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Lec 4 Fluoride and dental caries:

1- Fluoride: is the term used when fluorine is combined chemically
with a positively charged counterpart.
2- The presence of Ca may lead to formation of insoluble salts
with fluoride and absorption reduced to 70% and in food rich
with Ca to 60%.
3- Fluoride in Plasma: Plasma is the biological fluid into which
and from which fluoride must pass for its distribution elsewhere
in the body and for its elimination from the body.
- The concentration of ionic fluoride in soft and hard tissue is
directly related to the amount of ionic fluoride intake.
- Fluoride balance in infants can be positive or negative during
the early months of life, depending on whether intake is
sufficient to maintain the plasma concentration that existed
at the time of birth.
- The intracellular fluoride concentrations are from 10–50
% lower than those of plasma, but they change
simultaneously and in proportion to those of plasma.
- The tissue-to-plasma ratios of radioactive fluoride are
consistent with the hypothesis that hydrogen fluoride (HF)
is the form in which fluoride migrates and establishes
diffusion equilibrium across cell membranes.
- Since the pH gradient across the membranes of most cells
can be decreased or increased by altering extracellular pH, it
is possible to promote the net flux of fluoride into or out of
cells. This is the basis for the suggestion that alkalinization
of the body fluids is a useful adjunct in the treatment of
acute fluoride toxicity.
4- Dentine and bone appear to have similar fluoride
concentrations which increase with age, while that of enamel
is markedly lower. Surface enamel fluoride concentrations tend
to decrease with age in areas subjected to tooth wear but
increase in areas that accumulate plaque.
5- In Sweat Usually, only a few percent of the fluoride intake is
excreted in the sweat. However, under excessive sweating as
much as 50 percent of the total fluoride excreted may be lost via
perspiration.
 6- In Saliva Less than 1 percent of absorbed fluoride is reported
to appear in the saliva. The concentration of fluoride in saliva
is about two-thirds of the plasma fluoride concentration and
seems to be independent of flow rate, in contrast to the
situation for most electrolytes. In fact, saliva does not represent
true excretion, because most of the fluoride will be recycled in
the body.

Lec. 5-6 Systemic fluoridation

Dental fluorosis: Infants and toddlers are especially at risk for
dental fluorosis of the anterior teeth since it is during the first 3
years of life that the permanent front teeth are the most sensitive to
the effects of fluoride (The central incisor takes approximately 3
years to go through complete enamel mineralization.
- Fluoride accumulates at the transition/ maturation stage of
tooth development so that the entire tooth surface can be
affected.
- Children fed formula made with fluoridated water are at
higher risk to develop dental fluorosis.
1. Child from birth -3year takes excess fluoride from tap water
used for infant formula, Incisors, and first molars are most affected
teeth.
2. Child from 3–6 years takes excess fluoride from early
toothpaste use, premolars, canines and second molars are most
affected teeth.
3. Child from 0-6years takes excess fluoride from
Fluoride supplements and fluoridated water (drinking water
>4 ppm fluoride), all teeth affected.
- A direct relationship is present between dental fluorosis and
level of F ingested.
- The severity of dental fluorosis depend on:
1. Stage of tooth development.
2. Duration of exposure to fluoride.
3. Concentration of fluoride in foods and drinks.

- The earliest sign is a change in color, showing many thin

white horizontal lines running across the surfaces of the
teeth, with white opacities at the newly erupted incisal end.
The white lines run along the ‘perikymata’, a term
 referring to transverse ridges on the surface of the tooth,
which correspond to the incremental lines in the enamel
known as Striae of Retzius.
- Dental fluorosis is related to physiological conditions,
including body weight, rate of skeletal growth and
remodeling, nutrition, and renal function.
- It is widely known that F- affects the kinetics of
bio mineralization, triggering the incomplete mineralization
of enamel crystals and producing porous enamel-which is
typical of dental fluorosis.
- Bone is a reservoir of fluoride, as fluoride is incorporated
in the forming apatite crystals, and this ion can also be
released from these crystals as bone remodels. Therefore,
rapid bone growth, as occurs in the growing child, will
remove fluoride from the blood stream, possibly reducing
the risk of dental fluorosis by lowering serum fluoride
levels.
- Treatment of Dental Fluorosis:

Type of fluorosis Treatment

Mild bleaching, to make the color of the
tooth surface uniform
Moderate Composite restorations combined
with micro abrasion or application
of aesthetic veneers
Sever prosthetic crowns

- Incipient Caries and Fluorosis Diagnosis: It is important

to differentiate visually between incipient caries and
developmental white spot hypocalcifications (fluorosis) of
enamel.
1- Dental fluorosis is common to observe and is unaffected
by drying and wetting. So, a white spot that is an
incipient lesion will disappear upon wetting and a
hypocalcification will remain whether dry or moist.
2- White spot carious lesions usually occur around
margins of gingival (the favorable site for plaque
deposition).
Water fluoridation:
- The National Advisory Committee on Oral Health
suggested a range 0.6-1.1 mg/L with variation within that
range according to the mean maximum daily temperature.
 - Advantages of water fluoridation:
- 1- Low cost.
-2- No motivation or behavioral changes necessary.
- 3- Had pre and post eruptive benefit.
-4- Caries reduction 50-60% in permanent teeth, and 40-
50% in primary teeth. And the disadvantage is the
possibility of mild to moderate fluorosis
.
- Disadvantages of water fluoridation
1- Political and/or emotional objections to water additives.
2- Possibility of mild to moderate fluorosis if other sources
of fluoride are ingested
3- Alleged,toxicity.

- In recent years there have been attempte to link

fluoridation with a wide range of diseases, e.g. cancer,
Alzheimer diseases or that it interferes with the immune
function. But there is overwhelming agreement between the
scientific, medical and dental community worldwide that
fluoridation of water is a safe and effective public health
measure.
Fluoride Supplements:
- Fluoride supplement is daily used from 6months to 16 years
to give their maximum effect (To obtain the benefits from
fluoride supplements, long-term compliance on a daily basis
is required).
- To maximize the topical effect of fluoride, tablets and
lozenges are intended to be chewed or sucked for 1–2
minutes before being swallowed.
- Advantages and disadvantages of F salts:
Advantages:
-Wide coverage
-Need little action by the individual
- Low coast
- Freedom for the consumers as both fluoridated and non-
fluoridated salt is available
- It is safe
- Minimum possibilities of fluorosis.
 - Fluoridated milk
Disadvantages:
-Consumption of milk varies between different
socioeconomic groups.
-Consumption decrease with age so long term benefit is less
than water fluoridation
-Require high level of technical expertise.
–A high concentration of fluoride is needed for two reasons:
(1) the children did not drink the beverage throughout the
day.
(2) calcium in the milk complexes with fluoride, which
would reduce its availability for topical benefits

Disadvantages:
-Salt fluoridation need community education and
promotion.
-International efforts to reduce sodium intake to
help control hypertension.
- Consumption of fluoridated salt is lowered during early
life when the need for fluoride is the maximum.

- Lec 7- 8 Topical fluoride

- Advantages of topical fluoride:

. -Does not cause fluorosis.
. -Cariostatic for people of all ages.
. -Available only to people who desire it.
. -Easy to use.
Disadvantages of topical fluoride:
.- Person must remember to use.
.- High cost compared to water fluoridation.
- More concentrated professional use products can cause short-term side
effects like nausea immediately after use.
- The efficacy of topical fluoride depends on:
a. The concentration of fluoride used.
b. The frequency with which it is applied and the duration of application.
c. The specific fluoride compound used.
- Commonly used topical fluoride agents include: Sodium fluoride,
Sodium monofluorophosphate. Stannous fluoride and Amine fluoride.

- Goals of topical Fluoride (F) Administration

- .Do not harm the patient.
. -Prevent decay on intact dental surfaces.
.- Arrest active decay.
-Remineralize decalcified tooth surfaces

-Requisites for self-applied fluoride agents: [community and

individuals:
- Should be completely safe.
- Should be effective for preventing caries.
- Method should be suitable for use by large groups and
at a reasonably low cost.
- Should be acceptable to participants.
- Should be easy to use to ensure compliance.
- Should require few professional personnel.
- Should be able to be supervised by non-dental
personnel after short periods of in-service training.

- Most toothpaste nowadays contain sodium fluoride or sodium

monofluorophosphate as active ingredient, usually in concentration of
1000–1100 mg F/g.
- Most 1000 ppm fluoride containing toothpaste achieve this
concentration, i.e.
%0.1]F= 1 mgF/g paste] by adding one of the following fluoride salts.
Sodium fluoride 0.2% NaF
Sodium monofluorophosphate 0.76% Na2PO3F
Stannous fluoride [0.4% SnF2]

- Fluoride in toothpaste is taken up directly by demineralized

enamel and it also increases the fluoride concentration in
dental plaque, thus leaving a store of fluoride available for
remineralization when pH drops.
- For reasons of lowest expense, convenience in handling as
well avoidance of unpleasant taste, NaF became the most
 widely used of these tested products in public health
programs

- The combination programs between systemic and topical

fluoridation may give about 75% reduction in dental caries.

- Advantages of F varnishes:
1- The use of fluoride varnish increases the fluoride
concentration in
saliva, which remains significantly higher 2 hours
after its application than after the use of other fluoride
agents.
. - 2 Simple application and requires minimal training.
. 3Prolonged contact time between fluoride and the tooth
surfaces (increases fluoride uptake by dental hard tissues, as
well as the formation of CaF2 reservoirs), and the possibility
of using very small amounts of the product (a thin layer),
which minimizes the risk of
excessive fluoride ingestion.

- Fluoride containing restorative materials includes glass

ionomer cements, resin modified glass ionomer cements,
polyacid modified resin composites (compomers), resin
composites, fissure sealants and dental amalgam .Fluoride
releasing components have included fluoroaluminosilicate
glasses (FAG), stannous fluoride (SnF2), organic amine
fluorides (CAFH) and ytterbium fluoride (YbF).
- There are three types of slow-release F devices: the
copolymer membrane type, developed in the United States,
and the glass bead, developed in the United Kingdom. More
recently, a third type, which consists in a mixture of sodium
fluoride (NaF) and hydroxyapatite.

Lec 9 Fluoride toxicity:

- Factors affecting fluoride toxicity: The differences in toxic

potential of different fluoride compounds are related to:
- .1Solubility of the compound.
 - .2 Content of the compound, e.g. stannous fluoride is
slightly more toxic than sodium fluoride because high doses
of tin ion.
- . 3route of administration
- . 4Age.
- .5Rate of absorption.
- 6. Acid-base status.

- Table (1): Effect of fluoride in water on

human health when consumed for longer
durations
Fluoride concentration (mg/L) Effects

<1.0 Safe limit

1.0–3.0 Dental Fluorosis
3.0–4.0 Brittle and stiff bones and joints
4.0–10 Dental fluorosis, skeletal fluorosis
(pain in neck bones and back)