3 Fluoride

Prevention of Dental Caries with
Fluoride:
Fluoride is one of the halogens. It is the
most active element of this group so not
present in the free form. It is difficult to
obtain a sample of calcium compound from
a natural source in a completely fluoride
free condition.
It is present in soil, sea water,
rain water, sea food, etc.
Fluoride is the only proved
anticariogenic diet.
Route of administration
A)systemic route, (by ingesting)
B) topical application.
Mode of Action of Fluoride: (role in caries
control)
1. Ionic exchange of fluoride with the hydroxyl
group of calcium hydroxyapetite in enamel surface
changing it into fluoroapetite (less soluble in acids).
2. Enzymatic inhibition, it interfere with the
glucose breakdown to lactic and pyruvic acids. Both
phosphatase and anulase enzymes are inhibited by
fluoride.
3. Bacterial inhibition, it has a direct inhibitory
effect on the bacteria of the dental plaque.
4. Fluoride precipitate minerals as calcium &
phosphate on the surface of enamel from
saturated solutions as saliva. so it aids in
remineralization of partially demineralized enamel
in early caries.
5. Fluoride lowers free surface energy. This will
decrease the plaque accumulation on the treated
enamel surface.
6. Action on tooth size and morphology: In
communities with fluoridated water supply, there
is a trend towards shallower fissures and lower
cusp height and smaller tooth size. This will
decrease caries susceptibility.
Sources of Fluoride:
Main sources: water, foods and air. Water
and food are the most significant daily intake.
Water from deep wells and artesian wells usually
provide high natural fluoride concentration.
Food Most vegetables, fruits and dairy products

contain low amount of fluoride. Meat and poultry
also contain little fluoride but sea foods (fish,
salmon and sardines, shrimp, crab, etc) may
contain 2.5 ppm. Most beverages contain
amounts of fluoride especially tea.
Fruit juices and soft drinks are generally low in
fluoride, but the fluoride content of the water used in
the preparation of such beverages or in the cooking
of food will be reflected in the fluoride concentration
of the final product.
The required amount of fluoride will depend

upon the fluoride concentration in the water and food
as well as the amount consumed. The recommended
optimal fluoride doses for community water supplies
vary with the annual mean of the daily temperature
(0.7 to 1.2 ppm). The average diet provides 0.2-0.3
mg of fluoride daily.
Fluoride Content Of Enamel:
Enamel is composed mainly of hydroxyapetite

and a little proportion of calcium carbonate.
Traces from other elements present either
incorporated in the crystals structure or
concentrated on the enamel surface.
It was noticed that there is an inverse
relationship between fluoride and carbonate
concentrations in enamel. Fluoride is
concentrated at the surface (2000-3000 ppm in
water fluoridated areas) and decreases towards
the DEJ.
Uptake of Fluoride by the Teeth:
a) Before eruption:
During Calcification, traces of fluoride incorporated
into the crystalline structure of appetite lattice. Further
amounts of fluoride are taken up by the external enamel
surface from the surrounding tissue fluids.
b) After eruption:
Enamel surface continues to pick up fluoride from
diet, water and saliva. fluoride acquisition continues
throughout life from food and water.
Toxicity of Fluoride:
I-Acute toxicity (very rare but lethal)
High doses (5-10g for adult & 0.5-1g for children)
C.P. nausea, vomiting, diarrhea, abdominal pain,
increased salivation and thirst, cardiovascular &
respiratory depression and failure and may leads to
death.
Treatment:
1-Induce vomiting (either by digit or by drug (ipecac).
2-Giving Fl-binding sol. e.g. milk or lime water.
3-Hospitalization (gastric lavage, cardiac
resuscitation, artificial respiration……)
II-Chronic toxicity
it is more common and results in dental &
skeletal fluorosis. If occur (dose 6-8 ppm) during
the tooth developmental, Mottled enamel may
result with various degrees. If occur later in life
(10-25ppm) may result in bony deformities, joint
fixation and calcification of the ligaments.
Treatment: polishing, bleaching, micro-
abrasion, filing or crown restoration according to
severity degree.
Skeletal fluorosis medical consultation
Methods of Providing Fluoride:
1- Systemic Fluoride:
1. Water fluoridation:
There is an inverse relationship between
the fluoride level in drinking water supplies
and the incidence of dental caries and
direct relationship with the number of
caries free individuals in the community.
This beneficial effect continues associated
with increased fluoride levels of about 1-
1.5 ppm.
If fluoride increase above this level enamel
fluorosis will be occur (direct relation). 1ppm
concentration was found to be optimum
regards effective anticaries effect and lower
mottled enamel. So fluoride adjusted to this
Level In areas of communal water supply with
less than 1 ppm. Water Fluoridation’s is the
most economical way for combating dental
caries at the community level.
The optimal dose of fluoride for
children is 0.5 -1.0 mg fluoride (WHO).
1 ppm concentration is suitable for cold
weather countries while in hot
countries fluoride concentration should
be lower depending on the daily water
consumption. In Egypt the fluoride
concentration of Nile water is about
0.36 ppm in which is considered
optimum.
Fluoridation of school water supply:
used where fluoridation of communal water
supply is not possible. School children are
exposed to the benefit of fluoridation only
during school days and hours. So fluoride
concentration up to 5 ppm have been proved
effective in caries control. The decrease in
DMFS is about 40% with no evidence of
dental fluorosis .
3. Fluoride supplements:
fluoride tablets, drops or Syrups
indicated when fluoridation of water
supply is not possible. Considerable
caries reduction when started early
enough. The usual dose is 0.5 mg
F/day up to 3 years of age and 1.0 mg
F/day over 3 years of age.
The fluoride tablets (1mg F) crushed in
water or fruit juices. Fluoride administration
should continue till 10 years age (complete
crown formation of the second permanent
molar). Fluoride preparations should be
kept out of reach of children to avoid over
dosage. Fluoride tablets disguised as
sweets are, not advised.
4._Fluoride incorporation in various
foods: (fluoride enriched foods )
To make fluoride administration, a
personal choice, incorporation of fluoride in
salt, milk, bread, rice, etc. It is difficult to
adjust fluoride concentration to satisfy the
individual personal intake (the consumption
vary significantly). So it need careful
regulation of the prescribed daily dose and
parents cooperation.
Topically applied fluorides:
1. Self administered fluoride applications:
a) Fluoride tooth pastes (dentifrices). (Discussed
before).
b) Brushing or rinsing with fluoride solution:
regular rinsing or brushing (every week or fortnight)
with 0.2% sodium fluoride will reduce caries incidence.
Also daily rinsing with very dilute solution (0.02%) after
tooth brushing to obtain clean tooth surface and direct
access to the enamel surface is useful specially in high
caries patients. Mouth rinsing can be carried out in
schools successfully.
c) Fluoride gel: usually containing 1.23%
fluoride. It is widely used. It is loaded in a special
applicator for about 4 minutes. With some
applicators, the whole mouth can be treated at
once.
d) Fluoride dental floss: unwaxed
impregnated with fluoride is a valuable topical
fluoride vehicle. A significant fluoride uptake and
a reduction in the microorganisms on the
proximal tooth surfaces.
professionally applied fluoride: .
It is useful in caries reduction particularly in children
in low fluoridated areas.
Forms
a) 2% Sodium fluoride:
4 applications /4week/year 40% reduction in
caries incidence (considered single application).
b) 8% Stannous fluoride:
One application /year 65% caries reduction.
Since it is unstable it prepared freshly for each application by
dissolving 0.8 gm. of stannous fluoride in 10 ml distilled water.
Disadvantages: 1-It has
a disagreeable astringent taste, 2-
Discolors decalcified enamel.
C) Acidulated phosphate fluoride:

One application /year 50-70% caries reduction.
It formed of a Combination of 1.23% sodium fluoride
with 0.1 M orthophosphoric acid. It is stable, so it does not have to
be prepared freshly not discolor decalcified enamel.
Procedure for applying fluoride topically
A.. Stannous fluoride.
1. A thorough prophylaxis should be performed
(cleaning and polishing with pumice and rubber cup). It is
preferable to add one drop of 8% stannous fluoride solution
to the polishing paste.
2. The teeth on one side are isolated with cotton roll
and dried with air.
3. An freshly prepared 8% stannous fluoride solution is
applied to all surfaces of the dried teeth with a cotton
applicator. The teeth are kept moist with the solution for 4
min. by applying it every 15 to 30 sec.
b) Acidulated phosphate fluoride:
The same technique as for stannous fluoride.
c) Sodium fluoride:
The same technique as before but
3 subsequent visits, usually one week apart,
the procedure is repeated with the exception that
prophylaxis is omitted. The teeth should be
treated every year. Sodium fluoride is stable.
It is useful for children whom difficult to apply

fluorides every year to treat the teeth at 3,7,10
and 13 years of age to insure that all the primary
teeth and most of the permanent ones receive
the beneficial effect of fluorides just after their
eruption.
d) Prophylactic paste:
Used in the
dental office every six months to
increase the fluoride content of enamel
and consequently, its caries resistance.
The most recently available are
stannous fluoride-zirconium silicate
paste and acidulated phosphate
fluoride-silicone dioxide paste.

3 Fluoride

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3 Fluoride

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Prevention of Dental Caries with

Food Most vegetables, fruits and dairy products

The required amount of fluoride will depend

Enamel is composed mainly of hydroxyapetite

C) Acidulated phosphate fluoride:

It is useful for children whom difficult to apply

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