Vaishno devi mandir, Kattra (J.K.

Fluoride releasing materials

Presenter – Dr. Nikhil Saran (Istyear PG)

Department of conservative and endodontics 1
Sri Sai college of dental surgery, vikarabad
E-mail:- sarannikhil@[Link]
contents
 Significance and relevance of topic.
 Fluorides
1. Introduction .
2. History.
3. Availability.
4. Sources.
5. Application and optimal intake values.
a) Systemic
b) Topical
c) Self applied
6. Absorption.
7. Excretion .
8. Storage.
9. Mechanism of action.
2
cont.
Cont.
 Fluoride releasing material and their effects.
1. Restoration failure and its sequelae.
2. Secondary caries and its feature
3. Diagnosis of secondary caries.
4. Factors influencing F- release.
5. F- recharge.
6. Plaque and fluoride.
7. Mechanism of action(in relation to material).
8. Antimicrobial and F-releasing materials
9. Fluoride and adjacent tooth.
10. Review of various F-releasing restorative
materials 3
Relevance today and Then….
(21st Vs past)

4
relevance today and then. (21st vs past)
Dental caries
ü most prevailing
ü pre historic infectious diseases
ü exist in developed, developing and under developed counties
Once restored
ü Secondary account for 60%
ü Irrespective of material type
Other reason for restoration failure
ü Material failure,
ü Tooth fracture or defect,
ü Endodontic involvement,
ü Prosthetic abutment use,
ü Technical errors, and
ü Deterioration of aesthetic quality with tooth-colored restoratives.
5
 PREVENTION
THE ULTIMATE WEAPON IN CARIES
F
But again the complex material
brings the complex understanding of L
THE ULTIMATE WEAPON IN CARIES PREVENTION
its judicious use and technique.
O
U
R

responsibility.
Big power brings big
I
D
E
S

6
Secondary caries and the past.

PREVENTION
THE ULTIMATE WEAPON IN CARIES
F
L
ü Proper condensation of gold
restoration . O
ü Secondary expansion of amalgam U
and resiliency of dentine came
into play.
R
ü With the development of silicate I
------------------------------------------------ D
------------------------------------------------
--------------------------the story E
continues. S

7
8
fluorides
qFluorine word is derived from the Russian word
"flor" ---------- "flois" meaning destruction
in Greek and from Latin word "fluor" that
means to flow since it was used as a flux.

 Fluorine (F) most reactive nonmetal

 Most electronegative element

 It combines with all elements, except oxygen

and the noble gases, to form fluorides.
9
10
history
 Sir James Crichton Browne in 1802 first to
propose possible connection in dental health
and fluoride.
 1901 [Link] Mckay of Colorado (U.S.A)
discovered certain stains.

 ‘Shoe Leathery Survey’ by [Link] [Link].

11
Availability of fluoride
 13th trace elements the earth's crust.

 Highly reactive anion, atomic weight of 19, atomic

number of 9.

 Found in biosphere, lithosphere, hydrosphere,

atmosphere and in all living organisms.

 Chemically exist in the form of fluorides, chiefly as:

1. Fluorspar (CaF2)
2. Fluorapatite (Ca10(PO4)6F2)
3. Cryolite (Na3AlF6) 12
13
Sources of Fluoride
 Water.

 Present in all ground water.(except in certain

region)
 Also derived from plants, marine animals and even
dust particles.

 Fluoride content varies in different types of food,

like:
a) Tea -97 ppm.
b) Certain types of fishes -84.5 ppm. 14

c) Potatoes -6.4 ppm.

Fluoride  Application

15
Optimum Fluoride intake
Depending upon the mean maximum daily
temperature:
ü Cold climate 1.2 ppm
ü Summer season or temperate climate 0.7
ppm

Calculation of Optimum Level of Fluoride

ü ppm fluoride = 0.34/E
ü E = -0.038 + 0.0062 X temp, in °F
(E is estimated water intake)
16
Topical fluoride application
 Topical fluoride- Three methods.
[Link] method- Application of fluoride solution.

[Link] method- Use of a concentrated

fluoride rinse.

[Link] method- Tray  technique,

Usually 8% SnF2 (19,360 ppm) and
2% NaF (9,040 ppm) is used.

17
Self applied topical flouride
 Concentration ranges from 1,000- 1,500 ppm
of fluoride.

 Sodium fluoride, sodium monofluorphosphate

are added but not the stannous fluoride.

 Frequent source of fluoride in low

concentration can inhibit demineralization and
enhance remineralization. 18
Absorption of Fluoride
 Readily absorbed into the body.

 Stomach, through passive absorption.

 Can also occur from the lungs by inhalation.

 The solubility of inorganic fluorides in the diet and

its calcium content.

 Bone deposition of fluoride occurs to the extent of

50% in growing children but only 10% in adults

 Fluoride is not protein-bound and occurs as free

ion in the plasma . The volume of distribution is
0.5–0.7 litre/kg 19
Excretion of Fluoride
 Urine, feces and sweat.

 It occurs in traces in milk, saliva, hair and

tears.

 Urinary fluoride level is regarded as one of the

best indices of fluoride intake.

20
Storage of Fluoride

 Fluoride is stored in the hard tissues of the

body.

 Fluoride uptake depends upon the amount

ingested and absorbed.

 The duration of fluoride exposure and the

type, region and metabolic activity of the 21
tissue decide its storage factor.
Fluoride toxicity
chronic toxicity

 Chronic fluorosis:
1. Skeletal fluorosis and
2. Dental fluorosis.

 Skeletal fluorosis –
1. Joint stiffness and osteosclerosis (milder forms),
2. Calcification of ligaments, muscle wasting, osteoporosis, and neurologic
deficits (severe forms).
 Symptomatic after about 10 years of fluoride exposure at least 10
mg/day.

 Dental fluorosis-
1. Diffuse opacities on the enamel surfaces of the teeth.
2. Noteworthy because of cosmetic concern
 May be associated with increased porosity. porosity may stained
or coalesce into discrete pits.

 Dental fluorosis occurs as a result of high fluoride ingestion in

early life, primarily during the maturation phases of enamel
22
development
Acute toxicity

 Highly concentrated fluoride ingestion can have toxic effect as

 Toxic dose- 8 mg F per kilogram body weight could result in toxic

effects.

 Acute lethal dose- 32 mg to 64 mg F per kilogram body weight

could result in death.
23
 Toxic effects on ingestion 5 mg to 8 mg per kilogram body wt
Treatment of acute fluoride toxicity
 Treatment ranges from

1. Prevention of further absorption by ingestion of milk

3. 5% calcium gluconate

5. Supplemental oxygen therapy

7. Gastric levage.

9. Activated charcoal ingestion.

11. Blood-plasma dialysis

24
 Mechanism of caries
development
1 Reversible
Initial
1. subsurface demineralization
Initial subsurface lesion
demineralization
2 Extension of demineralized
zone towards dentine

3 Collapse of surface layer to form

cavity

4
Extension of caries lesion into dentine

5 Possible
Extension of caries into pulp formation of
apical
abscess
25
Mechanism Of Action of fluorides
 Increase in enamel resistance OR reduction in
enamel solubility.

 Increase in post eruptive maturation.

 Remineralization of incipient lesions.

 Interference with plaque microorganism.

 Modification in tooth morphology.

26
Increased enamel resistance OR
reduction in enamel solubility
 Dental caries involve dissolution of enamel
from acid produced by bacteria plaque. As
lactic acid , propionic acid, formic acid.

 Fluoride forma the fluorapatite, which is less

soluble mineral.

 This reduced solubility is the cause of the

caries prevention.

27
Increase in post eruptive maturation.

 In this case fluoride help in increased

Remineralization rate of the hypomineralized.

 Both the mineral and the organic material are

deposited from saliva.

 Fluoride help to Remineralization of the

demineralized area.

28
Remineralization of incipient lesions.
Fluoride is provide from
[Link]
[Link] mineral dissolved during demineralization

Fluoride help by accelerating the growth of the

enamel crystal.

29
Interference with plaque microorganism.

 High concentration of fluoride is bactericidal

200 ppm or more.

 Low concentration it is bacteriostatic.

 Fluoride in plaque inhibit bacterial enzyme,

causing acid metabolism.

 Fluoride mainly interact with the bacterial cell

well in aerobic and anaerobic condition their
by causing the disruption of the matabolism.
30
Modification in tooth morphology

 Studies shows that during tooth development

fluoride cause the slightly smaller tooth and
with shallow fissures

31
Fluoride releasing restorative material

32
 Salivary [Ca2+]

Demineralization Lo Salivary Remineralization

w [PO43-]
Salivary
[F-]

33
 Restorations life varies as per restorative
material.

 Amalgams have max. service period.

 Restoration fails, increases the size of the

cavity by 0.52 mm.

 When no caries is present by 0.25 mm.

 This implies that the replaced restoration

width will be larger by 0.5 to 1.04 mm. 34
Secondary caries
 Secondary is defined as caries detected at the
margins of an existing restoration. It may have
an inactive arrested lesion, an active incipient
lesion, or a frankly cavitated lesion.

 Only when marginal gaps are greater than or

equal to 250 micron can secondary caries be
identified clinical and microscopically.
• 35
cont.
secondary caries has certain features.

 Interproximal margins (>90% of failed amalgams,

>60% of failed composite resins).

 Secondary caries is seen as a white spot (active),

or a brown spot (inactive) lesion.

 A high proportion of secondary caries is located

along the cervical and amalgam restorations
impart color changes due to corrosion.

 Tran-illuminationmay be helpful with tooth-colored

restorative materials.

36
diagnosis
 Diagnosis of secondary caries is dependent on
following features.

2. visual inspection,
3. tactile sensation with judicious explorer usage,
and
4. radiographic interpretation.

 Whenever a restorative material is placed,

there is a possibility for a microspace (gap) to
be formed between the restorative material
and the cavosurface enamel, dentin, and 37
cementum.
Secondary caries and materials
 The ability of a material to resist secondary
caries development is dependent on

1. complete removal of carious tissue.

3. formation of an intimate cavosurface restorative

interface with minimal to no microspace, and

5. release of caries protective agents (fluoride,

metal ions, antimicrobials, acidic ions) to the
adjacent cavosurface and outer tooth surface.

38
Cont.
Prevention is better then cure.
 fluoride regimen implementation (rinses, gels,
fluoridated toothpastes);

 Antimicrobials (chlorhexidine);

 fluoride-releasing restorative material;

 Dietary review.

 Recaldent and ACP-CCP rigime

39
Break through
Silicate cement restorations- no secondary caries .

Today, there are several fluoride-containing dental

restoratives available in the market including
1. Varnishes
2. Sealents
3. glass-ionomers,
4. resinmodified glass-ionomer cements,
5. polyacid-modified composites (compomers), composites
6. and amalgams. and many more….

Different matrices and setting mechanisms of the

products shows their fluoride release capability.

Antibacterial and cariostaticproperties is associated

with the amount of fluoride released. 40
 ………Cont.

 Fluoride may be released from dental

restorative materials as part of the setting
reaction.

 It can also be added to the formulation with

the specific intention of fluoride release.

 Fluoride releasing components have included

1. Fluoroaluminosilicate glasses (FAG),
2. Stannous fluoride (Snf2),
3. Organic amine fluorides (CAFH) and
41
4. Ytterbium fluoride (ybf2).
Type of fluorides

42
Factors influencing the release of
fluorides
 The release of fluoride is a complex process.
 It can be affected by several intrinsic variables,
such as
1. formulation and fillers .
2. composition and pH-value of saliva,
3. plaque and
4. pellicle formation.
 It was shown that factor like
1. powder–liquid ratio of two-phase-systems,
2. mixing procedure,
3. curing time and
4. the amount of exposed area
5. different storage media affected the fluoride release.
43
Cont.
Cont.
 The highest release is found in acidic and
demineralizing–remineralizing regimes and lowest
in saliva.

 In acidic media it increases because decrease in

pH increases the dissolution of the material,
leading to fluoride release

 Adhesives or bonding agents when applied

increases short and long term fluoride release.

 Bleaching and brushing does not affect the fluoride

release.
44
Fluoride recharge

 “Recharging” is to maintain level of fluoride release.

 FROSTEN et al. found the phenomenon in GIC

 Fluoride reservoir ►►permeability of filling material.

 Glass-ionomers is best fluoride reservoir then others.

Because of loosely bound water.

 Exogenous sources of fluoride act as reservoir,

1. fluoridated dentifrices,
2. mouth rinses
3. high-dose fluoride gels and
4. Varnishes.

 In oral environment saliva and plaque has a role in fluoride

45
uptake.
Plaque and fluorides

 Plaque is ≡ caries development,

 But this organic film may act as a fluoride

reservoir.

 Only small concentrations of fluoride in

plaque, saliva, or calcifying fluids are
necessary to shift the equilibrium.

 Remineralization begins with only 0.03 ppm

fluoride.
46
Antimicrobial activity of fluoride

Dental plaque fluoride, releases hydrogen fluoride from

the plaque into the bacteria.

Hydrogen fluoride inside the bacteria acidifies the

bacterial cytoplasm and leads to release of fluoride
ions.

Bacterial metabolism enzymes as

1. enolase,
2. acid phosphatase,
3. pyrophosphatase,
4. pyrophosphorylase,
5. peroxidase,
6. catalase,
7. adenosine triphosphatase.

Increased plaque fluoride --------decreases -------- 47

adherence of bacteria to hydroxyapatite, which results
in reduced plaque formation.
Fluoride uptake of adjacent tooth
structure

 Tooth surfaces act as a reservoir for fluoride.

 Tooth-bound fluoride increases enamel resistance

to lesion formation.

 Because of microstructure and porosities fluoride

uptake is higher for dentin and cementum than for
enamel.

 Adhesive hybrid layer, may hamper fluoride

uptake.

 fluoride incorporated in dental hard tissues is of

minor importance compared to the fluoride
concentration in a fluid-filled micro gap between 48
the restoration and the tooth structures.
Fluoride-releasing materials
(Caries-preventive mechanisms of
fluoride releasing materials)

 Formation of fluorapatite

 Enhancement of Remineralization .

 Interference of ionic bonding during pellicle

and plaque formation.

 Inhibition of microbial growth and metabolism

49
Ho much is enough?

 Minimum inhibitory concentration is 100-

200μm/ml of sodium fluoride – bacteriostatic
for s. mutants

 30 times over the above value is bacteriocidal

50
Classification

 On the bases of similarity in

1. Physical properties
2. Mechanical properties
3. Setting properties

 They are classified as

ØResin composites
ØCompomer
ØResin modified glass ionomers
ØTraditional glass ionomers

51
52
Comparison of various f contaning
restorative

53
Review of various fluoride releasing
materials
1. Glass-ionomers,
2. Resinmodified glass-ionomer cements,
3. Polyacid-modified composites (compomers)
4. Giomer,
5. Composites,
6. Amalgams.
7. Polycarboxylates
8. Sealents
9. Varnishes
10. silicates

54
History of development of f releasing
materials
 1935 joseph H. SCHLESINGER- "Neutralization of
acids exuding from silicious cements“ .

 1949 Herbert RAUTER- "Improvement in dental

cement" (contains uranium and fluoride)

 1971 Joseph C. MUHLER- additions of either

1. stannous fluoride,
2. stannous fluorozirconate,
3. Indium fluorozirconate,
4. Zirconium hexafluorogermanate,

 1979 Werner SCHMITT et al.- "Light curable acrylic

dental composition with calcium fluoride pigment" 55
 cont….
 1985 Henry R. RAWLS- "Fluoride
interpolymeric resin“

 1997 British Technology Group ltd., of London-

"Introducing fluoride into glass“

 1998 Shoji AKAHANE- Dental filling resin

contaning fluoride“

 2001 Fred RUEGGEBERG- "Fluoride-releasing

amalgam dental restorative material"
56
57
58
Glass ionomer cements
Glass ionomer (polyalkenoate) cements are based on
an ion-leachable glass, which releases fluoride in the
setting process with polyacids

Positive aspects glass ionomer cements

1. chemical adhesion to tooth
2. Resistance to microleakage.
3. Good marginal integrity.
4. Dimensional stability .
5. Coefficient of thermal expansion = tooth structure
6. biocompatibility.
7. Fluoride release.
8. Rechargeability
9. Less shrinkage than resins upon setting

Negative characteristics of this material include

1. Early moisture sensitivity (requiring protection )
2. Poor abrasion resistance. and 59
3. Only average aesthetics.
Cont.
60
Cont.
 The rapid initial release of fluoride is
considered to be that of ‘loosely-bound’
fluoride in the cement matrix.

 The slower rate occurs with the release of

fluoride from the glass particles.

 Re-charging of glass ionomers has been

referred to as the ‘reservoir effect’.

 High initial fluoride release rate may be

positively correlated with a high recharging
ability. 61
Cont.
 Remineralisation of root dentine adjacent to GIC
restoration has been reported.

 Remineralisation of carious lesions has been

reported in dentine adjacent to glass ionomer
restorations.

 The effect of the glass ionomer was most

pronounced in the first week of application.

 Levels of fluoride in plaque adjacent to glass

ionomer restorations have been found to be higher
then other.

 A reduction in the acidogenicity of S. mutans has 62

also been found in relation to glass ionomer
63
64
Glass ionomer in nutshell

65
Commercial products
 Ketac-fil >>>>>>3M ESPE
 Fuji II>>>>>>>>GC America

 Ketac-molar>>> 3M ESPE

 Fuji IX>>>>>>> GC America

66
F release from RM-GICs

 Resin modified glass ionomer cement materials

introduce a polymerisation component to the basic
glass ionomer cement setting chemistry
 Highest during the first 24h (5–35 g/cm2,
depending on the storage media)
 Having a potential for releasing F in equivalent
amounts as conventional GICs.
 Recharging of RM-GICs - After onetime
refluoridation
➔ Increased F release for 24h
➔ Rapid return to near pre-exposure levels within
several days.
 RM-GICs may exhibit a reduced subsequent F
release when compared with GICs 67
Commercial products
 Photac-fil>>>>>>>3M ESPE
 Fuji II LC>>>>>>>GC America

 Vetremer>>>>>>> 3M ESPE

68
Polyacid-modified resin composites
(Compomers)

 Compomers have been developed in an

attempt to combine the therapeutic properties
of the conventional glass ionomer materials
with the more aesthetic resin composites.
 features are common with the glass ionomer
cement chemistry, most notably the release of
fluoride.

69
 The advantages of compomers include;
1. ease of placement,
2. no mixing,
3. easy to polish,
4. good aesthetics,
5. excellent handling,
6. less susceptibility to dehydration, and
7. radiopacity.

70
 Disadvantages of compomers include;
1. limited clinical experience
2. few long-term clinical trials
3. requirement for a bonding agent like composites
4. more marginal staining and chipping
5. wear more than composites
6. enormous variation in products makes longevity
difficult to predict
7. weaker physical properties than composites and
8. clinical significance of fluoride release undetermined

71
Cont.
 The maximum fluoride release from the
compomer occurs within the first day.

 It is unlikely that the fluoride release has a

significant effect on recurrent caries
prevention.

 This is compounded by observations that

recharging of fluoride from topical regimes is
minimal.

72
Compomer in nutshell
 No initial F ‘burst’ effect, but levels of F
release

 remain relatively constant over time

 Long-term release of F from compomers was

followed and measured up to 3 years

 Compomers don’t recharge from F treatment

as much as GICs
73
Commercial products
 Dyract AP>>>>>caulk dentsply
 Hytac>>>>>>>>3M ESPE

 Compoglass>>>Ivoclar vivadent

 F 2000>>>>>>>3M ESPE

74
giomer
 Unlike compomers, fluoro-alumino-silicate
glass particles react with polyacrylic acid prior
to inclusion into the resin matrix.

 pre-reacted glass-ionomers(PRG) helps to form

a stable phase of glass-ionomer fillers in the
restorative

75
Include pre-reacted glass-
ionomers(PRG) to form a
stable phase of glass-ionomer fillers
in the restorative

76
77
cont.
 F released from giomers-
1. Less information is available currently
2. - No initial ‘burst’ effect could be observed
3. - Amounts of F leached from giomers
☺slightly > Composites & Compomers
☹ < GICs
 F recharging ability
- F release from materials was greatly reduced
➔ Only recharge superficial part
- GICs > Giomers
- PRG in Giomers is surrounded with resin matrix
➔ Porosity of Giomers is lower than GICs
78
F-containing resin composite materials
 Recently, ‘fluoride-releasing’ resin composite
materials have been introduced which may
liberate fluoride through passive leaching from
suitably selected filler particles or from the
addition of fluoridated monomers.

 Ytterbium fluoride (YbF2) filler or organic

amine fluorides may be present.

 The amounts of fluoride released decreased

sharply after 24 hours and gradually reached
a plateau. 79
•Fluoride recharging on exposure to a 1,000
ppm NaF solution was successful.

•Incorporation of fluoride into resin composite

materials has not shown any beneficial effect
in reducing the demineralisation of carious
lesions in roots when compared to glass
ionomer cements.

80
Composites in nut shell

 F levels leached from composites

- Much < from GICs or RM-GICs
- Somewhat < from Compomers
 Long-term F release of resin composites is
reported to last for up to 5 years
 Recharging effect may simply be the release
of surface-retained F

81
Commercial products
 Haliomolar>>>>>Caulk Dentsply
 Tetric>>>>>>>>>Ivoclar Vivadent

 Solitaire>>>>>>>Heraeus Kulzer

 Surefil>>>>>>>> Caulk Dentsply

82
SMART COMPOSITES
Active dental polymers contaning bioactive amorphous
calcium phosphate (ACP) filler

capable of responding to environmental pH changes by

releasing calcium and phosphate ions and thus become
adaptable to the surroundings.

Also called as intelligent composites.

This class of composite was introduced as the product

Ariston pHc in 1998.

Ariston is an ion releasing composite material. It

releases functional ions like fluoride, hydroxyl, and
calcium ions as the pH drops in the area immediately
adjacent to the restorative materials 83
amalgam
 Although fluoride is not a component of silver
amalgam composition, it may be added in the
hope and expectation of caries inhibition,
principally as SnF2. Such materials are termed
‘fluoride-releasing’ amalgams.
 The caries inhibition was greater than that in
non-fluoridated amalgam and composite
groups as well as a fluoridated composite.
 Development of secondary caries adjacent to
amalgam restorations may be related to
marginal integrity.
84
Fissure sealant
 The fluoride release from F containing pit and
fissure sealants maximum on the first day.

 This decreases sharply on the second day and then

decreased slowly for the remaining period.

 Fluoride-releasing sealants
1. ProSeal,
2. GC Fuji Triage
showed a significant reduction in wall lesion
frequency when compared with a nonfluoride-
containing sealant
1. Delton

 The mean outer lesion depths in enamel adjacent

to fluoride-releasing sealants were significantly
reduced when compared with those in enamel
adjacent to a nonfluoride-containing sealant. 85
varnishes
 All thought they are used in the restorative
regime but can be used for the recharge of the
fluoride releasing restorative material.
 Also the patient those are most sustainable for
the caries can also be varnished.
 Fluoride varnishes significantly reduces the
[Link] count in plaque after 24hr.

86
87
88
89
90
Silicate cements
 First F-releasing material
Not much used presently because,
2. Poor bonding
3. High solubility
4. Poor mechanical properties
5. Do not survive well in oral environment.

Incidence of secondary caries is rare.

91
summary
 Dental caries is a progressive disease
characterised by demineralization
(dissolution) and destruction of enamel
and dentine
 Fluoride can reduce caries by
preventing demineralization and
promoting remineralization of tooth
surfaces and can also inhibit plaque
acid production
 Optimizing the base formulation can
increase fluoride bioactivity without
altering the fluoride level, with the
potential to enhance anti-caries efficacy
92
References:-

John Hicks et al.

DCNA
2002;46;247-
276

93
94
Thank you for
bearing me
on toes.

95