TOPICAL FLUORIDES

1
 CONTENT
 Introduction
 Topical fluoride mechanism of action
 Methods of application:
 Self applied
 Toothpaste

 Mouth washes

 Professional application
 Fluoride varnish

 Fluoride gel

 Literature review
 References

2
INTRODUCTION
Fluoride considered as Golden standard preventive agent.

fluoride has a direct topical influence on the dynamic mineralization- remineralization process that occurs under the plaque biofilm
that adheres to tooth enamel , cementum and dentin

They acts by promoting remineralization and, to a lesser degree, through antibacterial action.

Topical fluorides generally fall into two categories:

Self applied – e.g. toothpaste and mouth rinse, and salivary 3
Professionally applied – e.g. solutions, gels, foams and varnish,
fluoride slow release fluoride device.
 MECHANISM OF ACTION
1.Reduction in enamel demineralization.

2.Enhancement of remineralization.

3.Antibacterial effects

1. Featherstone JD. The caries balance: the basis for caries management by risk assessment. Oral Health Prev Dent. 2004;2 .
2. Cury JA, Tenuta LM. Enamel remineralization: controlling the caries disease or treating early caries lesions. Braz Oral Res. 2009;23. 4
3. Dijkman A, Huizinga E, Ruben J, Arends J. Remineralization of human enamel in situ after 3 months: the effect of not brushing versus the effect of an F
dentifrice and an F-free dentifrice. Caries Res. 1990;24.
4. Tenuta LM, Cury JA. Fluoride: its role in dentistry. Braz Oral Res. 2010;24.
 MECHANISM OF ACTION

Reduction in enamel demineralization:

• The interaction of fluoride with the mineral component of teeth produces a fluorohydroxyapatite (FHAP or FAP) mineral, by
substitution of OH- with F-. This results in increased hydrogen bonding, a more dense crystal lattice, and an overall decrease in
solubility.
• Thus, the surface may act more like FAP than HAP and have a different dissolution rate. When the enamel dissolves, it may
also contribute fluoride to the surrounding solution.
• Thus, both the concentration of fluoride (FHAP) at the crystal surfaces and the fluoride ion concentration in the liquid phase
during a cariogenic challenge are important.

Enhancement of remineralization:
• Partially dissolved enamel crystals (containing fluoride) act as a substrate for mineral deposition from the solution phase that
enables partial repair of the damaged crystals.
• The carious lesion occurs when the demineralization process outweighs the remineralization process, and net damage occurs.
• The remineralization process results in formation of a less soluble form of apatite. (compared to hydroxyapatite which makes
up enamel when first formed)

Antibacterial effects
• Interaction of fluoride with the enzyme enolase which could directly reduce the production of bacterial acids
• Decreases the amount of sugar entering the bacterial cell by limiting phosphoenolpyruvate
• Diffusion of fluoride into the cell occurs as hydrofluoric acid (HF) which then dissociates, lowering the intercellular pH and 5
disrupting the cell.

The overall effect is less acid and a less acidic environment that should reduce the driving force for dissolution.
 SELF APPLIED FLUORIDE:1.FLUORIDE
TOOTHPASTE.
Most commonly used form of self-applied fluoride.

Brushing with F toothpaste increases the fluoride concentration in saliva 100-1,000-fold this concentration returns to baseline levels
within 1 to 2 hours.1

Over the counter F concentration of 1,000 to 1,500 ppm. 2, 3,4

5,000 ppm fluoride as sodium fluoride. 2, 4

Active ingredients:
Sodium fluoride Sodium monofluorophosphate Stannous fluoride.3.4

Appropriate amount of toothpaste1 :

Children ˂ 3 year : rice grain size Children 3- 6 years : pea size
6
1. Recommendations for using fluoride to prevent and control dental caries in the United States. Centers for Disease Control and Prevention. MMWR Recomm Rep 2001;50(Rr-14):1-42.
2. Centers for Disease and Prevention. Other Fluoride Products. U.S. Department of Health and Human Services. Accessed July 15, 2021.
3. Adair SM. Evidence-based use of fluoride in contemporary pediatric dental practice. Pediatr Dent 2006;28(2):133-42; discussion 92-8.
4. Clark MB, Slayton RL. Fluoride use in caries prevention in the primary care setting. Pediatrics 2014;134(3):626-33.
 SELF APPLIED FLUORIDE: 2.FLUORIDE MOUTH RINSE OR GELS:

Daily or weekly use.

Over-the-counter solutions of (0.05% sodium fluoride [230 ppm fluoride]) for ˃ 6 years.1, 3, 4

Children ˂ 6 years are not recommended because of the risk of fluorosis. 2, 4

Higher strength (0.2% neutral sodium fluoride once a week) for individuals at high risk of decay. 1

Self-applied fluoride gel available by prescription as

• Sodium fluoride (1.1% [5,000 ppm] F)
• Stannous fluoride (0.15% [1,000 ppm]F )1,3

1. Centers for Disease and Prevention. Other fluoride products. U.S. Department of Health and Human Services. Accessed July 15, 2021.
2. 7 Rep
Recommendations for using fluoride to prevent and control dental caries in the United States. Centers for Disease Control and Prevention. MMWR Recomm
2001;50(Rr-14):1-42.
3. Adair SM. Evidence-based use of fluoride in contemporary pediatric dental practice. Pediatr Dent 2006;28(2):133-42; discussion 92-8.
4. Clark MB, Slayton RL. Fluoride use in caries prevention in the primary care setting. Pediatrics 2014;134(3):626-33.
 PROFESSIONALLY APPLIED 1.FLUORIDE GELS OR FOAMS.

Concentrated F than the self-applied fluorides (e.g., 1.23% fluoride ion [12,300 ppm]), not needed frequently.

Products available as:

• Acidulated phosphate fluoride (1.23% [12,300 ppm] fluoride) as GEL.

• Neutral sodium fluoride products (2% containing 9,000 ppm fluoride) as GEL.
• Sodium fluoride (0.9% [9,040 ppm] fluoride) as GEL or FOAM . 1,3

Fluoride gel is generally applied for 1 to 4 minutes. 1,3

Applications frequency, at 3- to 12-month intervals

Poses little risk for dental fluorosis, even among patients ˂ 6 years of age. 1,2

1.Centers for Disease and Prevention. Other fluoride products. U.S. Department of Health and Human Services. Accessed July 15, 2021.
2. Recommendations for using fluoride to prevent and control dental caries in the United States. Centers for Disease Control and Prevention. MMWR Recomm 8
Rep 2001;50(Rr-14):1-42.
3. Adair SM. Evidence-based use of fluoride in contemporary pediatric dental practice. Pediatr Dent 2006;28(2):133-42; discussion 92-8
 PROFESSIONALLY APPLIED 2.FLUORIDE VARNISH

Applied by painting technique directly onto the teeth and sets when it contact saliva. 1,2,3

It holds a high concentration of F in a small amount of material on teeth for several

hours.1

At least 2 applications per year.

Available as :

• Sodium fluoride (2.26% [22,600 ppm] fluoride).

• Difluorsilane (0.1% [1,000 ppm] fluoride). 1,2,3

9
1. Centers for Disease and Prevention. Other fluoride products. U.S. Department of Health and Human Services. Accessed July 15, 2021.
2. Adair SM. Evidence-based use of fluoride in contemporary pediatric dental practice. Pediatr Dent 2006;28(2):133-42; discussion 92-8.
3. Clark MB, Slayton RL. Fluoride use in caries prevention in the primary care setting. Pediatrics 2014;134(3):626-33.
 REVIEW OF LITERATURES
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 1. PREVENTIVE EFFECT OF HIGH-FLUORIDE
DENTIFRICE (5,000 PPM) IN CARIES-ACTIVE
ADOLESCENTS: A 2-YEAR CLINICAL TRIAL
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Aim:
• Evaluate a 5,000 ppm F compared to 1,450 ppm F dentifrice in caries-active adolescents disregarding their compliance and gender.

Subject and methods:

• Sample: 279,211 of which completed the trial
• Age (14 to 16 years)
• DMFS ≥ 5
• Single-blind randomized controlled trial
• Two groups:
• Even number → test group ,
• Odd number → control group.
• Low water fluoridation community (0.1 ppm)
• Test group →Duraphat 5,000 ppm F ,control group → Pepsodent Superfluor 1,450 ppm F both as NaF
• Use 1 g ( ≈ 2 cm),twice/day for 2 years, 12
A. Nordström D. Birkhed . Preventive Effect of High-Fluoride Dentifrice (5,000 ppm) in Caries-Active Adolescents: A 2-Year Clinical Trial. Caries Res
2010;44:323–331
 ..CONTINUE
scores
Dent caries level
 Subjects Later classified into:
 Subgroup A, excellent compliance,
Score 0 caries-free
 Subgroup B, poor compliance Score 1 lesion in the outer half of the enamel
 F varnish once a year,
 Clinical and radiographic examinations; Mesial of Score 2
lesion more than halfway through the enamel but not
2nd molar to Mesial of 1st premolar + Occlusal. passing the enamel-dentine junction
 Dental caries score:
score3 lesion with obvious spread in the outer half of the
dentine

score4 lesion with obvious spread in the inner half of the

dentine

score5 restored surface

score6 unreadable x-ray
score7 secondary caries

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RESULTS

Caries Incidence :
3.5

• Adolescents using the 5,000 ppm 3

toothpaste had significantly lower
2.5

NUMBER OF NEW DFS

caries incidence for compliance B
compared to those using the 1,450 ppm
toothpaste . 2
5000 PPM
1.5 1450PPM

1
Caries Progression :
0.5
• 5,000 ppm toothpaste had significantly
lower progression of caries compared 0 A B A+B A B A+B
to subjects using 1,450 ppm toothpaste, INCIDENCE
in both compliance A and B. PROGRESSION

caries progression for enamel lesions to dentine.

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RESULTS

With 5000ppm compliance B shows higher PF in both incidence and progression compared to compliance A

COMPLIANCE A COMPLIANCE B COMPLIANCE A+B

5000PPM 5000PPM 5000PPM
N=71 N=33 N=104

INCIDENCE 14% 42% 23%

PROGRESSION 38% 47% 40%

Treatment effect, expressed as Prevented Fraction (PF).

Gender Difference:
There is no significance differences between boys and girls, however compliance A had more girls while compliance B had
twice boys as girls.

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 CONCLUSION

Subjects using 5,000 ppm F toothpaste had significantly lower caries incidence compared to those using 1,450
ppm F toothpaste. This may indicate that 5,000 ppm F toothpaste has a greater impact on individuals who do not
use toothpaste regularly or do not brush twice a day.

Thus, 5,000 ppm F toothpaste appears to be an important vehicle for caries prevention and treatment of adolescents
with a high caries risk poor compliance.

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CRITICAL EVALUATION

Amount of toothpaste applied

technique of brushing/brushing time ?

post-brushing water rinsing?

Questioner bias

X-rays artifact

2 years study short time

Use of F.V may effect the result 17

 2. EFFECTIVENESS OF DIFFERENT
CONCENTRATIONS AND FREQUENCIES
OF SODIUM FLUORIDE MOUTH RINSE
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 Aim: Study group Frequency concentration
• compare the effectiveness of daily and weekly rinses at
concentrations of 0.02% and 0.09% fluoride ion. within
the same study population . 1 Group D.05 Rinsed 0.05% NaF
Daily

Material and methods: 2 Group D.2 Rinsed 0.2% NaF

Daily
• Subjects:2,014 student (12.5 years old).
• Water fluoride <0.3 ppm 3 Group W.05 Rinsed 0.05% NaF
Weekly
• Baseline examinations done by 2 examiners .
• rinses dispensed in 10 ml aliquots, and delivered to
4 Group W.2 Rinsed 0.2% NaF
classrooms. Weekly
• 1 min rinsing procedure was supervised by teachers.
• follow-up examinations after 2 years 5 Group C Rinsed 0.1% NaC1
Weekly (placebo)

19
M.L. Ringelberg, A.J. Conti, C.B. Ward, B. Clark, S. Lotzkar, .Effectiveness of different concentrations and frequencies of sodium fluoride mouth rinse, The
American Academy of Pedodontics/Vol. 4, No. 4
Findings:

Baseline mean DMFS shows

After 2 years, again significance Other groups showed no significance
significance difference in group W.2
difference was found in group W.2. difference .
compared to control.

Study group Baseline After 2 years

Mean DMFS

D.05 5.09 4.71

D.2 5.5 5.17

W.05 4.75 4.75

W.2* 4.46* 4.11*

C 5.16 4.93

Table 1: Mean baseline DMFS for all groups after two years.
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 Study group Mean DMFS increment % difference from control

D.05* 2.40 28.1

D.2 2.58 22.8

W.05 2.79 16.5

W.2 2.66 20.4

C 3.34

Table 2: compare Mean DMFS for multiple treatment groups after two years with control.

Group D.05 is statistically significant compared to control group by 28.1%.

Other groups shows no significant difference from control.

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 Study group Mean DFS increment % difference from control

D.05* 0.42 46.2*

D.2 0.67 14.1

W.05 0.52 33.3

W.2* 0.47 39.7*

C 0.78

Table 3 : shows the mean net increments on mesial and distal surfaces.

Both Group D.05 and W.2 show significant differences in DFS from the control

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 DMFS increment over 2 years by frequency DMFS increment over 2 years by concentration

Study group Mean DMFS increment % difference from control Study group Mean DMFS increment % difference from control

W* 2.72 18.6* 0.05 2.60 22.2*

D** 2.49 25.4** 0.2 2.62 21.6*

C 3.34 C 3.34

Both D and W frequency showed significant difference from control, but D shows higher significance from W.

While by concentration, both concentrations are showing almost similar significant difference from control.

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 CONCLUSION

From this study we can conclude that frequency of NaF has higher effectiveness compared to the concentrations which showed
almost similar results in both groups.

So when prescribing fluoride , there is no need to give higher concentrations with no remarkable benefits.

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 3. AN IN VITRO ASSESSMENT OF FLUORIDE
UPTAKE BY TOOTH ENAMEL FROM FOUR
DIFFERENT FLUORIDE DENTIFRICES
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 Introduction:

• Inorganic & organic F in toothpaste results in varied uptake of F on enamel

• Different influences on remineralisation

Material and Methods:

• 60 healthy extracted premolars

• Stored in deionised distilled water
• Covered with acid-resistant nail varnish
• 4X4 mm window left on buccal and lingual surfaces of crown
• Buccal window in each tooth served as experimental window (E)
• Lingual window as the control (C)
• Randomly divided into four groups
• 15 teeth in each group and a control group within

VH Patil, RT Anegundi. An in vitro assessment of fluoride uptake by tooth enamel from four different fluoride dentifrices. 26
Eur Arch Paediatr Dent (2014) 15:347–351.
Experimental groups
Teeth demineralised with solution containing lactic acid, calcium chloride, potassium dihydrogen
phosphate, NaOH for 2 days at 37ᵒ C in incubator

Lingual window covered with acid resistant nail varnish

Teeth then immersed in different dentifrice slurries and incubated at 37ᵒ C for 2 days corresponding to
2 years of tooth brushing twice daily for 2 min

Teeth washed with distilled water and dried

Acid biopsy technique used for F ion estimation

Samples etched for 60s in perchloric acid separately in the experimental window followed by control
window

Nail varnish removed from control window with acetone

Toothpaste Groups
Components Group A Group B Group C Group D

Fluoride Type Sodium fluoride Sodium monofluorophosphate Stannous fluoride Amine fluoride
dentifrice (NaF) dentifrice (NaMFP) dentifrice (SnF2) dentifrice (AmF)
Available Fluoride 1,000 mg/L 1,000 mg/L 1,000 mg/L 1,000 mg/L

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 Results
F uptake by tooth enamel was highest in samples treated with AmF toothpaste
slurry followed by SnF2, NaMFP and NaF slurries

Comparison of F uptake in mg/L between E and Control window among 4 groups

28
 Discussion

In two studies, F uptake by NaF This could be because NaF is

F uptake by demineralised toothpaste was higher than ionically bonded that is critical
surfaces in E windows higher NaMFP toothpaste and contrast for fluoride uptake as compared
VS respective controls with present study (To´th et al. to covalently bonded NaMFP
1998; Altenberger et al. 2010) toothpaste.

Uptake of F from AmF and

SnF2 (being acidic) is higher Organic material distribution is AmF being organic F led to
due to immersion of samples increased in demineralised highest F uptake and other F
prior to treatment with enamel dentifrices used are inorganic
toothpaste slurries

29
To´th Z, Gintner Z, Banoczy J. Effect of different fluoride-containing toothpastes on human dental enamel in vitro. Caries Res. 1998;32:275–6.
Altenberger MJ, Bernhart J, Schicha TD, Wrbas KT, Hellwig E. Comparison of in vitro fluoride uptake from whitening toothpastes and a conventional toothpaste in demineralised
enamel. Schweiz Monatsschr Zahnmed. 2010;120(1):104–8.
 Critical Evaluation

1.Variation in the initial F levels in human teeth

2.Why was enamel demineralised?

3.Title is misleading

4.F uptake on initial carious lesions – Better

5.No inclusion and exclusion criteria of extracted PreM mentioned

6.Amflor Toothpaste is indicated for children above 6 years only

7.Compared organic compound (AmF) VS inorganic compounds (SnF2, NaMFP and NaF)

8.AmF higher anti-cariogenic - two reasons: i) F & ii) Amine (organic) component

9.Antiplaque effect - Inhibit bacterial adhesion and tension-active property

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10.Allows F accumulation closer to tooth surface providing a sustained F release
 4.EVALUATION OF THE EFFECT OF FLUORIDE GEL
AND VARNISH ON THE DEMINERALIZATION
RESISTANCE OF ENAMEL: AN IN VITRO
31
 AIM

The study is to evaluate and compare the effectiveness of Fluoride Gel and
Varnish .

32
S. Tavassoli-Hojjati , R. Haghgoo , M. Mehran, A. Niktash. Evaluation of The Effect of Fluoride Gel and Varnish on The Demineralization Resistance of
Enamel: An in Vitro. Journal of Islamic Dental Association of IRAN (JIDAI) / Spring 2012 /24 /(2)
MATERIALS AND METHOD

Sample size: 60 sound extracted premolars

• Control group: washed with deionized/ distilled water.

• Gel (Kimia): APF gel (1/23%)
Groups • Gel (Sultan): APF gel (1/23%)
• Varnish fluoride: Durashield (2/26%).

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EXPERIMENTAL GROUPS

4×2 mm window was placed horizontally by paper sticker on the buccal surface of the tooth and the remainder of the
tooth surface was covered by nail polish

• control group: washed with deionized/ distilled water.

Specimens divided into 4 groups (15 • Weekly gel (Kimia): treated with APF gel (1/23%) for 2 minutes weekly.
each) • weekly gel (Sultan): treated with APF gel (1/23%) for 60 seconds weekly.
• weekly varnish fluoride: treated with Durashield (2/26%).

Specimens placed in a cycle of demineralization (pH= 4.3) for 6 hours and remineralization (pH= 7) for 17 hours.
(repeated for 3 weeks).

The teeth were sectioned bucco-lingually and evaluated under polarized light microscope. The depth of each lesion was 34
measured from the deepest demineralization point of the lesion.
 Results and discussion
After examining all specimen under microscope the minimum demineralization depth of all specimen treated with fluoride (regardless
the methods) shows zero penetrations.

The lowest mean depth was found in Fluoride varnish compared to all other groups.

The difference between the control group and the test groups was statistically significant

Group Number Minimum Maximum Mean Decrease percentage

Fluoride varnish 15 0 100 34.66 75.3

Kimia fluoride gel 15 0 200 60 57.2

Sultan fluoride gel 15 0 120 45.33 67.7

Control 15 100 200 140 0

Table; The mean and decrease percentage of demineralization depth

35
Conclusion

Regardless the type of fluoride used all showed noticeable

protection against enamel demineralization .

Fluoride varnish has slightly less demineralization depth

compared to fluoride gel.

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CRITICAL EVALUATION
In vitro ,the demineralization remineralization don’t mimic actual oral ph, oral temperature or dietary type.

Samples from different individuals with no known history of previous fluoride concentration.

The effect of F on plaque neglected (reservoir)

Bacterial adhesion

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 5.EFFECTIVENESS OF FLUORIDE VARNISH
ON CARIES IN THE FIRST MOLARS OF
PRIMARY SCHOOLCHILDREN
38

Shanshan Wu, Tingting Zhang, Qiulin Liu, Xueting Yu, Xiaojuan Zeng. Effectiveness of fluoride varnish on caries in the first molarsof primary
schoolchildren: a 3-year longitudinal study inGuangxi Province, China. International Dental Journal 2020; 70: 108–115
 • Effectiveness of F.V in preventing decay in P&F in patients not indicated
Aim for pit and fissure sealants.

• The 1st permanent molar is the first permanent tooth to erupt with higher
rate of dental caries compared to all other teeth due to deep P & F and
poor O.H in children.
• P & F sealant is more effective against pits and grooves but due to
Introduction difficulty in moisture control it is difficult to apply on newly erupted first
molars.
• Therefore fluoride varnish is indicated in these individuals.
39
 MATERIALS AND METHODS
• Sample size: 1000 in each group (control and varnish)
• Type of study: randomized clinical trials.
Sampling: • Study period: 3 years.
• Exclusion: Children with systemic diseases, a long history of medication use and a history of
allergies

The experimental group received oral health education and topical application of 5% sodium fluoride varnish to their first permanent
molars twice a year, while the control group only received oral health education twice a year

After brushing, the teeth were dried with cotton rolls, and 0.4 ml of fluoride varnish was applied to all the surfaces of the first molars.

Post application instructions were given to the group who received fluoride varnish.

Oral health education (diet and hygiene) given for both groups.

40
Dental examination conducted at baseline and 3 years later on permanent first molars.
The caries status of each surface of the first permanent molars was recorded according to the
modified International Caries Detection and Assessment System II (ICDAS-II)

ICDAS-II Modified ICDAS-II

Code Definition Code Definition

0 Sound 0 Sound

1 1st visual change in enamel 1 Enamel decay

2 Distinct visual change in enamel 2 Dentin decay

3 Localized enamel breakdown 3 Dentin decay close to pulp

4 Underlying dark shadow from dentin 4 Filled, sound

5 Distinct cavity with visible dentin 5 Missing due to caries

6 Extensive distinct cavity with visible dentin 6 Sealed

7 Unerupted
41
8 Unrecorded
STATISTICAL ANALYSIS

Sound surfaces at baseline • enamel decay ND01

that developed decay after • dentine decay ND02
3 years, were classified • dentine decay close to the pulp ND03
as:

42
 RESULTS
A total of 1,748 children were assessed after 3 years, and their results were included in the statistical
analysis

However, after 3 years of intervention, the prevalence of caries and DMFT and DMFS scores in the
experimental group were significantly lower than those in the control group

The incidence of caries in the two groups (experimental and control) was 34.8% and 42.1%, respectively,
and the difference was statistically significant
Year Study group Prevalence Incidence
2014 Experimental (853) 24.0 (205) _
Control (895) 23.4 (209) _
2017 Experimental (853) 58.9 (502)* 34.8 (297)*
Control (895) 65.5 (586) 42.1 (377) 43
The results shows less caries progression in all types of decay in Experimental group compared to control.

Hence the difference between the two groups are statistically significant.

Variable Type of decay

ND01* ND02* ND03*

Experimental 4.4% 0.7% 1.4%

Control 5.1% 1.0% 1.7%

Decay in tooth surfaces after intervention

44
 INCIDENCE OF CARIES
Site of caries

variable Fissure * Proximal Maxillary FPM* Mandibular FPM*

Experimental 10.9% 1.9% 18.9% 27.4%

Control 14.1% 2.0% 22.5% 35.5%

There was significant differences in caries development between group received F.V and control group with regard to
pit & fissures, proximal, maxilary & mandibular 1 st permanent molar.

There was no significant differences with regard to proximal caries which indicates that the varnish was not delivered
to this surface.
45
CONCLUSION
Use of 5% F.V twice/year was effective in reducing the incidence of caries in pit and fissures and is effective alternate
strategy when fissure sealant are not applicable.

Its cost effective

F.V was effective in reducing caries progression and incidence in both mandibular and max molar 1 st molar in all
surfaces but proximal which could be due to defective method of fluoride varnish delivery

46
CRITICAL EVALUATION
Un ethical.

Not blind experiment. (more favorable outcomes)

Control .G No placebo

Students dietary habits.

Brushing & oral hygiene care ?

Method of fluoride delivery.

47
Variation in 1st molar eruption time
REFERENCES

1. Recommendations for using fluoride to prevent and control dental caries in the United States. Centers for Disease Control and Prevention. MMWR Recomm Rep
2001;50(Rr-14):1-42.
2. Centers for Disease and Prevention. Other Fluoride Products. U.S. Department of Health and Human Services. Accessed July 15, 2021.
3. Adair SM. Evidence-based use of fluoride in contemporary pediatric dental practice. Pediatr Dent 2006;28(2):133-42; discussion 92-8.
4. Clark MB, Slayton RL. Fluoride use in caries prevention in the primary care setting. Pediatrics 2014;134(3):626-33.
5. Featherstone JD. The caries balance: the basis for caries management by risk assessment. Oral Health Prev Dent. 2004;2 .
6. Cury JA, Tenuta LM. Enamel remineralization: controlling the caries disease or treating early caries lesions. Braz Oral Res. 2009;23.
7. Dijkman A, Huizinga E, Ruben J, Arends J. Remineralization of human enamel in situ after 3 months: the effect of not brushing versus the effect of an F dentifrice and an F-
free dentifrice. Caries Res. 1990;24.
8. Tenuta LM, Cury JA. Fluoride: its role in dentistry. Braz Oral Res. 2010;24.
9. A. Nordström D. Birkhed . Preventive Effect of High-Fluoride Dentifrice (5,000 ppm) in Caries-Active Adolescents: A 2-Year Clinical Trial. Caries Res 2010;44:323–331 .
10. M.L. Ringelberg, A.J. Conti, C.B. Ward, B. Clark, S. Lotzkar, .Effectiveness of different concentrations and frequencies of sodium fluoride mouth rinse, The American
Academy of Pedodontics/Vol. 4, No. 4 .
11. VH Patil, RT Anegundi. An in vitro assessment of fluoride uptake by tooth enamel from four different fluoride dentifrices. Eur Arch Paediatr Dent (2014)
15:347–351.
12. S. Tavassoli-Hojjati , R. Haghgoo , M. Mehran, A. Niktash. Evaluation of The Effect of Fluoride Gel and Varnish on The Demineralization Resistance of Enamel: An in Vitro.
Journal of Islamic Dental Association of IRAN (JIDAI) / Spring 2012 /24 /(2).
13. Shanshan Wu, Tingting Zhang, Qiulin Liu, Xueting Yu, Xiaojuan Zeng. Effectiveness of fluoride varnish on caries in the first molarsof primary schoolchildren: a 3-year
longitudinal study inGuangxi Province, China. International Dental Journal 2020; 70: 108–115

48