Dr Mona Mustafa

BDS - MD - DRME
What is fluoride?
Why do we use fluoride in dentistry? How does it
work?
How should we use fluoride to prevent dental
caries?
What is fluorosis
What is fluoride?
Fluoride is the ionic form of the element fluorine.
It is negatively charged and will not remain as a free
element.
Fluoride has a high affinity for calcium therefore it is
very compatible with teeth and bone.
 Fluoride is the most effective tested anticarious agent
Fluorine can be found in nature in association with
calcium as --- Fluorite or fluorospar and with calcium
& phosphorus as-- fluoroappatite and with Na&Al as
--- cryolite .
Also it can be found in water, food e.g sea food such
as sardin& salamon
In drinks e.g fresh fruit juice, breast milk , beer and
wine
In tea , leafy plants , salt and sugar
In pharmmacetical products such as fluoride
dentifrice, F. gels and solutions and F. tabs that are
used for caries prevention
Sources of fluoride
Milk formula ( .05 to .35 ppm)
Soy Beans Formula ( 0.17 to 0.38 ppm)
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
Fish and seafood products
Dried seafoods (can contain 290 ppm)
Canned seafoods ( can contain 40 ppm)
Chicken products (0.6 to 10.6 ppm)
Dental Products
Dentifrices
Fluoride mouth rinse
Professional applied fluorides
Dietary fluoride supplements
Total daily intake of fluoride
Fluoride from Air
 Minimal

Fluoride from Water

 Is the most important single source of fluoride depending on
fluoride concentration and amount
 There is fluctuation due to climatic change in different
geographical areas
Fluoride from food
 0.04 to 0.07 mg/kgday
 Breast fed infant receives 0.003 to 0.004mg/day
Excessive consumption of tea and sea foods- increased fluoride

concentration

National Research Council 1980 – safe and adequate amount is

1.5 to 4.0 mg/[Link] in adults

0.04 to 0.07 mg/[Link] in children for optimal dental health

Fluoride metabolism &
Bioavailability
Fluoride metabolism is divided in to :
Absorption, distribution and elemination .
75 – 90 % of ingested fluoride is absorped in the alimentary tract ,
peak plasma concentration occurs within 30 – 60 mintues .Water
soluble fluorides:such as
NaF( Sodium fluoride), HF( Hydrogen fluoride) , H2SiF6,
( Fluorosilcic acid), Na2PO3F ( Sodium monofluorophosphate) are
copletlely absorbed where as less soluble fluorides such as CaF2 ,
MgF, Alf3 are less absorbed.
Rapid absorption occur in the stomach and the
remaining fluoride is absorbed in the small intestine.
Then distributed through plasma to the different
parts of the body e.g heart, kidneys, liver and bone
and excreted through urine.
With milk, F bioavailability decreased.
 Fluoride metabolism and
excretion
Fluoride in •50 % of the
Food, water absorbed fluoride
will be associated
with calcified tissue

75 to 90 % absorbed from the •50% excreted in

alimentary tract, more from urine
liquids than solids (10 to 25%
excreted via feces)
FLUORIDE

IN HARD TISSUE
90% of fluoride in the body is in the calcified tissues .
Bone: Total amount 2.6mg
Most of Fluoride in the body retained in the skeleton-

vary according to the renal clearance

Remodeling bones deposit more fluoride than in older

people
Fluoride deposition is a reversible process
 Teeth:- Deposition occurs in successive stages.

Initial deposition – organic and mineral phases are laid down

Pre-eruptive maturation phase i,e during tooth development, the
presence of fluoride in enamel increase the tooth resistance to
demineralization when the tooth surface is exposed to organic
acids. ( systemic)
Post eruptive maturation i,e after tooth eruption , topical fluoride
decrease the demineralization and increase the rate of
remineralization
 Fluoride concentration within atooth layers is not uniform

dentine contains 4 times more than enamel

Fluoride concentration in
Cementum
Higher than any skeleton or dental tissue

Tissue is very thin

Near the tissue surface- accessible to fluoride present in

blood
Mechanisms of Action
Topical
Systemic
Antibacterial
 Topical
 inhibits demineralization
 promotes remineralization
Systemic
improves enamel crystallinity
reduces acid solubility
improves tooth morphology (controversial)
Antibacterial
concentrates in plaque
disrupts enzyme systems
Fluoride inhibits bacterial metabolization of carbohydrates to produce
acid .
Summary of Anti-Caries Activity
of Fluoride
1. Fluoride prevents demineralization.
2. Fluoride enhances remineralization.
3. Fluoride alters the action of plaque bacteria.
4. Fluoride reduces enamel solubility therefore aids in
posteruptive maturation of enamel .
Administration of Fluoride
It can be administered systemically or applied
topically
1/ Systemic:
Ingested and delivered to the oral cavity via blood
stream:
1/ Water fluoridation:
a/ community water fluoridation
b/ school water fluoridation
2/ Dietary supplements:
a/ fluoride tablets & drops
b/ fluoridated salts, sugar, milk and fruit juices
c/ fluoride vitamins preparation
2/ Topical:
They are utilized intra orally for variable amount of
time to exposed crown and root surfaces to prevent
dental caries.
1/ those applied by professional:
a/ topical solutions & gels
b/ fluoride containing varnishes
c/ fluoride prophylaxis paste
d/ restorative material containing fluoride
2/ self applied fluoride agent :
a/ fluoride dentifrice
b/ fluoride rinses & gels
 Fluoride supplementation

Systemic Topical

Water fluoridation Professional application

1/School water fluoridation

Dietary fluorides Self
2/Community water application
Fluoride in salt ,
fluoridation
milk andsugar
Types of fluorides
In the United States, there are three types of fluorides
approved by the FDA as safe and effective for use in
dentifrices:
 Sodium fluoride (for use in paste, must be bound to another element
or it will bind to the abrasive ingredient)
 Sodium monofluorophosphate (holds fluoride in complex form )

 Stannous fluoride (was the first used in dentifrice, was previously

difficult to stabilize, has gingivitis-reduction properties, but has an

astringent taste and potential staining)
Fluorides for Professional Use
FDA approved for professional use:
Acidulated phosphate fluoride (APF) with 1.23% (12,300 ppm)
 Neutral sodium fluoride (NaFl) with 2% (9,000 ppm)
Fluoride for Home Use
Neutral sodium fluoride
05% (225 ppm) –rinse
2% (1,000 ppm) –Rx rinse
1,000 – 1,500 ppm –Regular paste over the counter ,

1.1% (5,000 ppm) –Rx paste

Example: Prevident 5000
 Acidulated phosphate fluoride
044% (1,100 ppm) –rinse
5,000 ppm –Rx gel
 Stannous fluoride

3,000 ppm –Rx gel

63% F --Rx rinse
Fluoride Dentifrices
Best topical application
 0.2 to 0.3 mg F can be swallowed by pre-school aged
children when brushing therefore instructions for use of
fluoride dentifrce is recommended
Recommendations/instructions for use
Very small, pea-sized amount for pre-school aged children
Parents must supervise small children
Rinse and expectorate following brushing
Fluoride Varnish
It is professionally applied adherent material, it increases the
fluoride concentration in saliva 2 hours after its’ application
It can arrest existing lesions on smooth surface of primary
teeth and roots of permanent teeth
NaF varnish delivers 2.26% fluoride (22,600 ppm), the
strongest concentration of fluoride delivered.
Application stays on tooth surface 4 to 6 hours after
application (product is purposely colored to detect presence)
Fluoride Varnish
Safe
Effective
Doesn’t take a lot of time
Fluoride varnish products
Fluoride varnish is available from 3 different
manufacturers. It consists of 5% NaF.
Duraflor
Duraphat
Cavity Shield
Fluoride varnish has been used since late 1960 in Europe
and Canada as a primary preventive agent, with as much as
a 75% reduction in decay .
Fluoride in varnish also gradually dissolves into the plaque,
saliva, and enamel providing bacteriocidal, bacteriostatic,
and remineralizing effects .
 No toxic effects were found in the blood plasma levels in preschool and
school children after treatment with varnish.
 The use of varnishes is therefore safer than gels for children because
children younger than six years of age tend to swallow 30 to 50% of gel
products .
 The FDA has cleared fluoride varnish as a cavity liner or root
desensitizer.
Advantages of fluoride varnish
Easy to apply
Teeth do not need professional prophylaxis
Children can eat and drink following applications
Potential ingestion of fluoride is low
Prevents caries
Frequency of Applications
2 to 4 applications per year
Fluoride Varnish Application
Clean and Dry Teeth

2 TO 4 applications per year

Apply Varnish with small brush
Fluoride Varnish Application
Apply varnish to
Anterior teeth

Posterior teeth
Fluoride Varnish Application
The varnish hardens
quickly after application
as a yellow film
The child can have a
drink of water
Post application instructions for
parents
Varnish will set on contact with saliva.

Child can eat or drink right after application

Do not brush your child’s teeth tonight. Start brushing

them tomorrow morning

Three Months Later

Remineralized Enamel
Fluoride in Prophylactic Paste
Contains 4,000 to 20,000 ppm
but does not adequately substitute for fluoride gel or
varnish in treating high risk caries patients .
Goals of fluoride administration
1/ do not harm the patient
2/ prevent decay on intact dental surfaces
3/ arrest active decay
4/ remineralized decalcified tooth surfaces
Water fluoridation
Definitions:-

 ‘Water fluoridation is defined as controlled adjustment of the concentration

of fluoride in a community water supply so as to maximize caries reduction

and a clinically insignificant level of fluorosis.’
 Defined as’ upward adjustment of the concentration of fluoride ion in a public

water supply in such way that the concentration of fluoride in the water may
be consistently maintained at 1 ppm by weight to prevent dental caries with
minimum possibility of causing dental fluorosis’
Fluoride compounds used in water fluoridation-
 Fluorospar
 Sodium fluoride- most expensive source
 Silicofluoride
 Sodium silicofluoride- cheapest form
 Hydrofluorosilicic acid
 Amonium silicofluoride
Types of equipments for water fluoridation-
 Saturation system- 4% NaF (recommended for small towns)
 Dry feeder system-NaF or silicofluoride (medium sized towns)
 Solution feeder- Hydrofluosilicic acid (large towns)
Optimal fluoride concentrations and climatic condition
In Temperate climates - 1ppm
Children living in this area- 1mg/daily

Galagan and Vermillion emperical formula:

Based on daily fluid intake, body wt and temp
ppm F =0.34/E E = -0.038+0.0062 t
E -daily water intake in oz/lb of body wt
t- max daily temp in degrees Fahrenheit

WHO recommended (1994)- 0.5 to 1.0 ppm

Fluoride tablets
Provides systemic effect before mineralization

In deciduous dentition:-
 Caries reduction 50 -80%

In permanent dentition:-
 20 - 40% caries reduction

 Longest clinical trial carried out by Aasenden and Peebles 0.5mg F tab given
below 3 years and 1 mg thereafter—followed by 8-11 years, caries reduction75
- 80%
Commercially available NaF (fluoraday,
tymaflour and luride)
– 2.2 mg NaF- 1mg of F
– 1.1 mg NaF -0.5mg of F
– 0.55 mg NaF – 0.25mg of F
• -up to 2 years drops are preferable
• Daily recommended dose:-
– Below 2 years – 0.5mg
– 2 to 3 years -0.5 to 0.7mg
– Above 3 years- 1 to 1.5mg
To enhance cariostatic effect-
 Chew and suck the tab

 Preferably at bed time..

 Continued at least until 12 to 14 years

Should not given if water supply exceed 0.7ppm

Should not given with milk and milk products

Cannot replace water fluoridation –parents fail to comply with

the regimen
School water fluoridation
Suitable alternative –because fluoride consumed during
school days was 4.5 to 6.3 ppm .
Caries reduction 45 - 50%
Advantages:-
 Effective public health measure- if fluoridated water supply
is not possible
Disadvantages:-
 5 to 6 years old upon starting school- will not provide
preeruptive contact..
 Intermittent fluoride exposure 180 days in a year
DEFLUORIDATION
Defluoridation means to improve the quality of water
with high fluoride concentration by adjusting the
optimal level in drinking water
common used materials: activated alumina, activated

bauxite, Zeolite, Tricalcium phosphate, activated bone

char, magnesite, magnesite etc
Fluoride Toxicity: ( Acute fluoride toxicity)
Symptoms of overdose
 GIT (nausea& vomiting , diarrhaea, )
 Pain in abdomen, increased salivation, difficulty in speech
 Weak pulse, coma
 CNS (convulsions)
 Cardiac arrithymias
 Death occur in 4 hours

Probable toxic dose = 5 mg F/kg

Certainly lethal dose = 16 – 32 mg F/kg
 CHRONIC TOXICITY
Fluoride level Water consumption Effects

0.7 to 1.2 ppm Depending on temp of Prevents dental caries

area

1.5 to 3.0ppm Period of 5 to 10 years Mild dental fluorosis

3.0 to 8.0ppm 15 to 20 years Severe dental fluorosis

Mild skeletal fluorosis

8.0ppm or more 5 to 10 years Severe form of dental

skeletal fluorosis
Treatment:
Determine child’s weight and estimate amount ingested
<8 mg F/kg: give milk, observe > 6 hours, refer if
symptoms develop
>8 mg F/kg: give syrup of ipecac, followed by milk; refer
immediately
Unknown dose: if asymptomatic, treat as <8 mg F/kg, if
symptomatic (already vomited) give milk, refer
immediately
Contact hospital: gastric lavage, IV calcium gluconate