Fluoride Supplements

Lecture outline Introduction History of fluoride supplements Forms of supplements available Evidence for effectiveness Issues with the use of Fluoride supplements Current guidelines on use

Introduction

Methods for fluoride delivery Fluoridated water. Fluoridated foods (salt, milk). Fluoride supplements. Home applied topical fluoride. Fluoride in dental materials. Professionally applied fluoride.

Systemic vs. Topical Recent research revealed that fluoride incorporated during tooth development: Does not reduce solubility. Is insufficient to play a significant role in caries prevention.

Ideal fluoride delivery Maximize fluoride presence in solution surrounding the enamel (topical effect). Minimize amount of fluoride being systemically ingested. Cost-effective.

History of fluoride supplements

History of fluoride supplements Fluoride-containing supplement pills were first developed in the 1890s. With emerging evidence for water fluoridation, they were suggested as an alternative.

History of fluoride supplements In the 1950s, they were thought to be an individual and public health measure where water fluoridation was not possible Aimed to emulate the effect of drinking 1 liter of fluoridated water a day (at 1 ppm F).

Forms of supplements available

Forms of supplements available Drops Tablets Lozenges Chewing gum Increase topical effect

Supplements contain 0.25-1mg fluoride Fluoride compounds Sodium fluoride (NaF). Acidulated phosphate fluoride (APF). Calcium fluoride (CaF2 ). F- Vitamins. Most common Supplements contain 0.25-1mg fluoride

Evidence for effectiveness

Impact on caries in permanent teeth Studies conducted before the use of fluoride toothpaste or other topical fluorides was wide- spread (1970s or prior). Conducted where there was no water fluoridation. Included supplementation in schoolchildren (5-11 years). Showed a reduction in caries increment in permanent teeth.

Impact on caries in permanent teeth *All at 1 mg per day, no water fluoridation or toothpaste Tubert-Jeannin et al. (2011)

Impact on caries in permanent teeth “The use of fluoride supplements is associated with a 24% reduction in decayed, missing and filled surfaces (DMFS)”. Tubert-Jeannin et al. (2011)

Impact on caries in primary teeth Evidence to support caries preventive effect on primary teeth is weak (Ismail et al., 2008; Tubert-Jeannin 2011). One study reported no significant effects on caries rates in primary teeth (O’Rourke 1988). Another reported a reduction in caries incidence in the primary teeth of children with cleft lip/palate (Lin 2000). Difference is likely due to the 2nd study being in a non- fluoridated area and the children didn’t use fluoride toothpaste

Impact of supplementation during pregnancy Exposure during prenatal period offers no additional uptake by dental tissues in comparison to postnatal (Sa Roriz Fonteles et al., 2005). Supplementation does not significantly improve the dental health of offspring (Leverett et al., 1997).

Comparison with topical fluorides Tubert-Jeannin et al. (2011)

Comparison with topical fluorides No significant differences in benefits in comparison with topical fluorides. Tubert-Jeannin et al. (2011)

Issues in using fluoride supplements

Issues in using fluoride supplements Require a high degree of cooperation over a long period of time. Relatively higher risk of acute toxicity. Relatively higher rates of systemic ingestion, leading to increased risk of fluorosis. Much of F-supplement research is outdated, and had methodological issues.

Individual cooperation Low-risk individuals are more likely to comply with a drug regimen, but are not likely to benefit from fluoride supplements. High-risk individuals are less likely to follow a drug regimen, creating an issue for the use of fluoride supplements.

Acute toxicity Easier for overdose to happen than when other sources of fluoride are used. Due to: Relatively high dose of fluoride in each pill/drop/lozenge. Lack of professional supervision of intake. Management of acute toxicity will be discussed later.

Fluorosis Animal experiments showed that fluoride given once a day is more likely to cause fluorosis than same amount given intermittently (water fluoridation). The use of fluoride supplements in early life (0-3 years) has been documented to increase the risk of fluorosis (Ismail 2008). 30-45% of regular supplement users develop fluorosis (Riordan 1999)

Fluorosis Window of susceptibility for mottled incisors is when supplements are taken at the age of 15–30 months The risk from could be lowered by: Giving the supplements after the age of three. Giving them within a school programs (i.e: under supervision)

Methodological issues Prior to wide-spread use of fluoridated toothpaste and other topical fluorides. Poor reporting on adverse effects, toxicity. Small number of participants. High drop-outs in some studies. Lack of randomization. Difficult to separate systemic effect from topical.

Current guidelines on use

Current guidelines on use No longer accepted as a public health measure, but only for certain high risk individuals. Dosage depends on child’s age and water fluoride levels. Different organizations issued different guidelines.

Current guidelines on use Aim is to maximize topical effect. This can be achieved by: Using lozenges or chewing gum. Allowing tablets to disintegrate slowly in the mouth. Changing tablet position in the mouth. Giving the supplement at different times to toothbrushing (also reduces simultaneous ingestion)

American Academy of Pediatric Dentistry (AAPD) Child age <0.3 ppm F 0.3-0.6 ppm F >0.6 ppm F 0-6 months 6 months – 3 years 0.25 mg/day 3-6 years 0.50 mg/day 6-16 years 1.00 mg/day

European Academy of Paediatric Dentistry (EAPD) Child age <0.3 ppm F 0-2 years 2-6 years 0.25 mg/day 7-18 years 0.50 mg/day Child age 0.3-0.6 ppm F >0.6 ppm F 0-3 years 3-18 years 0.25 mg/day

Public Health England (PHE) Scottish intercollegiate Guidelines Network (SIGN) Fluoride supplements are not recommended in light of the presence of topical fluoride agents.

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