fluoride in dentistry for caries prevention

1. FLUORIDES IN
DENTISTRY

2. What are fluorides?

Fluoride is a mineral

Fluoride ion comes from the element
fluorine
− Fluorine is 17th
most abundant element in the
earths crust
− Never encountered in its free state in nature
− Exits only in combination with other elements
as a fluoride compound

3. How does it work?

Changes the crystalline structure of
enamel to make it less soluble.

Suppresses cariogenic bacteria in
dental plaque.

Acts on the enamel surface to inhibit
bacterial adhesion

4. Changes the
crystalline structure of
enamel to make it less
soluble.

5. Nature of tooth mineral
{ Ca10-x(Na)x(PO4)6-y(CO3)z(OH)2-u(F)u}
Highly substituted carbonated apatite
Most soluble
{ Ca10-x(Na)x(PO4)6-y(CO3)z(OH)2-u(F)u}
Highly substituted carbonated apatite
Most soluble
Ca10(PO4)6(OH)2
hydroxyapatite (less soluble)
Ca10(PO4)6(OH)2
hydroxyapatite (less soluble)
Ca10(PO4)6(F)2 = fluoroapatite
Least soluble
Ca10(PO4)6(F)2 = fluoroapatite
Least soluble

6. Mechanism of action

Recent evidences
shows that the main
effect of fluoride in
caries prevention are
− POST ERUPTIVE
− Through Topical
effect

Recent evidences
shows that the main
effect of fluoride in
caries prevention are
− POST ERUPTIVE
− Through Topical
effect
OLD concept :
That major inhibitory
effect was thought to
be due to its
incorporation in tooth
mineral during the
development of the
tooth prior to eruption
OLD concept :
That major inhibitory
effect was thought to
be due to its
incorporation in tooth
mineral during the
development of the
tooth prior to eruption

7. Mechanism of action

Fluoride incorporated
during mineral
development at
normal levels of 20-
100 ppm does not
alter the solubility of
the mineral.

Fluoride incorporated
during mineral
development at
normal levels of 20-
100 ppm does not
alter the solubility of
the mineral.

Fluoride incorporated
developmentally into
the normal tooth
mineral is insufficient
to have a measurable
effect on acid
solubility

Fluoride incorporated
developmentally into
the normal tooth
mineral is insufficient
to have a measurable
effect on acid
solubility

8. Mechanism of action

Only when fluoride is
concentrated into a new
crystal surface during Re
mineralization, is it sufficient
to alter solubility beneficially.

Only when fluoride is
concentrated into a new
crystal surface during Re
mineralization, is it sufficient
to alter solubility beneficially.

9. Mechanism of action

If fluoride is present in the plaque
fluids at the time that bacteria generate
acids, it will travel with the acid down
into the subsurface of the tooth, adsorb
to the crystal surface and protect it
from being dissolve.

If fluoride is present in the plaque
fluids at the time that bacteria generate
acids, it will travel with the acid down
into the subsurface of the tooth, adsorb
to the crystal surface and protect it
from being dissolve.

10. Source: Featherstone , 1999

11. Fluoride inhibits
plaque bacteria.

12. Fluoride inhibits plaque
bacteria

Fluoride can not cross the cell wall and membrane
in its ionized form(F-
) but can rapidly travel
through the cell wall and into the cariogenic
bacteria in the form of HF.

Once inside the cell ,the HF dissociates again
acidifying the cell and releasing fluoride ions that
interfere with enzyme activity in the bacterium.

Interferes with glycolysis

13. HF H+
F-H+
+ F-
HF
Bacterial Cell
pH 7 H+
+ F-
HF
pH 4.5 H+
+ F-
HF

14. 
Acts on the enamel
surface to inhibit
bacteria adhesion

15. Sources of fluoride

Natural foods
− Tea, sea foods,
− Water

Fortified
− Milk
− Salt

Dentrifices

Professionally applied

Fluoride supplements

16. Sources of fluoride

Milk formulas ( .05 to .35 ppm)

Soy Beans Formula ( 0.17 to 0.38 ppm)

Bottled Mineral

In beverages :
− Tea ( raw tea leaves 400 ppm)
− Brewed tea ( 0.1 to 4.2 ppm_
− Daily consumption of 1 cup (200 ml) would yield 0.6
mg F/day

17. Sources of fluoride

Fish and seafood products
− Dried seafoods (can contain 290 ppm)
− Canned seafoods ( can contain 40 ppm)

Chicken products (0.6 to 10.6 ppm)

Salt with Fluoride, Sugar with Fluoride

18. Sources of fluoride

Dental Products
− Dentifrices
− Fluoride mouth rinse
− Professional applied fluorides
− Dietary fluoride supplements

19. Fluoride metabolism and
excretion
Fluoride in
Food, water
75 to 90 % absorbed
from the alimentary
tract, more from liquids
than solids (10 to 25%
excreted via feces)
•50 % of the
absorbed
fluoride will be
associated
with calcified
tissue
•50% excreted
in urine
50:50 distribution is shifted strongly in favor of retention
in the very young, greater excretion in later years of life

20. Fluoride Toxicity

Acute fluoride toxicity
− 5.0 mg per kg or more
− Very rare

Most recorded fatalities are suicides

Dental related fatalities are very rare
− Accidental swallowing of fluoride supplements

Chronic Fluoride toxicity

21. Fluoride Toxicity
PTD: Probable Toxic Dose

minimum dose that would cause toxic
signs and symptoms including death and
should trigger treatment management
and hospitalization.

5 mg fluoride/kg (Whitford,1987)

22. Acute Fluoride Toxicity
Accidental poisoning with

Toothpaste with Fluoride

Mouthwash with Fluoride
“usual cases reported are due to accidental
ingestion of fluoride rinses and tables-
usually by very young children”

23. Fluorosis

Skeletal Fluorosis

Dental Fluorosis

24. Chronic Fluoride Toxicity
Chronic Toxicity:
“other than dental fluorosis, there are no
known adverse effects of ingesting fluoride
in a chronic basis at levels associated with
drinking water concentrations of 4 p.p.m or
less.”

25. Things you should know

Skeletal fluorosis
− Confined to individuals
exposed to very high
fluoride
− Usually associated with
industrial situation or
unusually very high
fluoride level in drinking
water of 10mg/l

Osteosarcoma
− Studies have
failed to identify
any correlation
with fluoride
history

26. Dental Fluorosis

Will only affect teeth which are exposed to
obove optimal levels of fluoride during
enamel maturation

Once the tooth has erupted, dental fluorosis
can not take place.

28. Types of Fluoride Used in
Dentistry

Water fluoridation

School Water fluoridation

Dietary fluoride supplements

Self applied fluorides

Dentifrices with fluorides

Professionally applied fluoride

30. How to avoid Fluoride Toxicity
1. Parental supervision of the use of the
product that are used by children at home.
2. Teach children at an early age to
expectorate the product.
3. Keeping the product out of reach of
children

31. How to avoid Fluoride Toxicity
Manufacturer:
1. Decreasing the level of fluoride
concentration for children.(???)
2. Encouraging the use of pea size amount
3. Equip product containers with tops that are
difficult to open ( child proof)

32. Issues
1. Instituting regular tooth brushing drills will
fluoride toothpaste in all school
2. The monitoring of fluoride content in toothpaste?
3. Is there a need for lower fluoride content
toothpastes for children?
4. Dental professionals are not fully informed about
fluorides and fluorosis.

33. Nutritional management of
Periodontal diseases

34. Periodontium

36. PERIODONTAL DISEASE

DISEASES OF THE GUMS

DISEASES RELATED TO THE
PERIODONTIUM

39. Host
Pathogens
Microorganism
Environment
Nutrition
(modifiable variable
Host response and
susceptibility
to infection)

40. Periodontal disease

Delicate balance between host, environmental and
bacterial factors

Complex interaction between pathogenic bacteria
and host response to infection

Primary etiology is bacterial (anaerobic) but
susceptible host is necessary for disease initiation

Nutrition is a modifiable factor that impacts on
host immune response and the integrity of the
hard and soft tissues

41. Three main nutritional
considerations

Integrity of the oral mucosa

Maintenance of the hard tissues

Maintenance of the immune
response

42. 1. Integrity of the oral mucosa
Co factor for Energy Metabolism, and
needed in DNA, RNA synthesis
Tissue maintenance and new cell
production
Healing
Most common sx of vit b deficiency:
loss of integrity of the oral mucosa
Stomatitis, angular cheilitis,glossitis
Vitamin B

43. Integrity of the oral mucosa
Prevents oxidative cell damage, aids in the
maintaining the integrity of the oral mucosa.
Maintains microvasculature of the sulcus
Vit c def: Bleeding (increase permeability of
bld vessels)
Hydroxyline formation(stabilizes the
structure of collagen by cross linking) ,
collagen formation,
 Citrus fruits, dark and leafy green
vegetable, potatoes, cantaloupe
C
(Ascorb
ic acid)

44. Integrity of the oral mucosa
DNA and RNA replication
Transcription of RNA
Translation of protien necessary
for new cell growth
Early sign of vit a def: decrease in
the rate of proliferation of
epithelium
Wound healing
Vitamin A
Zinc

45. Integrity of the oral mucosa
Protien synthesisZinc
Silicon
Manganese
Cross-linking of
collagen and elastin
Copper
Boron
Supplementation
of minerals above
RDA is not
recommended
Zinc, copper and
iron all compete for
absorption so must
be balanced for
optimum wound
healing
Collagen
metabolism
Minerals

46. 2. Maintenance of Calcified
Tissues

Vitamins A, D,C,K

Zinc, Magnesium,Phosporus and Calcium

47. Maintenance of Calcified
Tissues
Regulates the absorption of
calcium from the GIT to maintain
calcium balance
Inadequate Ca intake, Vit D
stimulates osteoclastic activities,
mobilizes calcium stored in bone
Collagen synthesis and
accumulation of mineralized bone are
dependent on adequate levels of Vit
D and Calcium
Vit
D
Fortified
milk, eggs
liver

48. Maintenance of Calcified
Tissues
Bone density and strenght
Anti coagulant theraphy (group at
risk)
Green, leafy vegetables,liver
Vit
K

49. Vitamin C deficiency

Goetzl, Wasserman , Gilgi and Austen
(1974) : Vit C enhances the motility of
polymorphonuclear leukocytes

Sandler , Gallin, Vaughan (1975):decreases
host immune response

50. National Health and Nutrition
Examination Survey

Sample of 12,419 adults

Ages 20 to 90 years

Dental Measurements

Dietary assessment

Demographic and medical histories

51. NHANES III results

OR of having
periodontal disease is
1.2 times greater in
those with low dietary
Vitamin C intake

Smokers, and former
smokers with low
vitamin C intake are
at 1.6 times greater
risk of having
periodontal disease

52. Nishida, Grossi, Dunford, Ho,
Trevisan and Genco (2000)

“…dietary Vit C intake was weakly but
statistically significantly associated with
periodontal disease…

There is no clear evidence that supplementary vit.
C and possible other anti-oxidant will improve
periodontal health and response to therapy in
current and former smokers”

53. Boyd and Lampi (2001)

… “ megadoses of vitamin C have not
been shown to have a strong effect in
the healing response in initial
periodontal therapy and therefore
pharmacological doses should not be
recommended”

54. Maintenance of hard tissue
(Bone remodeling)
Magnesium
Boron
Copper
Milk products, tofu fortified with
calcium, legumes, fortified breakfast
cereal, orange juice
Calcium
Minerals

55. NHANES III results

Risk of periodontal
disease was 59%
greater in women
with less than
500mg/day of
Calcium

27% greater for
those taking less
than 800 mg/day

56. Boyd and Lampi (2001)

However it remains unclear how calcium
supplements might impact the course of
periodontal disease

57. 3. Maintenance of Host
Immune Response

Nutritional deficiencies quickly
alter immune cell function and
increases the risk of infection

58. Maintaining host immune
response

Proteins:

Antioxidants
− Vitamin A, C, E
− Minerals : Zinc, Copper, Iron, and Selenium

59. 3. Maintenance of Host Immune
Response
Mild protein malnutrition decreases
effectiveness of the inflammatory
response to invading pathogens
Neutrophil functioning
Collagen synthesis
Protiens