Fluoride can be applied topically or it can be ingested systemically. The following table illustrates the methods by which fluoride can be administered to a patient in dentistry. The importance of fluorides is now well known and its importance in children now needs no introduction. If you are regularly visiting your dentist then he must be appraising you of this and must be suggesting the various methods of fluoride applications to you. Sometimes it is applied by the dentist and also the patient is suggested to use fluoridated tooth pastes. The following table makes it amply clear.

Flourides Delivery System

Topical Fluorides

Those delivery system which provide fluoride for a local chemical reaction to exposed surfaces of the erupted dentition.

  • It is the directly applied to the erupted teeth.
  • Fluoride ions in such agents do not penetrate deeply into enamel.
  • Two methods are used
  • Professionally applied
  • Self applied 

Professionally Applied

It is dispended by dental professionals in dental office setting & usually involve the use of high fluoride conc. Products i.e. from 5000-19000ppm equivalent to 5-19mgF/ml.

 

Indications

  • Usually those patients who have high caries risk eg-xerostomic patient.
  • Children with newly erupting teeth and have high caries index.
  • Person having incipient lesions. As the incipient lesions can be remineralized by fluoride. 

Fluoridated Varnishes

Topical Fluorides

Those delivery system which provide fluoride for a local chemical reaction to exposed surfaces of the erupted dentition.

  • It is the directly applied to the erupted teeth.
  • Fluoride ions in such agents do not penetrate deeply into enamel.

Two methods are used

  • Professionally applied
  • Self applied 
Professionally Applied
It is dispended by dental professionals in dental office setting & usually involve the use of high fluoride conc. Products i.e. from 5000-19000ppm equivalent to 5-19mgF/ml.
 
Indications
  • Usually those patients who have high caries risk eg-xerostomic patient.
  • Children with newly erupting teeth and have high caries index.
  • Person having incipient lesions. As the incipient lesions can be remineralized by fluoride. 
Fluoridated Varnishes

Flouride Delivery System

Methods Of Application Of Topical Fluorides

There are different methods are available for fluoride application professionally the fluoride ca be applied by
  • PAINT ON TECHNIQUE
  • TRAY TECHNIQUE 
Paint On Technique 
  • Patient is instructed to rinse the mouth and teeth are isolated using cotton rolls.
  • Either a quadrant at a time or half of the mouth may be isolated and treated.
  • One min. air drying allows more fluoride uptake.
  • In this 2% NaF (neutral) aqueous solution is applied.
  • Keeping the teeth isolated for 4 min.
  • During this 4 min.unwaxed dental floss, which has been soaked in the fluoride solution is passed inter proximally.
  • Same procedure repeated for other quadrant.
  • After treatment patient expectorate but instructed not to rinse, eat or drink for one-half hour.

TRAY TECHNIQUE

  • With the introduction of APF, topical fluorides began to be marked as gels.
  • Fluoride gels are applied by this technique.
  • Various types of trays are available,eg-*foam lined tray
  • paper lined tray
  • custom vinyl tray with no absorptive lining
 Method of Application 
  • Disposable foam lined tray is preferred.
  • Clean the teeth by rinsing
  • Isolate and dry the teeth with compressed air. 

Flouride Delivery System

Flouride Delivery System

  •  Load the tray with minimum amount of gel about 0.5ml that it covers the tooth surface.
  • The patient should be told not to swallow the gel but to exert slight pressure using the cheeks & tongue as well as light biting forces in order to cause the gel to flow inter proximally.
  • Gel should be kept in mouth for 4 min.
  • Tell the patient to expectorate the remaining oral fluid.
  • Instruct the patient not to eat or drink for 30 min. after applications. 
Different Topical Fluoride Used In Preventive Dentistry
  • NEUTRAL SODIUM FLUORIDE(NaF)
  • NaF was the first topically applied fluoride compounds.
  • Minimum of four applications of 2% NaF solution application gives the maximum effect a reduction of about 40% in new carious teeth 
Methods Of Preparation Of 2% Neutral Naf
  • By dissolving 0.2gm of NaF powder in 10 ml of distilled water
  • It is stored in plastic bottle but not in glass containers, the fluoride ion of solution can react with silica of glass forming silicon fluoride 
Methods of Application (Knutson’s Technique) 
  • Oral prophylaxis is done in every application.
  • Isolation of the teeth with cotton rolls in one upper and opposing lower quadrant.
  • Teeth are dried thoroughly.
  • 2% NaF is then applied with tooth pick cotton applicator.
  • Let it dry on teeth for about 4 min.
  • Procedure is repeated for the remaining quadrants.
Instructions to Patient
  • Avoid eating, drinking or rinsing for 30 minute prolongs the availability of fluoride ions to react with tooth surface.
  • Recall the patient at weekly intervals for 2nd, 3rd & 4th application.
  • A full series of treatment recommended at ages 3, 7, 11, 13 years.
Advantages
  • There is no need to prepare fresh solution for each patient.
  • The taste is well accepted by patient and solution is non-irritating to gingiva.
  • Clinician in public health programmers can pursue a multiple-chair procedure.
Disadvantages
Major disadvantage is that the patient must make 4 visits to the dentist within a relatively short time.
 
STANNOUS FLUORIDE
  • It is second topical agent to gain wide acceptance.
  • It is 3 times more affective then NaF.
  • Available in conc. Of 2%, 8%.10%.
  • 10% solution- for adults
  • 8% solutions- for children 
Method of Preparation
  • Dissolve 0.8gm powder in 10 ml distilled water.
  • This solution is not stable, soon after mixing tin hydroxide is formed. aged solution  clinically is in-effective
Method of Application
  • Thorough oral prophylaxis is done.
  • Teeth are isolated with cotton rolls.
  • Dried with compressed air.
  • A freshly prepared 8% solution of SnF2 is applied with cotton applicators i.e. it is applied by paint on technique.
  • Teeth are kept moist with solution for 4 min.
  • But now it has been suggested that 30 sec. or even 15 sec. is adequate.
  • Recommended frequency for 8% stannous fluoride is once per year.
  • The rapid penetration of tin & fluoride within 30 sec.
  • Highly insoluble tin fluorophosphates complex forms on enamel surface that is more resistant to decay then enamel. 
Disadvantages
  • Unstable so every time it is prepared fresh for each patient
  • The solution has a metallic taste
  • It may cause gingival irritation particularly in diseased gingival tissue
  • Produce discoloration of teeth
  • Causes staining on the margins of restorations
 
ACIDULATED PHOSPHATE FLUORIDE
 
Brudevold introduced new topical fluoride preparation ie. APF.

METHOD OF PREPARATION OF APF

An aq. Solution of acidulated phosphate fluoride is prepared by dissolving 20g of NaF in 1L of 0.1M phosphoric acid, to this is added 50% hydrofluoric acid to adjust the pH at 3.0 and fluoride ion conc. at 1.23%.It is also called Brudevold’s solution
For the preparation of acidulated phosphate fluoride gel, a gelling agent methyl cellulose or hydroxyethyl cellulose is to be added to the solution and the pH is to be adjusted between 4-5.
 
Method of Application
  • Thorough oral prophylaxis
  • Isolation of teeth is done
  • Dried
  • APF solution is continuously & repeatedly applied with cotton applicator.
  • Teeth are kept moist for 4 min.
  • Recommended frequency of application is semi annually.
  • For APF gel application: plastic trays have been suggested for a more convenient procedure.
Advantages
  • Fluoride uptake following the application of APF solution is greatly accelerated where as that following NaF is much slower.
  • APF solution is cheap, can be prepared easily.
  • It is stable with a long shelf life, when stored in an opaque plastic bottle.
  • Requires only 2 applications in a year and is thus suited for most dental office routines
DISADVANTAGES
  • Teeth must be kept wet with the solution for 4 min.
  • APF solution is acidic, sour & bitter in taste so necessitates the use of suction.
  • It cannot be stored in glass containers. 
Comparison Of APF Gel & APF Solution
APF GEL
  • Relatively costly
  • Readily available
  • Self application is possible
APF SOLUTION
  • Relatively cheap
  • Prepared easily
  • Applied by the dentist or auxiliary staff
 
SELF APPLIED DENTIFRICES AND MOUTHRINSES
 
Fluoridated toothpastes
fluoridated mouthwashes       
          
SYSTEMIC FLUORIDES - COMMUNITY WATER FLUORIDATION
 
It is process of adjusting the amount of fluoride in community water supply to an optimum level for prevention of dental caries.
Sodium fluoride was the first compound used in a controlled fluoridation programs. Now most commonly used are sodium silicofluoride and hydrofluorsilic acid.
 
Recommended Level of Fluoride In Water (Who 1971)
  • Concentration 0.7-1.2ppm-depending upon community mean maximum daily temperature
  • Cold climate 1.2ppm
  • Summer season or temperate climate o.7ppm
  • Recent recommendation (WHO 1994)à0.5-1.0ppm
 
Benefits of Water Fluoridation
  • Water fluoridation has pre-eruptive & post eruptive effect.
  • Fluoridated drinking water not only acts systemically during tooth formation to make dental enamel more resistance to dental decay, but also has topical effect through the release in saliva after ingestion.
  • Fluoride in saliva through the systemic mode remains elevated for an extended period provides protection against demineralization and facilitates remineralisation.
  • Fluoridation of community water is the least expensive and most effective way to provide fluoride to large group of people.
 
School Water Fluoridation
  • It is adjustment of fluoride conc. Of a school’s water supply for caries prevention.
  • Children spent annually 20-25% of time in school so to compensate for this part time exposure to fluoride is currently recommended.
  • Level for school water fluoridation is 4-5ppm.
  • There is approximately 40% reduction in caries reported after 12 years.

Flouride Delivery System

 

DIETARY FLUORIDATION
 
Milk Fluoridation
 
Milk is essential component of human diet throughout life, both as a source of micro and macro nutrient.
Fluoridated milk can be produced in number of different ways     
  • Liquid pasteurized & sterilized
  • Powder    
  • Compounds used to fluoride milk
  • Sodium fluoride
  • Calcium fluoride
  • Disodium monofluorophosphate
  • Disodium silicofluoride
Recommendation of WHO expert committee (1994) in ranging from 0-1.0mgF/day according to the age of child and fluoride conc. In the local water supply.  

Flouride Delivery System

Disadvantages Milk Fluoridation 

  • It provides only a limited exposure to children, as consumption of milk tends to decline with increase in age.
  • Absorption is slow as compared to water fluoridation. 
Dietary Fluoride Supplements 
 
These were first introduced in 1940’s and were intended as a substitute for fluoridated water for children in non-fluoridated areas.
 
Fluoride Compounds Used
  • Sodium fluoride (NaF)
  • Acidulated phosphate fluoride (APF)
Concentration
Available in à 0.125mg drops
                      0.25mg drops
                       0.50mg drops
                       0.25mg tablets/lozenges
                       0.50mg tablets/lozenges
                       1.0mg tablets/lozenges
                       1mg 5ml – oral rinse supplement

These are administered in following forms.

  • Fluoride Drops
  • Fluoride Drops With Vitamins
  • Fluoride Tablets
  • Fluoride Sustained Release
  • Fluoride Tablet With Vitamins
  • Fluoride Rinse & Solutions

Flouride Delivery System

 

 

 

FLUORIDE SUSTAIN RELEASE & FLUORIDE RINSES

Flouride Delivery System

INDICATIONS FOR USE

  • In areas where there are no central water supplies, low conc. Of well water and where parental motivation is high
  • Where there is no community water fluoridation
  • Areas where water fluoridation or salt fluoridation schemes cannot be implemented.

DISADVANTAGES

Accidental ingestion of fluoride supplements can cause stomach upset.

Not more then 1.2-2.2mg NaF tablets should be dispensed at one time.

Salt Fluoridation

  • The addition of fluoride to table salt is a feasible way to deliver systemic fluoride, particularly in countries that lack a wide spread municipal water system.
  • It has been sold in Switzerland for many years. France and few new countries in western hemisphere have introduced salt fluoridation in recent years.
  • Salt as a vehicle for fluoride in the 1940’s.
  • Initially supplementation was 90mgF/kg of salt.
  • Recent recommended range is 200-250mgF/kg.
  • Commonly used salts are potassium fluoride (250mg/kg) and sodium fluoride (225mg/kg).

Advantages

  • No supervised water workers nor water distribution system are necessary.
  • It has low cost ie. Less expensive.

Disadvantages

  • Its consumption is lowest when need for fluoride’s is greatest i.e. in early years of life.
  • High salt intake causes hypertension

CONCLUSION

The goal of fluoride used in dentistry should be to achieve the maximum benefit with minimum side-effects. To be effective, prevention requires responsible action on the part of individuals themselves, government and society in general. Consumers & providers of health services have to become involved and their must be improved access to comprehensive care.

 

PRO FLUORIDE ORGANIZATIONS 

  • American Council on Science and Health
  • American Dental Association
  • British Fluoridation Society
  • Centers for Disease Control
  • National Center for Fluoridation Policy and Research
  • National Institutes of Dental and Craniofacial Research

ANTI FLUORIDE ORGANIZATIONS

  • Protect Our Water Alliance (POWA)
  • Fluoride Free Water (Ireland)
  • National Pure Water Association (U.K)
  • Fluoride Action Network (New Zealand)

Regardless of type of comprehensive preventive program, community or individually based, the suggested use of fluorides must be balanced between estimation of caries risk and possible risk for toxic effects of fluorides. The preventive program should be reevaluated at regular intervals and adapted to patient’s needs and risks.

 

 

 

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