7/28/2019 10 Fluoride 2
1/70
Preventive Dentistry(Lecture 10)
Other caries preventive factors
Dr Caroline Mohamed
1D Caroline Mohamed
7/28/2019 10 Fluoride 2
2/70
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
2D Caroline Mohamed
7/28/2019 10 Fluoride 2
3/70
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.
3D Caroline Mohamed
7/28/2019 10 Fluoride 2
4/70
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)
4D Caroline Mohamed
7/28/2019 10 Fluoride 2
5/70
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.
5D Caroline Mohamed
7/28/2019 10 Fluoride 2
6/70
From a cariostatic aspect, the most important
fluoride reservoirs are:
CaF2 and
fluoride bound to plaque bacteria.
6D Caroline Mohamed
7/28/2019 10 Fluoride 2
7/70
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).
D Caroline Mohamed 7
7/28/2019 10 Fluoride 2
8/70
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.
8D Caroline Mohamed
7/28/2019 10 Fluoride 2
9/70
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.
9D Caroline Mohamed
7/28/2019 10 Fluoride 2
10/70
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.
10D Caroline Mohamed
7/28/2019 10 Fluoride 2
11/70
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.
11D Caroline Mohamed
7/28/2019 10 Fluoride 2
12/70
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.
12D Caroline Mohamed
7/28/2019 10 Fluoride 2
13/70
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.
13D Caroline Mohamed
7/28/2019 10 Fluoride 2
14/70
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.
14D Caroline Mohamed
7/28/2019 10 Fluoride 2
15/70
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%).
15D Caroline Mohamed
7/28/2019 10 Fluoride 2
16/70
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.
7/28/2019 10 Fluoride 2
17/70
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
7/28/2019 10 Fluoride 2
18/70
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
7/28/2019 10 Fluoride 2
19/70
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
7/28/2019 10 Fluoride 2
20/70
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.
7/28/2019 10 Fluoride 2
21/70
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.
7/28/2019 10 Fluoride 2
22/70
7/28/2019 10 Fluoride 2
23/70
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.
7/28/2019 10 Fluoride 2
24/70
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
7/28/2019 10 Fluoride 2
25/70
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.
7/28/2019 10 Fluoride 2
26/70
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.
D Caroline Mohamed 26
7/28/2019 10 Fluoride 2
27/70
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
D Caroline Mohamed 27
7/28/2019 10 Fluoride 2
28/70
D Caroline Mohamed 28
American Dental Association. Fluoride and fluoridation. Available at:www.ada.org/public/topics/fluoride. Accessed June 20, 2007.
7/28/2019 10 Fluoride 2
29/70
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.
29D Caroline Mohamed
7/28/2019 10 Fluoride 2
30/70
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).
30D Caroline Mohamed
7/28/2019 10 Fluoride 2
31/70
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.
31D Caroline Mohamed
7/28/2019 10 Fluoride 2
32/70
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).
32D Caroline Mohamed
7/28/2019 10 Fluoride 2
33/70
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).
33D Caroline Mohamed
7/28/2019 10 Fluoride 2
34/70
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.).
34D Caroline Mohamed
7/28/2019 10 Fluoride 2
35/70
D Caroline Mohamed 35
7/28/2019 10 Fluoride 2
36/70
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
7/28/2019 10 Fluoride 2
37/70
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.
7/28/2019 10 Fluoride 2
38/70
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.
38D Caroline Mohamed
I i d
7/28/2019 10 Fluoride 2
39/70
Ionic compounds
39D Caroline Mohamed
7/28/2019 10 Fluoride 2
40/70
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
7/28/2019 10 Fluoride 2
41/70
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.
41D Caroline Mohamed
7/28/2019 10 Fluoride 2
42/70
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 .
D Caroline Mohamed 42
li f i l
7/28/2019 10 Fluoride 2
43/70
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.
43D Caroline Mohamed
7/28/2019 10 Fluoride 2
44/70
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)
44D Caroline Mohamed
7/28/2019 10 Fluoride 2
45/70
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
45D Caroline Mohamed
d fl d d d fl h h
7/28/2019 10 Fluoride 2
46/70
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.
46D Caroline Mohamed
7/28/2019 10 Fluoride 2
47/70
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).
47D Caroline Mohamed
7/28/2019 10 Fluoride 2
48/70
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.
48D Caroline Mohamed
The following measures may prolong fluoride
7/28/2019 10 Fluoride 2
49/70
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.
49D Caroline Mohamed
7/28/2019 10 Fluoride 2
50/70
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.
50D Caroline Mohamed
7/28/2019 10 Fluoride 2
51/70
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.
51D Caroline Mohamed
M th i
7/28/2019 10 Fluoride 2
52/70
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.
52D Caroline Mohamed
http://www.medicalproductslaboratories.com/images/naFrinse.jpg7/28/2019 10 Fluoride 2
53/70
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.
53D Caroline Mohamed
Artificial saliva
7/28/2019 10 Fluoride 2
54/70
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.
54D Caroline Mohamed
7/28/2019 10 Fluoride 2
55/70
55D Caroline Mohamed
Gels
7/28/2019 10 Fluoride 2
56/70
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.
56D Caroline Mohamed
Gels
7/28/2019 10 Fluoride 2
57/70
Gels
To improve the effect of the gels, the
recommended application time is 4 minutes ormore preferably applied in customized trays.
57D Caroline Mohamed
D li t f f i l t i l
7/28/2019 10 Fluoride 2
58/70
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%.
58D Caroline Mohamed
Th fl id d t l d
7/28/2019 10 Fluoride 2
59/70
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.
59D Caroline Mohamed
7/28/2019 10 Fluoride 2
60/70
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.
60D Caroline Mohamed
7/28/2019 10 Fluoride 2
61/70
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).
61D Caroline Mohamed
7/28/2019 10 Fluoride 2
62/70
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).
62D Caroline Mohamed
Fluoride gels
7/28/2019 10 Fluoride 2
63/70
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.
63D Caroline Mohamed
7/28/2019 10 Fluoride 2
64/70
Fluoride gel in disposable trays
64D Caroline Mohamed
7/28/2019 10 Fluoride 2
65/70
Prophylaxis pastes
They are used mainly for professional
mechanical tooth cleaning but also for
finishing and polishing and may contain
fluoride.
65D Caroline Mohamed
Semislow-release and slow-release fluoride
7/28/2019 10 Fluoride 2
66/70
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%.
66D Caroline Mohamed
7/28/2019 10 Fluoride 2
67/70
Fluoride varnish
67D Caroline Mohamed
https://decs.nhgl.med.navy.mil/DIS65/varnish.jpghttps://decs.nhgl.med.navy.mil/DIS65/varnish.jpg7/28/2019 10 Fluoride 2
68/70
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.
68D Caroline Mohamed
7/28/2019 10 Fluoride 2
69/70
Activity
Detail the techniques for fluoride gel
application and fluoride varnish application
and their indications.
D Caroline Mohamed 69
Thanks
7/28/2019 10 Fluoride 2
70/70
Thanks
It is not fun!