1. G00D MORNING

2. TOPICAL FLUORIDE Guided by Dr. MAHMOOD MOOTHEDATH Dr.ASEELA AHMED
Submitted by
WASSIM ABDULLA

3. INDEX Introduction Definition Indications Classification
Professionally applied topical fluorides
Rationale for using topical fluoride agents
Fluoride vehicles
Topical fluoride compounds used in preventive dentistry
Method of application of topical fluorides
Professionally administered application of fluoride solutions
Mode of action
Fluoride distribution on the surface of teeth

4. Limitations of professionally applied topical fluoride
Recommendations for topical application
Self applied topical fluorides
Dentifrices
Fluoride mouth rinses
Fluoride gels
Factors affecting topical fluoride deposition in teeth
Benefits of topical fluoride
Risk of topical fluoride
Toxicity of fluorides
Emergency treatment for fluoride overdose
Conclusion
References

5. INTRODUCTION
Dental caries is a major dental disease affecting a large proportion of the inhabitants of the world. It impairs the quality of life for many people causing pain and discomfort. The cariostatic efficacy has been convincingly demonstrated and the recent decline in caries prevalence is primarily attributed to the increased use of fluoride agents.

6. DEFINITION
By definition the term “TOPICALLY APPLIED FLUORIDES” is used to describe those delivery systems which provide fluoride for a chemical reaction to exposed surfaces of the erupted dentition.

7. INDICATIONS
Caries active individuals
Children shortly after periods of tooth eruption
Those who take medication that decrease salivary flow or have received radiation to head & neck
After periodontal surgery
Patients with RPD or FPD and after placement or replacement of restorations
Patients with an eating disorder
Mentally & physically challenged individuals

8. Professionally applied
Fluorides
Topical fluorides
Professionally applied
Self applied
Systemic fluorides
CLASSIFICATION

9. SYSTEMIC FLUORIDES a) Community water fluoridation b)Salt fluoridation
c)School water fluoridation
d)Milk fluoridation
e)Fluoride supplements

10. TOPICAL FLUORIDES A)Professionally applied B)Self applied
Sodium fluoride preparation
Stannous fluoride preparation
Acidulated phosphate fluoride
Fluoride varnish
Fluoride impregnated floss & prophylactic paste
Fluoride containing dental materials
B)Self applied
Fluoridated dentifrice
Fluoride mouth rinses
Fluoride gels

11. PROFESSIONALLY APPLIED TOPICAL FLUORIDES
Topical fluoride application by a dentist, hygienist or other dental auxillary has become an established caries preventive procedure in the dental office
Medicaments typically dispensed usually involve the use of high fluoride concentration products, ranging from 5000 &19,000 ppm, which is equivalent to 5-19 mgF/ml
Three agents currently in use are,
Neutral sodium fluoride(NaF)
Acidulated phosphate fluoride(APF)
Stannous fluoride(SnF2)

12. RATIONALE FOR USING TOPICAL FLUORIDE AGENTS
To speed the rate & increase the concentration of fluoride acquisition above the level, which occurs naturally
Since immature & porous enamel acquires fluoride rapidly and teeth undergoes rapid maturation ,it follows that best time to apply topical fluoride is soon after eruption
Pre treating enamel with 0.05M phosphoric acid ,in order to increase enamel surface area , greatly enhances the uptake and retention of fluoride
Lengthening the time interval between the applications of a solution also increases fluoride uptake

13. FLUORIDE VEHICLES
1)Aqueous solutions & gels
2 )Fluoridated prophylactic paste
3)Foam
4)Fluoride varnish
AQUEOUS SOLUTIONS & GELS
Gel adheres to teeth for considerable amount of time & eliminates the continuous wetting of enamel surfaces
Since each application may be loaded by coating it with a thin layer of gel , hazard of accidentally ingesting a large quantity of fluoride is minimized
Application of aqueous fluoride using the step prophylaxis & topical fluoride method is a time consuming procedure

14. FLUORIDATED PROPHYLACTIC PASTES
Surface enamel contains higher levels of fluoride than the internal layers which removes under a prophylaxis
Fluoridated prophylactic paste replenish the lost fluoride & there is a small , but significant net gain in the concentration of fluoride

15. FOAM
To minimize the risk of fluoride over dosage as well as to maintain the efficacy of topical fluoride treatment
The advantage of foam based APF agents are,
Only small amount of the agent is needed
Material can penetrate in to the proximal surfaces
Does not require suctioning

16. FLUORIDE VARNISH
Increasing the time of contact between the enamel surface & favors the deposition of more permanently bound fluorapatite & fluorhydroxyapatite
DURAPHATE, 1st fluoride varnish ,contain 22,600 ppm fluoride , shown caries reduction of 30%-40% in permanent dentition & 7% - 44% in primary dentition
FLUORPROTECTOR , contain 7000 ppm fluoride has an efficacy of 1% - 17%
CAREX contains a lower fluoride concentration than Duraphate & has an efficacy equivalent to that of Duraphate

17. FLUORIDE VARNISH APPLICATION

18. METHODS OF APPLICATION OF TOPICAL FLUORIDE
Paint on technique
Teeth are cleaned , dried & isolated
Saliva absorbers may also be used
The solution is continuously applied keeping the teeth isolated for 4 mints
During this 4 mints unwaxed dental floss which have been soaked in the solution is passed interproximally
2)Tray technique
Fluoride gels can be applied in trays
eg : APF

19. TOPICAL FLUORIDE COMPOUNDS USED IN PREVENTIVE DENTISTRY
1)NEUTRAL SODIUM FLUORIDE
First fluoride compound to be used
A minimum of four application with a 2% NaF solution gives a caries reduction of about 30%
Method of preparation
20gms NaF powder + 1 ltr distilled water(plastic container)
Method of application(Knutson’s technique)
4 appointments
The teeth are cleaned , dried & isolated
The solution is painted using cotton tipped applicator sticks& allowed to dry for 3 to 4 minutes

20. The procedure is repeated for each of the isolated segments
The 2nd , 3rd & 4th are scheduled at intervals of 1 week
Recommended for ages 3 , 7 , 11 & 13 years .

21. Mechanism of action
Reacts with hydroxyapatite crystals to form calcium fluoride
As a thick layer of CaF2 gets formed , there is a sudden stop of entry of fluoride , which is termed as “chocking off effect”
CaF2 reacts with hydroxyapatite crystals to form fluoridated hydroxy apatite

22. Advantages
No need to prepare a fresh solution for each patient
Acceptable taste
Non irritating to gingiva
Does not cause discoloration
Since solution is allowed to dry for 3 minutes , the clinician in public health programs can persue a multiple chair procedure
The series of treatments must be repeated only four times in general age range of 3 to13, rather than at annual or semiannual intervals
Disadvantages
Patient must visit 4 times to dentist within a relatively short period of time

23. STANNOUS FLUORIDE(SnF2)
Most commonly used is 8% SnF2 solution
Method of preparation
1 capsule 0.8 gms +10 ml distilled water (plastic container)
Technique of application(Muhler’s technique)
Teeth are cleaned , dried & isolated
Solution is applied using the paint on technique and kept for 4 minutes
Repeat applications are made after 6 months

24. Mechanism of action
At low concentration , tin hydroxy phosphate is formed
At very high concentrations , calcium tri fluoro stannate gets formed along with tin trifluoro phosphate , which is responsible for making the tooth structure more stable & less susceptible to decay.
CaF2 is also the end product both at low & high concentrations , which further reacts with hydroxy apatite & small fraction of fluoro hydroxyapatite also gets formed

25. Advantages
Using at 6 to 12 months intervals conforms to the practicing dentist ‘s usual patient recall system
Administrative difficulties , particularly in public health programs created by the need to arrange 4 appointments are avoided
Disadvantages
In aqueous solution the material is not stable
Disagreeable in taste
Cause irritation to gingiva
Cause pigmentation of teeth

26. ACIDULATED PHOSPHATE FLUORIDE(APF)
Brudevold’s solution
Method of preparation
20 gms NaF + 1 ltr 0.1 M phosphoric acid .To this is added 50% hydrofluoric acid to adjust pH at 3 & fluoride ion concentration at 1.23%
For gel preparation , a gelling agent like methylcellulose or hydroxy ethyl cellulose is added & pH is adjusted between 4-5
Technique of application
Aqueous preparation – paint on technique
gel preparation – tray technique
Recommended for application at 6 or 12 months interval
Patient should sit upright
Oral prophylaxis is done

27. Teeth are isolated & dried
Clinical application APF gel using trays
After the trays have been positioned , saliva ejector is used
It is reapplied every seconds throughout the 4 mints period
The patient should be told to exert slight pressure using the tongue & cheeks. The fluoride gel should be in the mouth for 4 mints and then the remaining oral fluid should be expectorated
Patient is instructed not to eat, drink or rinse for at least 30 mints

28. Mechanism of action
When APF is applied on the teeth , it initially leads to dehydration & shrinkage in the volume of hydroxy apatite crystals which further on hydrolysis forms an intermediate product called di calcium phosphate di hydrate( DCPD)
DCPD is highly reactive with fluoride ion
Fluoride penetrates into the crystals more deeply through the openings produced by shrinkage & leads to formation of fluorapatite

29. Advantages
Requires only 2 applications in a year
The gel preparation can be self applied & thus the cost of application also gets reduced
Has the ability to deposit fluoride in enamel to a deeper depth
It is stable & need not be freshly prepared for each patient
Disadvantages
It is acidic , sour & bitter taste
It needs more chair side time
It cannot be stored in glass containers

30. PROFESSIONALLY ADMINISTERED APPLICATIONS OF FLUORIDE SOLUTIONS
The Knutson’s technique
Muhler’s single application technique
The Mercer and Muhler technique
The Dubbing and Muhler technique
Szwejda – Knutson multiple chair technique
The Englader technique

31. METHODS OF ENHANCING FLUORIDE FIXATION IN ENAMEL
Increase in frequency of application and time exposures
Pretreatment of enamel surface
By acidified saturated solution of Dicalcium Phosphate Dihydrate
Use of complexing agents

32. MODE OF ACTION Remineralization of enamel Alteration in the morphology
Delayed eruption of teeth
Inhibition of plaque bacteria
Inhibition of plaque formation

33. FLUORIDE DISTRIBUTION ON THE TOOTH SURFACE
In young anterior teeth , fluoride concentration on the enamel surface decreases from the incisal edge towards cervical margin
In older teeth this pattern is reversed
From the enamel surface to the interior the concentration of fluoride decreases
Porous or carious enamel readily absorbs fluoride while sound enamel absorbs very little or at least not in a permanently bound form

34. Personal costs associated with one to one method of fluoride delivery
LIMITATIONS OF PROFESSIONALLY APPLIED TOPICAL FLUORIDE
Personal costs associated with one to one method of fluoride delivery
Use of operator applied topical fluoride in public health programs has been the difficulty of implementation in areas with a shortage of dental personal

35. RECOMMENDATIONS FOR TOPICAL APPLICATION
No more than 2gm of gel per tray or approximately 40% of tray capacity should be dispensed. Even more conservative amounts should be considered for small children.
Because patient may have the need to swallow during a 4 minute topical application procedure, the use of a saliva ejector during the procedure is recommended.
Following the 4 minute application procedure the patient should be instructed to expectorate thoroughly for 30 sec to 1 minute, regardless of whether high speed suction is utilized or not. Expectoration is probably the single most effective way of reducing orally retained fluoride.

36. SELF APPLIED TOPICAL FLUORIDES
Control of dental caries rests largely in the personal lifestyle of the individual and that the sensible use of the fluoride at home is an important part of this behavior
Self applied topical systems include
Fluoride dentifrices
Fluoride gels
Fluoride mouth rinses

37. DENTIFRICES Fluoride compounds in dentifrices
Sodium fluoride dentifrices
Stannous fluoride dentifrices
Mono fluoro phosphate
Amine fluoride dentifrice
Adverse effects of dentifrices
A single brushing with a full ribbon of paste on a brush head will cause toxicity when children eat it.
Detergents & flavoring oils irritate the stomach when ingested in large amounts & cause vomiting
Abrasives may interfere with complete intestinal absorption of fluoride from tooth paste
Produce dental fluorosis from the regular ingestion of small amounts by children

38. FLUORIDE MOUTHRINSES 1)Sodium fluoride mouth rinses
Formulated at concentrations of either 0.2% for weekly use or 0.05% for daily use
Preparation
Home use;
200mg NaF tablet+5 teaspoons of clean water
In schools;
Packet of NaF powder+100 ml water
2)Other mouth rinses
Stannous fluoride rinses
Amine fluoride rinses
Ammonium fluoride rinses
Mechanism of action
Fluoride changes the enamel structure of teeth from predominantly hydroxy apatite to fluorapatite
Fluoride may act by inhibition of bacterial metabolism & plaque acid formation

39. FLUORIDE GELS Gels are either applied in trays or brushed on the teeth
Professionally applied - twice a year
self applied – once a day or more
Patients brush their teeth for 1 mint with the gel or if trays are used several drops are placed in each tray and held in contact with the teeth for 5 mints. Patient should be cautioned to expectorate excess gel and not to swallow it. Also patient should rinse with tap water after brushing or tray application

40. FACTORS AFFECTING TOPICAL FLUORIDE DEPOSITION IN TEETH
1)Tooth condition
Tooth age
Natural fluoride concentration
Enamel defects
Dentine/cementum
2)Treatment formulation
Fluoride agents pH
Fluoride concentration
Formulation components
Abrasives

41. 3)Application procedures
Prophylaxis
Effect of time
Temperature
Number of applications
Sequential APF – SnF2 application
Enamel pre treatment
Barrier coating

42. BENEFITS OF TOPICAL FLUORIDE
Prevention of dental caries
Promote gingival health by selectively affecting ‘strepto coccus mutans’
Bone metabolism in both healthy & diseased individuals
Important in the arrest & reversal of incipient lesions
Economic & psychosocial benefits

43. RISK OF TOPICAL FLUORIDE
Relatively few physical problems such as
Gastro intestinal disturbances
Staining of the teeth
Gingival mucosal irritation
Dental fluorosis
Only serious one is dental fluorosis , because it is the only condition that is permanent & also that has the potential of causing psychosocial problems

44. TOXICITY OF FLUORIDE Acute toxicity
Results from rapid excessive ingestion of fluoride at one time
Most frequently encountered adverse effect of topical fluoride therapy is nausea
Other symptoms of fluoride toxicity include abdominal cramps , vomiting , diarrhea , increased salivation , dehydration & thirst
Causes death by blocking normal cellular metabolism
Certainly Lethal Dose(CLD) – 64 mg of fluoride/kg body wt
Safety Tolerated Dose(STD) – 16 mg of fluoride/kg body wt

45. 2)Chronic toxicity
Results from long term ingestion of small amounts of fluoride
A)Dental Fluorosis
Caused by excessive intake of fluoride during tooth development
Ingestion of water with a fluoride concentration 2 or 3 times greater than recommended amount causes white flecks & chalky opaque areas on the tooth enamel
Consumption of water containing 4 times the recommended amount of fluoride causes a brown pitted corroded appearance on the enamel surface

46. Skeletal fluorosis
Caused from ingestion of very high amounts of fluorides for long periods of time
Severe pain in the back bones , joints , hips , stiffness in joints & spine
Outward bending of legs & hands is seen in advanced stages and these parts loose their shape & contours. This is called Knock-Knee syndrome
Pregnant & lactating mothers and children are the most vulnerable group.
Fluoride may lead to blocking & calcification of blood vessels
In its severe form , “crippling fluorosis” the spine becomes rigid & the joints stiffen virtually immobilizing the patient

48. EMERGENCY TREATMENT FOR FLUORIDE OVER DOSE
Milligram fluoride ion per kilogram body weight
Treatment
Less than 5mg/kg
1)Give calcium orally
2)Induced vomiting not necessary
More than 5mg/kg
1)Empty stomach by inducing vomiting with emetic
2)Give calcium orally
3)Admit to hospital & observe for a few hours
More than 15mg/kg
1)Admit to hospital immediately
2)Induce vomiting
3)Begin cardiac monitoring
4)Slowly administer 10 ml of 10% calcium gluoconate iv
5)Adequate urine output should be maintained using diuretics if necessary
6)General supportive measures

49. When used appropriately fluoride is safe and effective agent that can be used to prevent & control dental caries
Useful in management of root caries & root surface hypersensitivity in adult patients with exposed root surfaces
Useful alternative for caries in special needs such as those with developmental disabilities
Children and adolescents undergoing orthodontic treatment tent to have poor plaque control and benefit generally from varnish application

50. REFERENCES
Essentials of Preventive & Community Dentistry – Soben Peter
Textbook of Preventive & Community Dentistry – S S Hiremath
Primary Preventive Dentistry – Norman O Harris