2/19/2016
Fluoride A Dental Wonder Drug
2
History Of Fluoride and Dentistry
What Is Fluoride?
• 1900’s‐ Dr. McKay saw this condition in some of his patients • Residents called it Colorado Brown Stain; He called “mottled enamel” • Dr McKay noted these patients had less tooth decay • 1930’s Churchhill discovered CBS caused from fluoride • 1930’s Dr. Dean did studies & discovered 1 PPM in water prevented caries but did not cause fluorosis
The anion of fluorine, an element of the halogen family Chemical symbol of F‐ F F F is everywhere in nature, including ground water‐ naturally occurring even in air, soil, plants 2
3
History
4
How much is 1ppm?
• 1930’s – fluoride in water recognized as etiology by Churchill, Colorado brown stain became fluorosis
One drop in a bathtub full of water (16 gallons)
• 1930’s ‐ Dr. Dean conducted epidemiological studies and discovered 1 ppm of fluoride in water prevented caries but did not cause objectionable fluorosis
Mathematically it is 1/1,000,000 or .000001 5
6
1
2/19/2016
What is “Fluorosis”? • First signs are called “white spots” or “enamel opacities” • Form of enamel hypoplasia • They start to appear when water contains 2 ppm or person is getting fluoride from multiple sources • 2ppm or higher of fluoride disrupts ameloblast activity • Approx. 20% of school age children have fluorosis
Can be slight to severe
Can develop when excess fluoride is ingested during the years the teeth are developingonly through systemic fluoride! Most susceptible 22 months- 9 years
When did ingestion occur? Critical period 1-4 years old
7
8
History of Fluoride History • 1945 – fluoride added to water supply of Grand Rapids, MI. DMFT rates fell by 55% • 1946 – studies began on use of topical fluorides applied in dental offices • 1947 ‐ other cities become fluoridated • 1954 – experimental results published on adding stannous fluoride to dentifrices
• 1956 – Study showed the cost of dental care for kids in Newburgh, NY (fluoridated) less than ½ of cost for kids in Kingston, NY (nonfluoridated) • 1967 –First dentifrice containing fluoride gets ADA Seal of Approval (Crest)
9
10
History • By 1980, 98% of dentifrices contained fluoride • Numerous methods for delivering fluoride were available • By 1990’s studies showed water fluoridation prevented less decay because: – Dilution – Less cavities to prevent, so percent down – Diffusion–Benefits of fluoride reach nonfluoridated areas
11
12
2
2/19/2016
Methods of Fluoridation • Topical‐ direct contact of fluoride with exposed tooth surface
• Systemic‐
Topical Fluoride
entry of fluoride into the blood supply of developing teeth (ingested)
13
14
Other Post Eruptive (topical) Sources of Fluoride
Types of Topical Fluoride APF‐ Acidulated Phosphate Fluoride NaF‐ Sodium Fluoride SnF2‐ Stannous Fluoride MFP‐ Monofluorophosphate
• • • • • • •
Fluoridated water Dentifrices Home use Rinses (Prescription and OTC) Home use Gels (prescription and OTC) Prophy pastes Floss Varnishes
15
16
In Office F‐ Applications
Methods of Delivery
• Two forms used primarily – Sodium fluoride – NaF – Acidulated phosphate fluoride – APF
• Professionally applied
• Stannous sometimes given in combination with APF (as rinse‐ out dated)
• Self‐ applied
17
18
3
2/19/2016
Indications for Professional Application
In Office F‐ Applications • Application methods
• APF for children and young adults‐ Newly erupted teeth *Critical to apply topical fluoride during the enamel maturation period when the fluoride is rapidly absorbed into the enamel
– paint on solution (varnish) – tray
• Exposed root surfaces to prevent root caries
**side noteFluoride can also be used as a chemotherapeutic agent in subgingival irrigation as an antimicrobial agent (primarily- Stannous 1.64%) for perio debridement pts. 19
20
Indications for Professional Application
Indications for Professional Application
• Compromised immune system
• • • • •
Orthodontic appliances, over dentures, or implants (neutral only) Lots of past restorative work Poor OH No fluoride in drinking water High carb intake
Xerostomia • • • •
Radiation of head and neck Sjogren’s syndrome Medications Bulimic patient
21
22
Dental Caries • • • • •
Caries
Infectious, multifactorial disease Transmissible Preventable & controllable Constant battle between demin/remin Remineralization requires higher dose of Fl‐ than for prevention!
Rampant
23
24
4
2/19/2016
Know what factors (yes answers)‐ put in higher category
“Single greatest individual risk factor for predicting dental caries is dental caries experience in the previous two or three years. (ADA, 1995; ADA, 2006). In infants, risk is often determined by caregiver or sibling status.”
Another Indicator: Patient Risk
Evidence Based Treatment
Another Indication– Dentin Hypersensitivity
Fluoride trm’t for Adults?
• Dentin contains millions of tubules of live tissue that run from the pulp to the dentin’s outer margins. If the tubes are exposed, they are often sensitive • Fluoride ions can block those tubes as can stannous (tin) ions (mechanical) • Higher concentrations used (varnish) if severe • Can also use other occluding or “blocking agents” (ACP products, sodium citrate, potassium nitrate, etc….) • Insurance code is DIFFERENT (D9910, D9911) for sensitivity v/s fluoride application (& charge is usually higher) • Can follow root instrumentation • Approval of varnish is primarily for sensitivity (anticaries is “off label” use)
95% of dental professionals believe adult patients benefit from Fl‐ application BUT only 14% actually offer topical fluorides to adults WHY?? Caries is still the most common dental disease 40% of adult tooth surfaces are affected by caries; worse for patients >65 LITTLE BENEFIT IF IN LOW RISK CATEGORY
29
30
5
2/19/2016
In Office APF
In Office F‐ Applications: Benefit • When higher concentrations such as APF or NaF gel, solution or foam is applied, calcium fluoride (CaF2) is formed • CaF2 coats the teeth and acts as a reservoir of Ca+ and F‐ ions for remineralization • Remineralizes lesions we CANNOT SEE
Remember CaF2 forms with in office fluoride treatments
31
• Most commonly used • 1.23% concentration • Contains 2.5% sodium fluoride and .08% hydrofluoric acid • Ph is 3.5 (ideal) • Rapid F‐ esp. first minute but 4 minutes best & researched (1 minute not supported by clinical trials) • Thixotropic (gel) • Also comes in foam • The more acidic pH in APF enhances the rate of the reaction with hydroxyapatite in the enamel • NO polishing necessary****
32 Do NOT use with sealants, porcelain crowns or composites unless protect
In Office Stannous Fluoride (SnF2) & APF combo
In Office Neutral Sodium Fluoride
Apply 1‐2 x’s a year .32 APF & 1.64% SnF2 Must be freshly mixed Can cause artifacts on radiographs Tastes the worst of the 3 Acidic Gingival irritation, bitter taste, staining, sloughing Contains tin SELDOM USED anymore Also, APF & Stannous rinse Not ADA approved but still sold (not cov’d by ins. either) • Can still use 1.64 % Sn F as irrigation in Perio
• • • • • • • • • •
• 2% sodium fluoride, no acid pH 7 • Use when patient has porcelain crowns, veneers, sealants or composites • Comes in thixotropic form, gel turns to liquid when activated, foam has had little research • Uptake slower‐ recommended time usually 4 minutes but some available in 1 minute applications (80% uptake 1st minute) • *Better to use APF if can
33
In Office Fluoride Varnish • • • • • •
• • • • •
34
Fluoride Vanish
Paint on thin layer Used for hypersensitivity‐ blocks tubules (not yet approved for anti‐caries) 5% sodium fluoride Delivers 22,000+ ppm fluoride Adheres to enamel for several hours Instruct patients not to eat abrasive foods, brush, floss or drink hot liquids for 4‐6 hours (if possible, wait longer) Some now have added benefit of ACP Some products require drying teeth‐ some not‐ so read manufacturers instructions! Can be caramel or white Viscous – so less swallowing/stays longer Always recommended for children