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TOPICAL FLUORIDE

DEPARTMENT OF PEDODONTICS CASE DISCUSSION

SHANGEETHA A/P KUMARUSAMY 160112162523

LEENA LOSHEENE A/P VIJAYA KUMAR 160112162522

Pembesaran dan
Pengecilan Logo

SUPERVISOR:

Prof. Dr. drg. Williyanti Suwondo, Sp. Ped. (K)

1 cm

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DEPARTMENT OF PEDODONTICS
UNIVERSITAS PADJADJARAN
Perlakuan Pembesaran / Pengecilan :
FAKULTAS KEDOKTERAN GIGI
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5 cm
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Mechanism of Action on Teeth

Systemic Fluoride

Systemic fluorides are those ingested into the body. These include dietary
fluoride supplements and fluoridated water. When compared to topical fluorides,
systemic fluorides differ in that during tooth formation, these ingested fluorides
are incorporated into the tooth structure. When fluoride is ingested during the time
when teeth are developing, it is deposited throughout the entire tooth surface and
can provide longer lasting protection than topical application (ADA, 2005).
Because ingested fluoride is present in the saliva, systemic fluoride is also able to
offer topical protection. The fluoride is incorporated into the tooth surfaces and
dental plaque and promotes remineralization, thus preventing tooth decay.

Tooth enamel is primarily composed of a phosphate and calcium

compound referred to as hydroxyapatite. This calcium phosphate mineral begins
to dissolve when exposed to an environment at sufficiently low pH (~5 or less).
Bacteria that thrive on the sugars found in the oral cavity can accumulate and
produce acids, which cause demineralization of tooth enamel. If this exposure to
acids is present for several weeks or months, early stages of dental caries can
form. The oral cavity combats this through saliva. Saliva is able to neutralize the
acid, which allows the teeth to remineralize enamel. As long as the rate of
demineralization and remineralization remain in balance, teeth will remain strong
and healthy. When more minerals are lost from teeth than are replaced, dental
caries and cavities can develop. Fortunately, fluoride has the capability to slow or
prevent dental caries. Fluoride is able to do so through three different
mechanisms.

First, fluoride inhibits demineralization of enamel. This effect is due to

fluoride’s incorporation into the hydroxyapatite crystals of enamel, resulting in
fortified enamel that is less susceptible to acid erosion (Figure 1).
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Second, fluoride promotes the remineralization of damaged enamel.

Fluoride increases the concentration of calcium in plaque fluid and triggers the
formation of calcium-phosphate fluoride salt, which precipitates onto enamel on
the teeth’s surface (Figure 1). This promotes a more stable crystal structure in the
enamel that is more caries resistant.

Figure 1: Remineralization in the presence of fluoride. Taken from Cury, 2008.

Finally, in concentrated forms, such as varnishes or gel and foams,

fluoride can inhibit the growth of bacteria on teeth. If the fluoride concentration in
dental plaque is high enough, it can result in the reduction of bacterial enzymes
responsible for producing acids from fermentable sugars. It has been shown that
when enolase, a bacterial enzyme in the oral cavity, is inhibited, lactic acid
production is. In addition to interfering with enzyme activity, high concentrations
of fluoride can inhibit the phosphotransferase system, which facilitates the
transport of sugars into cells. By decreasing the amount of sugar in the oral cavity,
fluoride is depriving the bacteria of its food source, thus reducing acid production.

The primary and most important action of fluoride is topical, when the
fluoride ion is present in the saliva in the appropriate concentration.
Hydroxyapatite is the main mineral responsible for building the permanent tooth
enamel after the development of the teeth is finished. During tooth growth, the
enamel is constantly exposed to numerous demineralization processes, but also
important remineralization processes, if the appropriate ions are present in the
saliva. These processes can either weaken or strengthen the enamel. The presence
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of fluoride in an acidic environment reduces the dissolution of calcium

hydroxyapatite. The main action is inhibition of demineralization of enamel,
which is carried out through different mechanisms. There are different cariogenic
bacteria in the plaque fluid the most important being S. mutans. When bacteria
metabolize sugars, they produce lactic acid which decreases the pH in saliva.
When the pH falls below the critical level of hydroxyapatite (pH 5.5), the process
of demineralization of enamel takes place and caries is formed. At the beginning,
the process is reversible and it is possible to reduce the formation of new lesions
with appropriate preventive measures. If fluoride is present in plaque fluid, it will
reduce the demineralization, as it will adsorb into the crystal surface and protect
crystals from dissolution. Because the fluoride ion coating is only partial, the
uncoated parts of the crystal will undergo dissolution on certain parts of the tooth,
if the pH falls below level 5.5. When the pH rises above the critical level of 5.5,
the increased level of fluoride ion leads to remineralization, because it absorbs
itself into the enamel and forms fluorhydroxyapatite. After repeated cycles of
demineralization and remineralization, the outer parts of enamel may change and
become more resistant to the acidic environment due to a lowered critical pH level
of newly formed crystals (pH 4.5). The most important effect of fluoride on caries
progression is thus on demineralization and remineralization processes. It has also
been proposed, that the fluoride ion can affect the physiology of microbial cells,
which can indirectly affect demineralization. Fluoride ions affect bacterial cells
through several mechanisms. One of them being a direct inhibition of cellular
enzymes – glycolytic enzymes, H+ATPases. It affects cellular membrane
permeability and also lowers cytoplasmic pH, resulting in a decrease in acid
production from glycolysis.

Topical Fluoride

Topical fluorides are delivered to exposed surfaces of the dentition, at

elevated concentrations for a local protective effect in making the teeth more
resistant to decay. Topical fluorides are applied to the teeth directly and are most
effective when delivered at very low doses several times a day (Ijaz, 2010).
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Topical treatments can be divided into self-applied and professionally applied

fluorides. Self-applied therapy includes toothpastes and mouthrinses, while
fluoride gels, foams, and varnishes are typically applied to teeth by a dental
professional.

Fluoride gels and foams are generally administered by a dentist for

patients who are at high risk for dental caries. For individuals at a moderate risk
for caries, fluoride gels or foams are recommended every 6 months (Marinho,
2002). High risk individuals can receive gel treatments as often as every 3 months
(Marinho, 2002). Some gels and foams can be self-applied at home with the aid of
a toothbrush, but the concentration of fluoride in these products is significantly
lower. In a professional setting, a dentist will load the gel or foam into a tray then
insert it into the patient’s mouth. Approximately 5 ml of gel is used in a single
tray (Marinho, 2002). The patient bites down on the tray for about four minutes.
Afterwards, patients are advised not to rinse, eat, or drink for about 30 minutes in
order to prolong contact between the fluoride and tooth enamel. A dentist can also
make a tray that is custom fitted for a patient’s teeth, and fluoride treatments can
be loaded into this tray and be used overnight at home. Fluoride gels do contain
abrasives, such as calcium carbonate, dehydrated silica gels, hydrated aluminum
oxides, magnesium carbonate, phosphate salts and silicates, which can be found in
toothpaste (Marinho, 2002). The concentration of fluoride in gels is significantly
higher than that which is found in toothpaste. Fluoride gels can include sodium
fluoride, stannous fluoride and acidulated phosphate fluoride. Typically, gels will
consist of 12,300 ppm F (Marinho, 2002). Because this is such a highly
concentrated form of fluoride, excessive ingestion of gels can lead to acute
toxicity. Nausea, vomiting, headache and abdominal pain are symptoms if
overexposure of fluoride occurs (Marinho, 2002). Because of the risk of over
ingestion the use of gels in young children is not recommended (Marinho, 2002).

One form of topical fluorides used in dentistry is sodium fluoride (NaF).

When NaF is applied on the tooth surface it reacts with hydroxyapatite crystals in
enamel to form calcium fluoride which is the dominant product of the reaction. As
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a thick layer of calcium fluoride forms, it interferes with further diffusion of

fluoride from the topical fluoride solution to react with hydroxyapatite and blocks
further entry of fluoride ions. This sudden stop is termed as ‘chocking off effect’.
Thus, calcium fluoride acts as a reservoir and fluoride slowly leeches out of it. In
short, the calcium fluoride forms reacts with the hydroxyapatite. This fluoridated
hydroxyapatite increases the concentration on fluoride on the enamel surface and
prevents caries.

The more common form of topical fluoride is acidulated phosphate

fluoride (APF) with a fluoride concentration of 12300 ppm. Mechanism of action
when APF is applied to teeth it initially leads to dehydration and shrinkage in the
volume of hydroxyapatite crystals which on hydrolysis forms an intermediate
product called dicalcium phosphate dihydrate (DCPD). DCPD is highly reactive
and starts forming immediately after APF is applied. Fluoride penetrates into the
crystals more deeply through the openings produced by shrinkage and forms
fluorapatite. For the conversion of whole DCPD formed into fluorapatite, a deeper
penetration and continuous supply of fluoride is required. Because of this, APF is
applied every 30 seconds and the teeth have to be kept wet for 4 minutes as per
manufacturer’s instructions.

Level of evidence for professional topical fluorides - moderate and high

caries risk

Children Under 6 Years of Age

In children younger than 6 years, there is strong evidence from systematic

reviews of randomized controlled trials supporting fluoride varnish applications at
six-month intervals for moderate- and high-risk patients and for applications of
fluoride varnish every three months in high-risk patients. Prior to the introduction
of fluoride varnish, there was no safe way to administer topical fluoride to
children 0-3 years of age. Their limited ability to control swallowing and
variable ability to spit effectively on command preclude the use of foams, gels
and rinses. These are not recommended for this age group.
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Fluoride varnish’s tenacious adherence to the tooth provides for slow

release of the fluoride over time and results in only a small amount being
swallowed at a time. Weintraub et al. reported that children ages 6-44 months
who received no varnish were more than two times as likely to develop decay
as those who received annual varnish application. Stearns et al. reported that
children 6-44 months of age who had four or more visits where varnish was
applied as a part of a preventive/referral service showed a 39% reduction in
caries-related treatment in anterior teeth.23 Fluoride varnish should be part of all
preventive strategies aimed at high-risk children in this age group.

Miller and Vann expanded on the ADA panel’s recommendations, which

addressed recommendations for topical fluoride use in children under age 6, but
not specifically ages 0-3 years; they recommended that “based on available
evidence including dose reductions and efficacy justifications, we advocate
that varnish should be the only topical fluoride modality used for children 0-
3. Because of safety concerns we advocate further that varnish should also be the
only modality used for children with special health care needs who exhibit
attention span and/or cooperation problems.

Children Ages 6-18 Years

In children ages 6-18 years with moderate and high caries risk, there is
evidence from systematic reviews to support the use of fluoride varnish or gel
every six months as well as to support the use of fluoride varnish every three
months in high-risk children. The level of evidence for the use of fluoride gel
every three months in high-risk children ages 6-18 is lower. For children 6-18
years of age, a systematic review by the Cochrane Collaboration found a caries
reductions of 28% for gels, and a separate review for varnish found DMFS
reductions of 46% for permanent teeth and dmfs reductions of 33% for primary
teeth in children up to 16 years of age.
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Adults (All Patients Over 18 Years of Age)

The primary uses for fluoride varnish in adults are for remineralization
or control of root caries in older patients, prevention of caries in high-risk
adults and treatment of dentinal sensitivity. There is some evidence supporting
the use of fluoride of either modality (varnish or gel) every six months for patients
over 18 years of age at moderate and high risk, and for high-risk patients at three-
month intervals. The level of evidence is lower and is based on expert committee
reports or opinions rather than prospective, randomized clinical trials.

Data on the effectiveness of fluoride varnish being superior to other

treatment options for root caries is equivocal. Several investigations show
equivalence – no superiority of fluoride varnish over the use of chlorhexidine
varnish or stannous fluoride solution (8%) or in combination with Cariosolve
chemomechanical technique. There is tentative support for threemonthly
application of fluoride varnish for remineralization of root caries. There are no
clinical trials providing evidence to support the use of professional topical
fluoride gels or foams for the prevention and treatment of root caries. Support is
definitely adequate to recommend using fluoride varnish as a part of a total
preventive plan including the other agents investigated in these reported studies.

One study found 5% sodium fluoride varnish to produce sensitivity relief

results that are equivalent to that of oxalate preparations. In another study 2%
fluoride iontophoresis, Gluma Comfort Bond Plus Desensitizer, copal varnish and
5% sodium fluoride varnish all resulted in significant relief at 24 hours; after 7
days, results were statistically significant for 2% fluoride iontophoresis and
Gluma Comfort Bond Plus Desensitizer.33,34 A recent study compared the use of
5% sodium fluoride varnish and shellac-based fluoride varnish for sensitivity
relief and found both to be equally effective and to provide relief.35 Fluoride
varnish can be effective for up to three to six months for sensitivity relief,
depending on the patient, when used according to the directions for use.
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Level of evidence for professional topical fluorides - moderate and high

caries risk

Recommended dietary fluoride supplement

.
References

American Dental Association Council on Scientific Affairs, 2006. Professionally applied

topical fluoride: Evidence–based clinical recommendations. The Journal of the
American Dental Association, 137(8), pp.1151-1159.
Buzalaf, M.A.R., Pessan, J.P., Honório, H.M. and Ten Cate, J.M., 2011. Mechanisms of
action of fluoride for caries control. In Fluoride and the oral environment (Vol.
22, pp. 97-114). Karger Publishers.
Cury, J.A. and Tenuta, L.M.A., 2008. How to maintain a cariostatic fluoride
concentration in the oral environment. Advances in dental research, 20(1), pp.13-16.
Fincham, A.G., Moradian-Oldak, J. and Simmer, J.P., 1999. The structural biology of the
developing dental enamel matrix. Journal of structural biology, 126(3), pp.270-
299.
Ijaz, S., Marinho, V.C., Croucher, R., Onwude, O. and Rutterford, C., 2010.
Professionally applied fluoride paint‐on solutions for the control of dental caries in
children and adolescents. Cochrane Database of Systematic Reviews, (2).
Marinho, V.C., Higgins, J., Logan, S. and Sheiham, A., 2003. Fluoride toothpastes for
preventing dental caries in children and adolescents. Cochrane database of
systematic reviews, (1).
American Dental Association. (2005). Fluoridation Facts. Chicago, IL. Retrieved from
http://www.ada.org/sections/professionalResources/pdfs/fluoridation_facts.pdf

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