delivery system,types,toxicity,management

1. 1

2. PRESENTED BY MONIKA IRMALWAR
(INTERN ‘09 DENTAL COLLEGE AMRAVATI)
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3. Contents
 Fluorides delivery methods
 Fluoride toxicity
 Defluoridation of water
 Preventive and treatment aspect
3

4. Fluorides Delivery Methods
There are two basic methods of fluorides delivery
1. Topical
2. Systemic
4

5. Topical Fluorides 5
Topical Fluorides
They strengthen teeth already present in the mouth, making
them more decay-resistant. Topical fluorides include
toothpastes, mouth rinses & professionally applied fluoride
therapies.

6. Topical Fluorides 6
Definition: The term “topically applied fluorides” is used to
describe those delivery systems which provide fluoride for a
local chemical reaction to the exposed surfaces of erupted
dentition.
INDICATIONS:
1. Caries active individuals
2. Children shortly after periods of tooth eruption, especially those who
aren`t caries free
3. Those who take medication that reduce salivary flow or radiation
therapy
4. Post periodontal surgery when roots are exposed

7. Types Of Topical fluorides
Two Types Of Topical Fluoride Used In Preventive Dentistry
 Self applied products
 Professionally applied products
7

8. Self Applied
 Self applied products
 One method of self-applied topical fluoride that is responsible for
a significant drop in the level of cavities since 1960 is use of a
fluoride-containing toothpaste.
 Other sources of self-applied fluoride are mouth rinses designed
to be rinsed & spit out. For patients who have unusual
susceptibility to dental caries (due to dry mouth, medical
conditions, or other factors) dentists may recommend a
prescription fluoride gel or paste to be used in addition to regular
toothpaste.
8

9. Professionally Applied
 Professionally applied topical fluorides:
 It was introduced by Bibby in 1942.
 Involve the use of high fluoride concentration products
ranging from 5000-19,000ppm, which is equivalent to 5-19
mgF/ml.
 Self applied products: Include fluoride dentifrices, mouth
rinses & gels Are low fluoride concentration products ranging
from200-1000ppm or 0.2-1 mgF/ml.
 PROFESSIONALLY APPLIED In the form of a gel or
foam, applied by a dentist or dental hygienist. More
concentrated due to which not needed frequently
9

10. Fluoride Vehicles 10
Aqueous solutions & gel
The gel adheres to teeth &eliminates the
continuous wetting of enamel surfaces required
when solutions are used.
Fluoridated Prophylactic Pastes
 If prophylaxis pastes containing fluoride are
use, the lost fluoride is replenished(restore a
stock or supply to a former level or condition.)
& there is a significant gain in the
concentration of fluoride.

11.  Foam
 Developed to minimize the risk of fluoride
over dosage as well as to maintain the
efficacy of topical fluoride treatment.
 Advantages
 Its lighter than a conventional gel &
therefore only a small amount of agent
is needed for topical application
 The surfactant has cleansing action by
lowering surface tension, this facilitates
the penetration of material into
interproximal surfaces.
 It doesn`t require suctioning so it offers
advantages for home use
11

12.  DURAPHAT
 It s a viscous yellow
material, containing 22,600
ppm fluoride as sodium
fluoride in a neutral
colophonium base.
12 FLUORIDE VARNISH –
 Increasing the time of contact
between enamel surface &
opical fluoride agents favours
the deposition of fluorapatite
&fluorhydroxyapatite.

13.  FLUORPROTECTOR
 Its a clear polyurethane based product containing
7000 ppm fluoride from difluorosilane. Its
dispensed in ml ampules each ampule containing
6.21mg of fluoride.
 CAREX
 It has low fluoride concentration than duraphat &
has equal efficacy to that of duraphat as caries
preventive agent.
13

14. Topical Fluorides Compounds
Topical Fluorides Compounds Used In Preventive Dentistry
1. Sodium Fluoride
2. Stannous Fluoride
3. Acidulated Phosphate Fluoride
4. Amine Fluoride
Neutral Sodium Fluoride - a minimum of four
applications with a 2% sodium fluoride solution gives
a caries reduction of 30%.
1. Method of Preparation : It is prepared by
dissolving 20 gms of NaF powder in 1L of
distilled water in a plastic bottle.
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15. Method of applications :
Knutsons Technique
 At the initial appointment teeth are cleaned with pumice
slurry &then isolated with cotton rolls & dried with
compressed air
 Using cotton-tipped applicator sticks ,the 2% NaF is painted
on air dried teeth so that all tooth surfaces are
visibly wet.The solution is allowed to dry for 3-4 min.
 This procedure is repeated for each of the
isolated segments until all the teeth are treated.
 A 2nd, 3rd and 4th fluoride application, each not
preceded by a prophylaxis, is scheduled at
intervals of approximately one week;
 The four-visit procedure is recommended for ages 3, 7, 11
and 13years, coinciding with the eruption of different groups
of primary and permanent teeth
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16.  Advantages of neutral sodium fluoride solution :
 It is relatively stable when kept in a plastic container;
 The taste is well accepted by patients;
 The solution is non-irritating to the gingiva;
 It does not cause discoloration of tooth structure;
 The series of treatments must be repeated only 4 times in
the general age range of 3 to 13, rather than at annual or
semiannual intervals.
 Disadvantage of neutral sodium fluoride solution:
 The major disadvantage of the use of sodium fluoride is
that the patient must make 4 visits to the dentist within a
relatively short period of time.
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17. Stannous Fluoride
 Stannous fluoride has been used at 8% and 10% concentrations
 Solutions of stannous fluoride are not stable. Soon after mixing
they become cloudy due to the formation of tin hydroxide.
 A fresh solution of stannous fluoride be prepared for each patient.
 To prepare 8% stannous fluoride solution, the content of one
capsule which is 0.8gms is dissolved in 10 ml of distilled water in a
plastic container.
 Technique of application (Muhler‟s technique) :
 1. Each tooth surface is cleaned with pumice or other dental
cleaning agent for 5 to 10 seconds;
 2. Unwaxed dental floss is passed between the interproximal
areas;
 3. Teeth are isolated and dried with air.
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18. Advantages of stannous fluoride :
 Using an 8% stannous fluoride solution at 6 to 12 months
intervals confirms to the practicing dentist`s usual patient –
recall system
 Administrative difficulties are avoided.
Disadvantages of stannous fluoride :
 In aqueous solution the material is not stable;
 8% solution is quite astringent and disagreeable in
taste, its application is unpleasant;
 The solution occasionally causes a reversible tissue
irritation manifested by gingival blanching;
 Causes pigmentation of teeth which has a
characteristic light brown color.
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19. Acidulated Phosphate Fluoride (APF)
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Technique of application
 Acidulated phosphate fluoride is recommended for
application at 6 or 12months intervals
 Oral prophylaxis is done
 The teeth to be treated are completely isolated and
thoroughly dried with air
 Clinical application of APF gels
should be done using trays that fit
the patient`s upper and lower dental
arches. A disposable foam-lined
tray is preferred

20.  To reduce ingestion of fluoride, a
minimum amount of fluoride gel
that will permit complete coverage
of the tooth surfaces should be
dispensed
 After the trays have been properly
positioned saliva ejector is used to
evacuate the stimulated saliva and
excess fluoride;
 It is reapplied every 15-30 seconds
so as to keep the teeth moist with the
fluoride solution throughout the 4
minute period
 The patient is instructed not to eat,
drink or rinse his mouth for at least
30 minutes
20

21. characteristic
s
Sodium
fluoride
Stannous
fluoride
APF
percentage 20% 8% 1.23%
Fluoride
concentration{
ppm}
9,200 19,500 12,300
PH neutral 2.4-2.8 3.0
Frequency of
application
4 at weekly
intervals
3,7,11&13
years
biannually biannually
Adverse
effects
No Tooth
pigmentation
gingival
irrtiation
No
21
- soben peter 4th edition

22. Systemic water fluoridation
 Water fluoridation
 Community Water Fluoridation
 School water fluoridation
 Dietary fluoridation
 Salt Water Fluoridation
 Milk fluoridation
22

23. Systemic fluorides
 Systemic fluorides provides a low concentration
of fluoride to the teeth over long period of time.
 It circulates through blood stream and is
incorporated into developing teeth.
 After teeth erupt, fluoride contact the teeth
directly through salivary secretions.
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24. Community water fluoridation
 It is most common form of systemic fluoride administration
 It is the addition of fluoride to public water supplies.
 The optimal level of fluoride in water for
protection against dental caries is approximately
1 part per million.
 Water fluoridation is defined as the upward
adjustment of the concentration of fluoride ion in
a public water supply in such a way that the concentration of
fluoride ion may be consistently maintained at 1ppm by weight
to prevent dental caries with minimum possibility of causing
dental fluorosis.
 1ppm is 1mg fluoride in 1 liter ; 1 mg fluoride in 1 kilogram
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25. FLUORIDITATION STUDIES
 GRAND RAPIDS-MUSKEGAON STUDY
 On January 25th, 1945, sodium fluoride was added to the Grand Rapid
water supply. Muskegaon was the control.
 For the first time a permissible quantity of a beneficial quantity of a
beneficial dietary nutrient was added to the community water.
 The effects of 6 ½ years of fluoridation in Grand Rapids were reported
by Arnold et al in 1953.
 The results showed that the caries experience of 6yr old Grand Rapids
children was almost half that of 6yr old Muskegaon children.
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26.  NEWBURGH – KINGSTON STUDY
 On may 2nd 1945, sodium fluoride was added to the drinking water of
Newburgh on the Hudson river. Kingston town was control
 After 10yrs of fluoridation, Ast et el (1956) rate had reported that the
DMF had fallen from 23.5% to 13.9%,thus confirming the caries
inhibitory property of fluoride in drinking water .
 TIEL – CULEMBORG FLUORIDIATION STUDY
 In march 1953 the drinking water in Tiel was fluoridated to a level of
1.1ppm.
 Culemborg with water fluoride level of 0.1ppm was the control.
 After 13yrs of fluoridation, the number of anatomical sites of teeth
affected by dental caries was 58% lower in Tiel than in culemborg.
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27. Fluoride compound used in water
fluoridation
 Fluorspar
 Sodium fluoride
 Sodium silico fluoride
 Hydrofluosilicic acid
27

28. Advantage of community
water fluoridation
 Consumers receive continuous protection with no
conscious effort on their part of participation when
they drink optimally fluoridation water.
 It work without requiring individuals to gather in central
location as with other disease prevention
programmes, as immunisations.
 It does not require the costly services of health
professional to deliver.
 It is socially equitable and does not discriminate
against any group.
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29. Benefits & Limitations
 Benefits
 Reduction of dental caries:50-70%
 75% reduction in first permanent molar loss
 There is drastic reduction in progression and development
of dental caries and in flouridated areas.
 There is reduction in number of surfaces attacked by dental
caries.
 Limitations
 Water fluoridation can be implemented only in area which
have center pipe water supply system.
 It interferes with personal choice.
 People may think of overprotection.
 Initial cost for installing fluoridation plant is more.
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30. Salt Fluoridation
 Salt is a good vehicle for systemic
fluoride introduction.
 It was introduced by Wespi in
Switzerland in 1995.
 It is most popular in Colombia,
Hungary and Spain.
 Recommended concentration is
250mg of fluoride/kg salt.
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31. Salt Fluoridation
 Advantages
Quite economical
Practical/feasible
Caries reduction is about 40-50%
 Disadvantages
Consumption of salt till 4 to 5 years after
birth is negligible, hence no benefits for
younger children's.
Not useful in case of medically
compromised patient.
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32. School Water Fluoridation
 School water fluoridation
reduces dental caries by
40%.It’s primary effect are
systemic and also have
topical effects.
 Recommended
concentration of fluoride in
school water fluoridation is
4.5 ppm.
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33. School water fluoridation
 Advantages
Target population school children.
Caries experience is high.
Quite economical.
 Disadvantages
There is a need for school authorities.
All children may not attend the school for
all day.
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34. Milk fluoridation
 Milk fluoridation is quantity of fluoride to
bottle milk or milk packets.it is mainly
recommended for growing children's.
 Milk fluoridation was strongly promoted
by Ziegler, a pediatrician.
Concentration
 2.2mg of sodium fluoride was added to
¼ lit. of milk.
Disadvantages
 There is a need for school
authorities.
 All children may not attend the
school for all day
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35. Fluoride tablets/ Drops/ Lozenges35
• Sodium fluoride is the most
commonly used.
• The other compounds used are acidulated
phosphate fluoride, potassium fluoride or
calcium fluoride.
• Supplements contains a measured amount
of fluoride typically 0.25mg,0.5 mg or 1.0
mg.
• Fluoride drops are dispensed with a
measured dropper and are convenient for
infants.
• Tablets and lozenges should be chewed,
swished and swallowed.

36. Toxicity of fluorides
Fluoride is often called as a double-edged
sword that is help and hinder.
 This is because inadequate ingestion of
fluoride is associated with dental caries
 Excessive intake of fluoride can lead to
dental and skeletal fluorosis.
 It is classified as-
 Acute-due to a single ingestion of a
large amount of fluoride.
 Chronic-due to long term, ingestion of
smaller amounts.
36
-soben peter
4th edition

37. Prevalence (%) of dental fluorosis in different parts of
India by age groups 37
State/Area Age group (Years) Prevalence(%)
Raigad, Maharashtra 0-23 91.7
Nalgonda, A.P adults 30.6
Shivpuri, M.P 13-50 86.8
Vadodra, Gujrat adults 39.2-59.3
Durg, Chattisgarh adults 8.2
Punjab 5-60 91.1
Davangere, Karnataka 12-15 13-100
-REVIEW
ARTICLE-
FLUOROSIS IN
INDIA
(APRIL 2013)

38. Acute Toxicity Of Fluorides
 ACUTE TOXICITY: The amount of 32-64mg F/kg body
weight of soluble fluoride is considered to be lethal.
 Safely tolerated dose 8-16mg F/kg body weight.
 Signs and Symptoms :
 Nausea
 Vomiting
 Diffuse abdominal pain
 Diarrhea
 Excess salivation
 Thirst
 Muscle tremors
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39. 39
-soben peter 4th edition

40. Chronic Fluoride Toxicity
 CHRONIC TOXICITY: Chronic toxicity is due to long-
term ingestion of a smaller amount of fluoride which
usually affects the hard tissues & kidney. The effect of
chronic fluoride toxicity on enamel is dental fluorosis.
 Dental fluorosis occurs when dosage becomes 2 times
greater than optimal. If dose exceeds 10-25mg/day,
skeletal fluorosis occurs.
40
-soben peter
4th edition

41. Clinical Features of Dental Fluorosis
 Lusterless, opaque white patches in the enamel which
may become mottled, striated or pitted.
 Mottled areas may become stained yellow or brown.
 Hypoplastic areas may also be present to such an
extend in severe cases that normal tooth form is lost.
41

42. Fluorosis 42

43. Mild Fluorosis
 Small opaque paper white areas are scattered over less than 25%
of tooth surface.
43

44. Moderate Fluorosis
 All enamel surfaces of the teeth are affected, and the
surfaces subject to attrition show wear. Brown stain is
frequently a disfiguring feature.”
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45. Severe Fluorosis
 All enamel surfaces are
affected and hypoplasia is
so marked that the general
form of the tooth may be
affected. The major
diagnostic sign of this
classification is discrete or
confluent pitting. Brown
stains are widespread and
teeth often present a
corroded like appearance.
45

46. Treatment
 Treatment options for fluorosis varies with severity. It
may be :-
 Bleaching
 Composite restorations
 Veneers
 Full crowns
46
- Google
(Article from journal of
conservative dentistry)

47. 47
- Google
( readings taken on1st april 2014)

48. Symptoms 48
 Skeletal fluorosis occurs from ingestion of very
high amount of fluorides for long periods of
time.
 At water fluoride level 8ppm, skeletal fluorosis
may develop.
 Severe pain in back bone, joints, stiffness in
joints and spine.
 Outward bending of legs and hands is seen in
advanced stages i.e knock knee syndrome.

49. Treatment
 As of now, there are no established treatments for skeletal fluorosis
patients.
 However, it is reversible in some cases, depending on the
progression of the disease.
 If fluorine intake is stopped, the fluorine existing in bone structures
will deplete and be excreted via urine.
 However, it is a very slow process to eliminate the fluorine from the
body completely. Minimal results are seen in patients. Treatment of
side effects is also very difficult.
 For example, a patient with a bone fracture cannot be treated
according to standard procedures, because the bone is very brittle. In
this case, recovery will take a very long time and a pristine healing
cannot be guaranteed.
49
-wikipedia

50. Defluoridation
 Definition
 “The downward adjustment of level of fluoride in drinking
water to optimal level of 1ppm.”
Methods of Defluoridation
 Defluoridation can be done by two methods:
 Based on ion exchange process or adsorbtion and
 Based on addition of chemicals to water during treatment.
50

51. Ion exchange resins
 Anion exchange resin
 Anion exchange resins are polysterine anion exchange
resins in general and strongly basic quaternary ammonium
type resins in particular
Tulsion A-27 , Deacodite FF, Lawatit MIH-59.
 Cation exchange resins.
1) Carbon
2) Magnesia.
51

52. Nalgonda Technique
 NEERI-National environmental Engineering research
Institutie –Nagpur)
 Process for removal of excess fluoride in ground water by
using Nalgonda technique:
 By this method, safe drinking water with fluoride content
within permissible limits of 1.5mg/l for domestic and
community use can be supplied.
52

53. 53
1.Rapid mix-mixed
for 30-60 sec at a
speed of 10 – 20
rpm so that the
coagulant is
uniformly dispersed
2.flocculation
-gentle and
prolonged
mixing for 10-
15min with
speed of 2-
4rpm
3.sedimentation-
separation from
the water by
gravitational
settling of
suspended
particles that are
heaviour than
water.
4.filtration-
separating
suspended
impurities by
passage through
a porous media.
Water is allowed
to settle for 24hrs
then supplied

54. Prevention
 Parental vigilance is the key to preventing fluorosis. – At
home, keep all fluoride-containing products such as
toothpaste, mouth rinses, and supplements out of the reach of
young children.
 Since the major source of fluoride is drinking water, de-
fluoridation is the best preventive measure which can be
carried out at domestic as well as community level.
 Nutritional interventions like high intake of vitamin C and
Calcium also helps reduce the problem.
54

55. REFERENCES:-
 ESSENTIALS OF PREVENTIVE AND
COMMUNITY DENTISTRY- SOBEN PETER
4TH EDITION.
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