has proved beneficial, it does not
afford as much protection as bioavailable F. Moreover, the high doses of F
required, systemically or topically (which often becomes systemic intake)
are partly responsible for the increasing incidence of fluorosis. Current
clinical recommendations for preventive F measures are 1) to determine
total F intake per day from all sources in order to assess over or under F
exposure, 2) determine caries risk, 3) institute a regimen commensurate
with individual caries risk status which emphasizes bioavailability of post-
eruptive topical F (e.g. regular use of F dentifrice and other home products
if indicated), 4) administer professional topical F treatments, the timing of
which should also be gauged to caries risk (This may not be needed in low
risk individuals) and 5) administer systemic topical F if indicated. (The
latter is currently under review. Present Academy of Pediatric Dentistry
recommendations are presented below.
Prevention of Caries
3.
TEXT

32. FLUORIDE SUPPLEMENTS
AGE <0.3ppm 0.3-
0.6ppm
>0.6ppm
6m-3y 0.25 0 0
3-6y 0.5 0.25 0
6-16y 1.0 0.5 0
F in drinking water
F
Academy of Pediatric Dentistry current
recommendations
TEXT

33. 1. Determine F intake
2. Determine caries risk
3. Devise personalized plan based
on risk level.
4. Stress bioavailability of F.
5. Monitor F intake of young
patients in an effort to prevent
fluorosis.
SUMMARY OF PREVENTIVE F

34. Mechanisms: Caries arrest means that active lesions become
inactive. This is accomplished clinically by adjusting several
aspects of the oral environment such as by reducing intake of
cariogenic dietary substrates, reducing plaque volume, stimulating
salivary flow, increasing plaque levels of Ca++ and PO4---,
promoting favorable microbial shifts (i.e. reducing acidogenic and
aciduric bacteria and encouraging proliferation of alkalinogenic
bacteria) and increasing bioavailable F. Bioavailable F arrests
caries by 1) inhibiting decalcification by coating enamel crystals,
intact or partially decalcified, with loosely bound F and thereby
preventing further dissolution of crystals, 2) catalyzing
reprecipitation of dissolved enamel crystals and 3) inhibiting
acidogenesis and aciduricity of cariogenic bacteria. Arrested
incipient lesions appear either as dark stained fissures which resist
explorer penetration (Active probing of stained fissures with sharp
explorers is not recommended as it may induce cavitation.), stained
cervical incipient lesions or shiny enamel surfaces covering white
spot lesions. Arrested carious dentin or root surfaces exhibit dark
staining with hard and often shiny surfaces.
Arrest of Active Decay
1.
TEXT

35. Clinical recommendations: 1) Determine total F exposure, 2)
determine caries risk and tailor clinical measures to risk
status, 3) institute dietary and plaque control procedures, 4)
control cariogenic bacteria, if indicated and 5) have patient
maintain continual low level F exposure to decalcified sites.
Arrest of Active Decay
2.
TEXT

36. ARREST OF ACTIVE DECAY
incipiencies
Root caries
Indications:
Cases difficult to treat, i.e.,
certain ECC cases
Interproximal
caries in low or
moderate risk
patients.

37. ARREST OF ACTIVE DECAY
PO4PO4
Ca
Ca
MS
LB
1.
2.
3.
Increase topical Ca
and PO4 intake.
Encourage
beneficial
microbial shifts.
4.
Plaque control
Procedure:
Diet
control

38. ARREST OF ACTIVE DECAY
5. Increase bioavailable F
F
Arrested caries turns
dark, is firm and often
glossy.
F
F
S
P
T F
ACID
SUGAR

39. Indications and mechanisms: This clinical manipulation is intended to
restore lost mineral from incipient lesions and reverse appearance of white
spot lesions. (Review notes on remineralization from Cariology course.)
Generally, remineralization procedures are indicated for non-cavitated
carious dental surfaces (enamel or cemental) in individuals who are not in
the high or severe caries risk category. These are the same as caries arrest
procedures with the exceptions that 1) only non-cavitated lesions are
indicated and 2) F, Ca++ and PO4--- exposure are monitored more
carefully.
Recommendations: Follow recommendations for caries arrest, above,
along with application of recalcifying solutions (e.g., Enamelon, which
contains F) and/or F to affected sites. Recalcification of white spot lesions
on anterior smooth surfaces require low concentrations of topical F (100
to 250ppm) since higher ones do not penetrate enamel as effectively and
may cause preservation of the white spot by reacting only with the outer
enamel layer.
Remineralization of Decalcified Surfaces
1.
2.
TEXT

40. REMINERALIZATION
Same procedures as for
arresting caries.
Exceptions or additions:
1. Only non-cavitated
lesions can be
remineralized.
2. Not recommended for
severe of high caries risk
patients.
3. Ca, PO4 and F are
administered more
precisely.
White spot
before after

41. Clinical Fluoride Products
These include 1) professional topical F, 2) F varnishes 3) home rinses
and gels, 4) dentifrices, 5) supplements and 6) other agents such as
sustained release devices. A detailed summary is presented in Tables at
the end of the presentation.
Professional Topical F
Products and description: The principal products are 2.72% acidulated
phosphate fluoride(APF) gel and 2% neutral sodium fluoride gel.
Stannous fluoride (SnF2) is no longer used routinely for professional
topical applications. APF, pH 3.5, contains 12,300 ppm F and is
formulated from sodium fluoride and 0.1M phosphoric acid. This gel is
intended to dissolve surface enamel which will re-precipitate with
higher FHA content. Neutral NaF gels (9200 ppm F) are indicated when
composite restorations are present since APF will etch glass filler
particles of the composites. This product will not produce comparable
surface FHA deposition, but according to research evidence, achieves
the same caries protection as APF.
1.
TEXT

42. Mechanisms of caries protection: The earlier theories
centered on increasing deposition of FHA. Now it is
believed that benefits are derived mainly from residual F
buildup in plaque and other oral surfaces or biofilms in
the form of CaF2, other minerals and protein-bound F.
These reservoirs release F during acidification which acts
as bioavailable F. (Note: sealants should not be placed
immediately after professional topical F treatment due to
instability of the CaF2 layer which precipitates on the
tooth surface. Sealants may be placed after 24 hours.)
When applied every 6 months to children in F deficient
regions, all types of professional topical F agents
achieved roughly 30% caries reduction versus sham
treated controls.
Professional Topical F
2.
TEXT

43. PROFESSIONAL TOPICAL F
2.72% acidulated
phosphate F (APF),
1.23% free F, 12,300
ppm F.
2.0% neutral sodium F,
0.9% free F, 9200 ppm
F.
8% stannous F (no longer
used routinely).
F
0.1 M H3OP4
PO4
Ca
Ca
F
Dissolution of
surface layer
Reprecipitation of
fluorapatite
1.
2.
3.
APF
Ca
Topical Fluorides:
H+
H+
Precipitation of
calcium
fluoride on
enamel surface
Ca
PO4

44. PROFESSIONAL TOPICAL F
CaF2
Do not seal teeth immediately
after a topical F treatment
due to CaF2.
APF will etch
glass in filled
resins. Use
neutral F gel.
T
H+
Plaque acids will
release bioavailable F
from CaF2.
F
F
Ca
Ca
resin
Etched
glass
H+ H+

45. Recommendations: 1) Determine total F exposure. 2)
Determine caries risk. 3) Administer as indicated by # 1
and 2. (Timing may be monthly, 1, 2, 3 or 4 times a
year or even contra-indicated.) 4) Apply for 4 minutes.
5) Add no more than 2ml to the gel tray and make every
effort to keep patient from swallowing the gel. 6) Have
patient refrain from rinsing, eating or drinking for 30
minutes after application.
Professional Topical F
3.
TEXT

46. PROFESSIONAL TOPICAL F
Recommendations:
1. Determine total F
exposure.
2. Administer 0,1,2,3,4 times
a year as indicated by
caries risk level.
3. Apply for 4 minutes.
4. Use only 2 ml of gel in
trays, keep patients from
swallowing the gel.
5. No rinsing, drinking or
eating for 30 min.
afterwards.
caries
Two topical F
treatments per
year reduced
caries by 30%
versus placebo
gel.
topical
placebo

47. Fluoride Varnish
Products and use: Application of F varnish is essentially a professional
topical F treatment. Duraflor is currently the only concentrated F varnish sold
in the US (called Duraphat in Europe) and contains 5% NaF. Flor-Protector
contains 0.7% silane F and is used as a cavity varnish. For topical treatments
Duraflor should be applied to, and allowed to dry on all cotton roll-isolated
teeth. Afterwards the patient should not eat for 2 hours. Although the caries
benefits are similar to topical F gels, less total F is released into the oral
cavity during treatment (i.e., only 3 to 6mg ) than from gels.
Indications: Apply to: 1) teeth during operating room procedures, 2) enamel
incipiencies, 3) exposed roots, 4) margins of restorations, 5) teeth at risk
which cannot be sealed such as erupting molars or premolars or 6) carious
anterior teeth in very young children.
1.
2.
TEXT

48. FLUORIDE VARNISH
Duraflor – 5% NaF,
26,000 ppm F, 3-6 mg F
per dose.
Fluor-Protector –
0.7% silane F. Used
as a cavity varnish

49. FLUORIDE VARNISH
Cavity Shield (OMNI) –
5% NaF
0.40 ml for
mixed
dentition
0.25 ml for
primary dentition

50. FLUORIDE VARNISH
White spots or
other
incipiencies
All teeth in
the OR
Exposed
roots and
root caries
Margins of
restorations
Erupting
teeth
Carious anterior
teeth in young
children
Indications:
2.
3.
4.
5.
1.
6.

51. Home Rinses
Products and use: These are available as over-the-counter
(OTC) daily rinses (0.05% NaF, 230ppm F; 0.02% NaF,
200ppm), or as prescription weekly rinses (0.2% NaF, 910ppm
F or 0.4% SnF2, 970ppm F). Patients should rinse 1x/day for 1
minute with 10ml.
Indications: 1) High caries risk patients. 2) Exposed root
surfaces. 3) School prevention programs.
1.
2.
TEXT

52. HOME F RINSES
ACT
0.05% NaF, 0.023%
free F, 230 ppm F, 2.3
mg F / dose
Daily Rinse:
PHOS
-FLOR
0.02% APF, 0.02%
free F, 200 ppm F, 2
mg F / dose.
Weekly Rinse
PREVI-
DENT
0.2% NaF, 0.091% free
F, 910 ppm F, 9.1 mg F /
dose.
Indications:
1. High caries risk
2. Exposed roots
3. Prevention programs

53. Home Gels
Products and use: Home gels are available as prescription
1.1% NaF (5000ppm F) and 0.4% SnF2 (1000ppm). These
are self-administered by the exposure of F to teeth than do
rinses.
Indications: 1) High or severe (rampant) caries risk patients.
2) Exposed root surfaces when evidence of caries is present.
3) School prevention programs.
TEXT

54. HOME GELS
GEL-CAM –
0.4% SnF2,
0,097% free F,
970 ppm F, 2-
3mg
F/ dose.
PREVIDENT –
1.1% NaF,
0.5% free F,
5000 ppm, 10-
25 mg F/ dose.
Indications:
1. Severe caries
2. Root caries
3. Prevention
programs
Radiation
caries

55. Dentifrices
Product descriptions: Dentifrices are sold as pastes or gels. The latter theoretically
penetrates retention sites better, and are more acceptable to young children than pastes.
The main ingredients of dentifrices, from a preventive standpoint, are F salts and
abrasives. One of 4 types of F salts are used, i.e., 1) 0.2% NaF, 2) 0.76% sodium
monofluorophosphate (MFP), 3) 0.4% SnF2 or 4) amine F. Amine F is not sold in the US.
Most dentifrices contain 1mg F/gram which amounts to 1mg or 1000ppm F in each tooth-
brushing dose. A few newer products contain up to 1500ppm F. According to trial data, all
F dentifrices reduce caries by 25 to 32% versus control paste without F, when used twice
daily. MFP and NaF are the standard types of F used in the US. SnF2 exhibits a shorter
shelf life and may cause staining of teeth. MFP is formulated with covalently bound
fluoride which improves stability, and can be used with abrasives containing Ca++ which
will react with and inactivate
non-covalently bound F. F is released from MFP in vivo by enzymatic reactions and
supposedly achieves better enamel uptake of the F ion than NaF pastes. Common
abrasives are a) sodium metaphosphate, b) silica, c) sodium bicarbonate, d) acrylic
polymer, e) dicalcium phosphate or f) calcium carbonate. The latter two can only be
used with MFP. The FDA requires that at least 60% of free F ion be available in doses,
over the life of the dentifrice. NaF and MFP dentifrices lose about 20% F availability
within 2 years.
TEXT

56. DENTIFRICE (TOOTHPASTE,TP)
Gels:
1. Better
interdental
penetration
2. More
acceptable
to children
Pastes
Key ingredients in TP:
1. F salt
2. Abrasive

57. DENTIFRICE
1. 0.2% NaF
2. 0.76% sodium
monofluorophosphate
(MFP)
3. 0.4% stannous F
4. Amine F
1 gram of TP = 1
mg F
Na
FPO4
MFP does not react with
calcium abrasives (F is
covalently bound) and has
better uptake by enamel
crystals.
Na
F
The ADA requires that 60% of free F ion be
available over the shelf life of the TP. NaF
and MFP lose about 20% free F in 2 years.
F salt (all reach 1000-1500 ppm F)
F salt in TP:
F
Sn
F
SnF2 exhibits less shelf life
and may cause dental
staining
F
Amine F is not sold in the
US. It adsorbs to enamel
and has anti-bacterial
properties

58. Na
DENTIFRICE
Na PO4
CO3
H
Ca
Ca
Ca
PO4
CO3
Ca These can be
used with MFP
It is desirable to have
PO4 and Ca and HCO3
as abrasives
H+
Abrasives:
Sodium metaphosphate
Sodium Silica
Na bicarbonate
Acrylic polymer
Dicalcium
phosphate
F
2.
5.
4.
3.
1.
Na
6. Calcium
carbonate
Ca
CO3
Ca
PO4
PO4
F

59. Use considerations: Noteworthy concerns are fluorosis from swallowed
toothpaste in children, and the F content of commercial products. The latter
involves toothpaste trial data showing that preventive effects correlate
positively with F content. As a result, commercial products are prepared with
increasing amounts of F, and this may become a fluorosis concern with young
children. Accepted provisions for reducing child intake of F are use of
toothbrushes with small heads to limit paste application, and instructing
parents to use no more than a “pea size” amount of paste (approximately
0.5g) on the toothbrush (High concentration F dentifrice should not be used
before age 7.). Another concern is rinsing after tooth-brushing. Studies show
that 50% of the benefit is lost when this is routinely practiced. No rinsing
after brushing, or rinsing with an OTC F mouthrinse are recommended.
Finally, tooth-brushing should be conducted just before bed-time in order to
take advantage of night-time reduction of oral clearance mechanisms. F
bioavailability will thus be increased.
Dentifrices
TEXT

60. F USE CONSIDERATIONS
F
F
F
F
F
F
Evidence shows that
increased F use and F
concentration
increases
bioavailability in
stagnation sites.
(Note: be aware of
fluorosis susceptible
patients.)
FS
P
T
FS
P
T
F F
F
F
awake
asleep
High
salivary
flow
Low
salivary
flow
Brush
before
bedtime
Rinsing after brushing
reduces F effectiveness
by 50%.
Recommendations: Do
not rinse after brushing
or rinse with a F rinse.

61. Type of F F salt Free F Brand
name
Company F
ppm
F mg/dose
Professional gel 2.72%
APF
1.23% Nupro Dentsply 12,300 24.6-61.5
2.0%
NaF
0.9% “ “ 9200 18.4-46
F varnish 5.0%
NaF
2.6% Duraflor Pharma
Science
26,000 3-6
Daily rinse 0.05%
NaF
0.023% Act J&J 230 2.3
0.02%
APF
0.02% Phos-Flor Colgate 200 2.0
Weekly rinse 0.2%
NaF
0.091% Prevident Colgate 910 9.1
Home gel 0.4%
SnF2
0.097% Gel-Kam Colgate 970 1.94-4.85
1.1
NaF
0.5% Prevident Colgate 5000 10-25
Commonly Used F Products

62. Type of F F salt Free
F
Brand
name
Company F
ppm
F mg/dose
Supplements
F tablets 2.2% NaF 1.0% Luride Colgate 1000 1
1.1% NaF 0.5% “ “ 500 0.5
0.55%
NaF
0.25% “ “ 250 0.25
F drops 1.1% NaF 0.5% “ “ 500 0.25mg per
1/2ml
Dentifrice 0.22%
NaF
0.1% 1000 1
0.76%
MFP
0.1% 1000 1
Commonly Used F Products