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Preventive Dentistry(Lecture 10)

Other caries preventive factors

Dr Caroline Mohamed

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Outline of lectures

OTHER CARIES-PREVENTIVE FACTORS

FluoridesTopically applied fluoride

Systemically administered fluoride

Fluorides agents and compounds for topical use

Delivery systems for topical self-application of fluoride

Other oral hygiene aids

Delivery systems for professional topical application of

fluorides

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Topical Applied Fluoride

The posteruptive cariostatic effects of fluoride arecorrelated with :

fluoride concentration as well as with

total exposure time.The latter is also influenced by the "substantivity" of

fluoride in the oral cavity.

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Fluoride clearance fases.

First within 1 hour.

The analysis of saliva after a single application of a fluoridedentifrice or mouthwash shows that much of the retained fluoride

is cleared from the mouth within 1 hour.

Secondary clearance phase of 2 hours or more. The salivary fluoride concentration decreases more slowly.

The initial rapid clearance phase is the result ofsalivary washout

and the second phase is initiated by the release into saliva

of fluoride initially retained in oral reservoirs.(Duckworth et al, 1991, 1994)

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Potential reservoirs are:

the teeth,

the plaque,

the soft tissues of the

gingiva,

the tongue, the cheeks, and

stagnation zones between

the teeth, under the

tongue, and in the buccal

sulcus.

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From a cariostatic aspect, the most important

fluoride reservoirs are:

CaF2 and

fluoride bound to plaque bacteria.

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The most important effects of posteruptive (topical) use of

fluoride are:

the inhibition of demineralization and

enhancement of remineralization.

Fluoride exerts physiochemical effects in:

the oral fluids, such as the interrod and intercrystalline

fluid, pellicle fluid, plaque fluid, and saliva,

bound in CaF2, FA, and FHA (fluorohydroxyapatite).

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Fluoride also:

reduces acid formation in the dental plaque,

may reduce plaque formation rate and plaque adhesion,

and

may change the ecology of the plaque microflora.

Of these effects, the most important is the reduction of acid

formation.

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The fall in plaque pH following sucrose exposure is reduced when

plaque fluoride content has been enhanced by repeated topical

treatment.

Fluoride alone is inadequate to completely arrest caries processbecause its cariostatic effect is limited.

If plaque pH falls below about 4.5 , the plaque fluid becomes

undersaturated with respect to fluorapatite, and

demineralization will occur, regardless of the presence offluoride.

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Systemically administered fluoride

The cariostatic effect of fluoride is almost 100%

posteruptive (topical effect).

Fluoride has been systemically administered in:

drinking water,

salt,milk,

tablets,

lozenges,chewing gums,

drops.

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Different concentrations ofsodium fluoride have been used

in these delivery systems.

Fluoridated drinking water is the most cost-effective public

health measure for prevention and control of caries and

remineralization of early enamel caries.

This is due to the fact that most people drink water several

times a day with even those without regular dental care andregular use of fluoride toothpaste benefit from water

fluoridation.

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Water fluoridation should therefore be recommended in all

populations in which there is a relatively high caries prevalence,

poor oral hygiene, and a lack of organized preventive programs or

daily use of fluoride toothpaste. The recommended fluoride concentration in temperate climates,

is 0.7 to 1.2 mg of F/L, but in warm to hot subtropical and tropical

regions, only 0.5 to 0.7 mg of F/L is recommended, to prevent the

development of esthetically unacceptable fluorosis.

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Results from early studies with fluoridated watershowed about 50% caries reduction in the permanent

dentition and 40% in the primary dentition, compared tocontrol areas. Significant reductions in root caries were also

seen (Murray et al 1991).

At that time, caries prevalence was high in the United Statesand in Europe, where the studies were run, and few topical

agentssuch as toothpaste and mouthrinses were available.

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Nowadays, the supplementary effect of fluoridateddrinking water would be only 5% to 25% in most European

countries and the USA, because of improved oral hygieneand daily use of fluoride toothpaste and other topical

fluoride agents, which have resulted in very significant

reductions in both caries prevalence and incidence.

However, in regions with relatively high

caries prevalence, limited dental resources,

and no daily use of fluoride toothpaste,

water fluoridation should still achieve about

50% caries reduction.

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However, only about 3% of the world population has access to

fluoridated drinking water, mostly in the USA, where caries

prevalence is low and almost 100% of the population usefluoride toothpaste and other topical fluoride agents daily.

The use of the other fluoride delivery systems in the world is

marginal (salt, 0.6%; tablets, etc 0.3%).

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Prevalence of dental fluorosis an increase in the prevalence of dental fluorosis has

been noticed.

The increase is in the mild and very mild forms of

fluorosis, and is proportionally greater in non-fluoridated areas than in fluoridated areas.

This is because of the increase in the mean fluoride

intake from all sources since the 1940s.

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Some of the reasons that were postulated for

the increase in the prevalence of fluorosis widespread use of fluoride in both

fluoridated and non-fluoridated

communities.

Foods and beverages may be processed in

fluoridated communities but are shipped,

sold, and consumed in non-fluoridated

communities.

Hallo effect

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Worldwide distribution Endemic in 22 countries

in Asia, India and China are worst affected

Mexico in North and Argentina in Latin America

East and North Africa are also endemic

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Risk factors The most important risk factor in determining

fluorosis occurrence and severity is the total

amount of fluoride consumed from all sources

during the critical period of tooth development. Demographic risk factors:

Age: fluorosis is related to the ingestion of F

during critical period of tooth development. SES : fluoride intake from tooth paste and infant

formula can vary by SES status

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Optimal levels of fluoride

drinking water It was accepted that optimal level of fluoride in

drinking water was 1PPM.

With other sources of fluoride now days this level

become 0.5 to 1 ppm according to the community. Waters with high levels of fluoride content are

mostly found at the foot of high mountains and in

areas where the sea has made geological deposits.

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Known fluoride belts on land include:

one that stretches from Syria through Jordan,

Egypt, Libya, Algeria, Sudan and Kenya,

and another that stretches from Turkey

through Iraq, Iran, Afghanistan, India,

northern Thailand and China.

There are similar belts in the Americas and

Japan. In these areas fluorosis has been

reported.

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Fluoride dietary supplement Was used in non

fluoridated areas

There is strong evidence

that fluoridesupplements are risk

factor to mild to

moderate fluorosis.

The risk is high in

fluoridated areas.

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Early use of fluoride tooth paste Young children in whom

the swallowing reflex is

not fully developed can

ingest up to 0.3

o,5mgF at each brushing.

The risk is not as high as

fluoride supplement

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Infant formula: B/C its own F content and especially

because it is mixed with fluoridated water.

Other factors that have been associated with

susceptibility of populations to dental fluorosis are

altitude, renal insufficiency, and possibly

malnutrition.

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Dietary supplements

Fluoride dietary supplements were first introduced in the

late 40s and were intended as a substitute for fluoridatedwater for children in non-fluoridated areas.

Supplements contain fluoride from 0.25 , 0.5 to 1.0 mg

usually as sodium fluoride or calcium fluoride, acidulated

phosphate fluoride or potassium fluoride. The original pills have been joined by chewable tablets and

lozenges.

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Animals experiments shown that fluoride given once a day is

more likely to cause fluoroses than the same ammount of

fluoride given intermittently.

In Europe, it is recommended that a dose of 0.5 mg F/day

should be prescribed only to children living in areas

with water supplies containing less than 0.3 ppm F,

who are considered to be high risk, after a dietanalyses, starting only at age of 3 years.

THE FLUORIDE SUPPLEMENT HAS NO PLACE IN PUBLIC

HEALTH

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American Dental Association. Fluoride and fluoridation. Available at:www.ada.org/public/topics/fluoride. Accessed June 20, 2007.

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The aim of using fluoride tablets is to achieve a supplementary

posteruptive cariostatic effect similar to that provided by other

topical fluoride agents, such as toothpaste.

Therefore, slow release lozenges should be recommended

because of the prolonged fluoride clearance time in the oral

fluids.

An optimal effect should be achieved if the lozenges are used as a

"dessert" directly after meals, particularly in adults with reduced

salivary secretion rates.

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For very caries-susceptible patients fluoride chewing

gum should be the preferred systemic agent, to be

used for 15 minutes directly after every meal. It is recommended primarily for caries-susceptible adults

with reduced salivary secretion rates and for caries-

susceptible children and young adults, especially during the

eruption of molars (5.5 to 7 years and 11.5 to 13 years).

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Fluoride agents and compounds for topical use

The caries-preventive effect of most topical fluoridemeasures to range between 20% and 40%.

Topical fluoride agents are available for selfcare or

professional application (eg, by dentists, dental hygienist or

dental assistant).

For selfcare, the fluoride agents can be used: toothpastes;

toothpicks, dental tape, and dental floss; mouthrinses; gels,

artificial saliva, lozenges, and chewing gum.

Professionally applied fluoride agents are paints; gels;

prophylaxis pastes; varnish, glass-ionomer cement (GC), and

other slow release agents.

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Toothpastes

The cariostatic effect of fluoride toothpastes wasrecognized more than 40 years ago.

More than 90% of toothpastes in the industrializedcountries contain fluoride (WHO 1994).

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Fluoride toothpaste is by far the most frequently used topical

fluoride agent, used by 450 million people (WHO 1994).

Only 20 million people use mouthrinses or tablets, while 20

million receive professional applications of fluoride (WHO

1994).

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The main functions of toothpastes are to

facilitate mechanical plaque removal by

brushing and to serve as vehicles for activeagents (fluorides, chemical plaque control

agents, anticalculus agents, etc.).

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Fluoride

1. Twetman S, et al. Acta Odontologica Scandinavica 2003;61;6:347-355.2. Volpe AR, et al. Am J Dent. 1993;6:S13-S42.3. Sullivan RJ, et al. J Clin Dent. 1995;6:135-138.

The use of fluoridedentifrices has reduced theincidence of caries by 9.7%24.9%1

Sodium fluoride (NaF) andsodiummonofluorophosphate (MFP) are the mostcommon sources of fluoride

in dentifrices

These can be used aloneor in combination

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Fluoride formulation factors

and mode of action Not all fluoride toothpastes are

the same

Different fluoride source,

pH and choice of

formulation can affect

fluoride uptake1,2

Fluoride needs to be deposited

and slowly released to be

effective following brushing3

The amount of fluoride

released into saliva andadsorbed by enamel

during the period after

brushing

is critical1. Friberger P. Scand J Dent Res 1975:83;339-344.2. White DJ, et al. Caries Res 1986;20:332-336.3. ten Cate JM. Eur J Oral Sci 1997;105:461-465.

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Many different fluoride compounds are used in agentsfor self-care and professional application. The threemain categories are:

1. Inorganic compounds, including NaF, stannous fluoride(SnF2), ammonium fluoride (NH4F) etc.

The salts are readily soluble, providing free fluoride.

2. Monofluorophosphate-containing compounds, such assodium monofluorophosphate (Na2FPO4): The fluoride iscovalently bound in the FPO3

2- ion and apparently requireshydrolysis to free the F-.

3. Organic fluorides,such as amine fluoride, and silanefluorides.

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Ionic compounds

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Factors that influence fluoride delivery

Fluoride source(NaF, MFP, stannous fluoride)

For example, MFP requires activation by

hydrolysis by salivary phosphatase to release

active F-

Fluoride concentration in formulation

Formulation properties

pH will drive different fluoride modes of action

Ingredients such as divalent cations (eg, Ca2+)

can reduce the amount of available fluoride

Ingredients such as high levels of phosphates

can reduce fluoride uptake

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Sometimes two or more of the above compounds arecombined in the same topical fluoride agent.

The fluoride concentration in agents for self-care, such astoothpastes and mouthrinses, varies from 0.012% to 0.15%

fluoride, while up to 1 % fluoride is usedin gels.

The fluoride concentration in agents for professionalapplication is usually much higher, ranging from about 0.7%

to 6.0%, which, as discussed earlier, will promote

precipitation ofCaF2 reservoirs.

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Fluorides mouthwashes

Stannous Fluoride- antiplaque properties

Sodium Fluoride

The stannous ion, not the fluoride, which is

responsible for antimicrobial effect. Mechanism of action:

Tin from the stannous ion enters the cell, impairsthe metabolism and effect the growth andadherence properties of bacteria. Weekantiplaque activity .

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li f i l

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Delivery systems for topical

self-application of fluorides

The following topical fluoride agents are available forself-care:

toothpastes;

toothpicks,

dental floss, and dental tape;

mouth rinses;

gels;

artificial saliva;lozenges; and

chewing gum.

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The following fluoride compounds are used in

toothpastes:

l. Inorganic fluorides

a. Sodium fluoride (NaF)

b. Sodium monofluorophosphate (Na2FPO3)

c. Stannous fluoride (SnF2)

d. Potassium fluoride (KF)

e. Aluminum fluoride (AlF3)

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2. Organic fluorides

a. Amine fluoride (Hetaflur)

b. Amine fluoride (Olaflur)

3. Combinations of fluorides

a. Sodium fluoride + sodiummonofluorophosphate

b. Amine fluoride + Stannous fluoride

c. Amine fluoride + Sodium fluoride

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Sodium fluoride and sodium monofluorophosphate

are by far the most common, followed by stannous

fluoride and amine fluoride.

Almost all the NaF, SnF2, and amine fluoride in

toothpastes will be dissolved in the mouth during

brushing, releasing optimal amounts of free F-

ions.

On the other hand Na2 FPO3 initially releases fewer

free F- ions, but also supplies FPO32- ions which

within about 1 hour are broken by phosphateenzymes in the mouth, releasing F- ions.

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From 1955 to 1985 the standard fluoride

concentration in toothpastes was about 1,000

ppm of fluoride (0.1% F=1 mg F/g toothpaste),supplied as 0.2% Na F, 0.76% Na2FPO3, SMFP

and 0.4% SnF2.

The average caries reduction achieved in

various 2- to 3-year clinical studies was about

25% to 30% (Johnson,1993; Volpe et al, 1993).

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The cariostatic elfects of fluoride toothpastes are alsorelated to accessibility and fluoride clearance in the oralfluids.

Accessibility may be improved by:

1. Frequent mechanical removal of dental plaque,particularly on the approximal surfaces of the posteriorteeth.

2. Deliberate application of fluoride toothpaste to theposterior interdental spaces before approximalcleaning.

3. Thorough swishing with the remaining toothpaste

slurry after cleaning, followed only by one brief rinsewith water.

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The following measures may prolong fluoride

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The following measures may prolong fluoride

clearance time from the oral fluids:

1. Using as high a fluoride concentration as possible.

2. Increasing the daily frequency of fluoride toothpaste.3. Using the toothpaste technique recommended above.

4. Filling the posterior interdental spaces with fluoride

toothpaste after cleaning at bedtime.

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Toothpastes containing fluoride as well as chemical plaque

control agents should be recommended, particularly to

caries-susceptible patients with high plaque formation rates

(Plaque Formation Rate Index score 4 to 5, periodontitis, orgingivitis. )

Toothpastes containing SnF2 or amine fluoridealso have documented antiplaque effects.

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Other oral hygiene aids

Oral hygiene aids that not only mechanically remove plaque but

also at the same time, release fluoride to the most caries

susceptible tooth surfaces in the dentition, the approximal

surfaces of the posterior teeth, would be most appropriate.

Several brands of fluoridated toothpicks (TePe, Butler, Elmex,

Jordan, etc) and dental tape and floss (Johnson & Johnson, Oral-

B, Butler, Elmex,Jordan, etc) have been introduced

commercially.

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Mouthrinses

Weekly school-based mouthrinsing with 10-mL neutral 0.2% NaF

solutions for 1 minute are still very cost effective for caries controlin regions where water fluoride concentration is low, for

populations with high prevalence of caries, poor oral hygiene and

no daily use of fluoride toothpaste.

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Rinsing with 10 ml of fluoride solution (0.025% F) for 1 minute

after every tooth cleaning procedure is an efficient

supplement for caries control in caries-susceptible patients. Fluoride mouthrinses containing chemical plaque control

agents (triclosan + copolymer+ sodium lauryl sulfate [Colgate

Total], chlorhexidine, amine fluoride + SnF2 [Meridol], etc)

should have a greater cariostatic effect than pure neutral NaF

solutions.

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Artificial saliva

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Artificial salivaFor patients with dry mouth (xerostomia), artificial saliva

containing NaF is available to improve physical and subjective

symptoms and reduce the risk of rampant caries in theseextremely high-risk patients.

However, in these patients, meticulous mechanical and chemical

plaque control and combination of the most efficient fluorideagents are also essential.

Fluoridated artificial spray is formulated either as a gel or as a

spray; patient acceptance is generally higher for the spray,which is usually applied 20 to 30 times a day.

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Gels

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GelsThe effect of fluoride gels is related to the concentration, time

of application, accessibility, and other factors.

Most commercial fluoride gels for daily use by self-care contain

about 0.5% fluoride in the form of neutral NaF, acidulated

phosphate fluoride, SnF2 or amine fluoride plus NaF. The last

two also have documented anti plaque effects.

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Gels

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Gels

To improve the effect of the gels, the

recommended application time is 4 minutes ormore preferably applied in customized trays.

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Delivery systems for professional topical

application of fluorides

The following systems are available for professional application:

fluoride solutions for painting gels,

prophylaxis pastes, and

slow-release agents, such as varnishes and glass-ionomer

cements.

The fluoride concentration in agents for professional use ranges

from 1% to 8%.

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The fluoride compounds most commonly usedprofessionally are neutral NaF, acidulatedphoshate fluoride,and SnF2 .

Amine fluoride and silane fluoride are also insome commercial products.

For optimal accessibility, plaque must beremoved by professional mechanical tooth

cleaning before the fluoride agent is appliedto the tooth surfaces at greatest risk.

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Professionally applied fluoride agents are

recommended for public health programs for.

1. for areas with relatively homogenous high-risk

prevalence, fluoride-deficient drinking water and lack

of fluoride toothpaste, but personnel resources

available for a school-based preventive program;

2. in special risk groups such as the mentally

handicapped or elderly people with reduced salivaryflow, exposed root surfaces and heavily restored

dentitions; and in people with senile dementia.

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From a cost-effectiveness aspect

professionally applied fluoride agents arealso justified as a public health measure for

specific groups of children, during eruption

of the first and second molars (5 to 7 year

olds and 11 to 13 year olds).

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Fluoride solutions for painting

The most common fluoride solutions forpainting are neutral 2% NaF (1% F), 8% SnF2

(2% F) and acidulated phosphate fluoride

(1.23% F).

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Fluoride gels

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g

Fluoride gels for professional use contain a similarassortment of fluoride compounds as gels for self-care

(neutral NaF, acidulated phosphate fluoride, SnF2,amine fluoride plus NaF).

For optimal accessibility, plaque must he removed byprofessionally by mechanical tooth cleaning, the gel

syringed into the posterior interproximal spaces,followed by gel application in a customized tray formore than 4 minutes.

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Fluoride gel in disposable trays

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Prophylaxis pastes

They are used mainly for professional

mechanical tooth cleaning but also for

finishing and polishing and may contain

fluoride.

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Semislow-release and slow-release fluoride

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agents

These are such as fluoride varnishes, glassionomercements.

Examples offluoride varnishes are:

Duraphat (5% NaF; 2.3% F), Fluor Protector (silan

fluoride; 0.1% F) and Bifluorid 12 (6% NaF + 6% CaF2;about 6% F).

Based on clinical studies, the caries reduction achieved

by fluoride varnishes ranges from 20% to 70%.

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Fluoride varnish

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It is recommended that the initial varnish application be

repeated 3 times within 7-10 days in patients with caries

risk, to heal gingivitis, thereby reducing the plaque formation

rate, and to arrest enamel caries by sealing the outermicropore surface as soon as possible.

Thereafter the varnish should be reapplied at needs related

intervals, 2-4 times/year.

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Activity

Detail the techniques for fluoride gel

application and fluoride varnish application

and their indications.

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Thanks

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Thanks

It is not fun!