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Flourides

Fluoride is a mineral that is best known for its role in making teeth more resistant to decay. Fluoride is found naturally in varying amounts in water, reaching streams and rivers from rocks and soil. Cavities used to be a fact of life but as a result of fluorides, tooth decay has been reduced dramatically. It also helps repair the tooth in the early stages of decay.

Topical

Gels

Gels and foams are used for individuals who are at high risk for caries, orthodontic patients, patients undergoing head and neck radiation, patients with decreased salivary flow and children whose permanent molars should, but cannot, be sealed.

The gel or foam is applied by the use of a mouth tray. The tray is held in the mouth by biting. Application generally takes about four minutes and patients should not rinse, eat, smoke or drink for at least 30 minutes after application.

Some gels are made for home application and are used in a manner similar to toothpaste. The concentration of fluoride in these gels is much lower than professional products. Most widely operator administered fluoride in gel form is APF gel (Acidulated phosphate fluoride).

APF gel

A gelling agent methylcellulose or hydroxyethyl cellulose is to be added to the solution and the pH is to be adjusted between 4-5.

Method of application
  • Oral prophylaxis.
  • Teeth to be isolated with cotton rolls on both lingual and buccal sides.
  • APF solution is continuously and repeatedly applied with cotton applicators.
  • Teeth are kept moist for 4 minutes.
Recommended frequency

Twice a year

Mechanism of action

When APF is applied to the tooth it forms an intermediate product called DCPD (Dicalcium phosphate dihydrate). This DCPD is highly reactive with fluoride and penetrates into the crystals more deeply and leads to the formation of fluorappitite.

Advantages
  • It doesn't stain the tooth structure.
  • Since it is a gel, self application is possible.
Disadvantages
  • Sour and bitter in taste.
  • Repeated applications necessitates its use in the field.
Stannous Fluoride Gel

Stannous Fluoride concentrate is an excellent home care product for the control of plaque and root caries.

Advantages

Provide stannous ion: Stannous ion inhibit or disrupt plaque colonies.

Provides fluoride ion: Fluoride ions have multiple benefits.

Great tasting: Easy to apply with a brush. Comes in 3 flavours: Red Berry, Cinnamon, Peppermint.

Sodium Fluoride Gel

For those patients that need home fluoride but cannot tolerate the acidic stannous type gels. Comes in convenient 4.3 oz. bottles. 24 bottles per case. Sodium Fluoride concentrate is 1.1%.

Advantages

Neutral formulation: Ideal for patients with porcelain or composite restorations. Provides high concentration of fluoride ions.

DS-8 Desensitizing Gel

A highly effective tooth desensitizing gel for home use. Excellent for hypersensitivity, gingival recession and localised pain. Available in 6 bottles containing 2-oz. of medication.

  • Contains high concentrations of stannous and sodium fluoride ions that bond with other soluble ions such as calcium to help speed the obstruction of exposed tubules.
  • Formulated with enamel clinging thickeners.
  • Easy to use and apply.
Colgate Gel-Kam

Gel-Kam Gel is a 0.4% stable stannous fluoride gel that is an effective decay-preventive home-use gel of significant value when used as directed. With regular use it relieves sensitivity in normal teeth. However, clinical effectiveness against plaque, gingivitis or other periodontal indications has not been proven.

Ingredients
  • Active ingredient: 0.4% (w/w) Stannous Fluoride
  • Other ingredient: Glycerin, Hydroxyethylcellulose.

Varnish

Fluoride varnish has practical advantages over gels in ease of application, a non-offensive taste and smaller amounts of applications are required. Varnish is intended for the same group of patients as the gels and foams. The varnish is applied with a brush and sets within seconds. A varnish is better over the gel since it is sticky in nature and stays longer as compared to the gel.

Two most commonly used varnish

  • Fluorprotector (Silane fluoride).
  • Duraphat (Sodium fluoride).

Composition

Fluorprotector

A colourless, polyurethane lacquer. The fluoride compound is diflurosilane ethyl diflorohydroxy silane. Fluoride available is 7000ppm.

Duraphat

It is a sodium fluoride in varnish form containing 22.6mgF/ml suspended in alcoholic solution of natural organic varnishes. The active fluoride available is 22,600ppm.

Since the fluoride concentration in varnishes is higher they are better preventatives compared to mouth rinses.

Method of application

  • Oral prophylaxis.
  • Teeth are dried.
  • Teeth are not isolated as varnish is sticky and thereby stick to cotton.
  • The application is done in lower quadrant due more salivary accumulation.
  • Application is done with a single tufted brush.

Instructions to follow after application

  • Patient is asked to keep their mouth open for four minutes.
  • Patient is not supposed to eat or drink atleast for an hour after application.

Mouthwashes

The most common fluoride compound used in mouth rinse is sodium fluoride. Over-the-counter solutions of 0.05% sodium fluoride (225 ppm fluoride) for daily rinsing are available for use. Fluoride at this concentration is not strong enough for people at high risk for caries.

Prescription mouth rinses are more effective for those at high risk for caries, but are usually contraindicated for children, especially in areas with fluoridated drinking water. However, in areas without fluoridated drinking water, these rinses are sometimes prescribed for children.

Most commonly administered fluoride mouth rinses are sodium fluoride and stannous fluoride.

Sodium fluoride (2%)

This solution is prepared by dissolving 20 gms of sodium fluoride in 1 liter of distilled water and is stored in a plastic bottle.

Method of application
  • Oral prophylaxis.
  • Isolation of both the quadrants.
  • Teeth are dried thoroughly.
  • 2% NaF is applied with cotton applicators and is allowed to dry for 4 minutes. The same technique is employed for rest of the quadrants.
  • Patient is instructed not to eat or rinse for next 30 minutes after application.
  • Second, third, fourth applications are done at weekly intervals.
Recommended ages

Recommended at age interval of 3,7,11,13 yrs.

Mechanism of action
  • Due to high concentration of fluoride in NaF a solubility product of calcium fluoride is formed.
  • Once a thick layer gets formed it further causes diffusion of fluoride from topical fluoride solution to react with hydroxyapatite.
  • Calcium fluoride reacts with hydroxyapatite to form fluoridated hydroxyapatite which increases the concentration of surface fluoride thus making the tooth structure more stable.
Stannous fluoride (8%)
It is to freshly prepared each time before use. 0.8 gm of stannous fluoride is dissolved in 10 ml of distilled water in a plastic container and is to be shaken briefly.
Method of application
  • Oral prophylaxis.
  • Isolation of both the quadrants.
  • Teeth are dried thoroughly.
  • 8% stannous fluoride is applied with cotton applicators and is allowed to dry for 4 minutes.The same technique is employed for rest of the quadrants.
  • Patient is instructed not to eat or rinse for next 30 minutes after application.
Recommended frequency

Once a year

Mechanism of action
  • Tin of stannous fluoride reacts with enamel and new crystalline product stannous tri-fluorophosphate is formed which is more resistant to decay.
  • The other end products are

    • Tin hydroxyphosphate.
    • Tin trifluorophosphate.
    • Calcium trifluorostannate.
    • Calcium fluoride.

Systemic

Systemic fluorides are those that are ingested into the body and become incorporated into forming tooth structures.

Systemic fluorides such as community water fluoridation and dietary fluoride supplements are effective in reducing tooth decay. These fluorides provide topical as well as systemic protection because fluoride is present in the saliva.

Community Water Fluoridation

Water fluoridation is the most effective way to prevent tooth decay in the community irrespective of race, class, gender, age or educational level. It is the least expensive way of ensuring that the greatest number of people achieve the maximum gain in protection against tooth decay. A reduction of the disease burden is likely to be seen within two years of the programme being instituted.

The fluoride level in water is a major factor in determining the dosage for children between 6 months and 16 years of age.

Age Fluoride ion concentration in drinking water
0.3 0.3-0.6 0.6
Birth-6 months None None None
6 mon-3 yrs 0.25 mg/day None None
3-6 yrs 0.50 mg/day 0.25 mg/day None
6-16 yrs 1.0 mg/day 0.50 mg/day None

(acc. to ADA, AAPD, AAP)

Dietary Fluoride Supplements

Dietary fluoride supplements (tablets, drops or lozenges) are available only by prescription.

Prescribing information for fluoride supplements
Name/Strength Form Child Dosage Max child dosage
Sod. fluoride, drops-2mg/ml fluoride Drops 1/2 dropperful= 0.25mg 1 dropperful= 0.5mg 2 dropperful= 1mg
Prescribe no more than 200ml per household
Sodium fluoride Drops 2 drops= 0.25mg
4 drpos= 0.5mg 8drops= 1mg
Prescribe no more than 30ml per household
Sodium fluoride, drops-  2.5mg/ml fluoride Drops 2 drops= 0.25mg
4 drpos= 0.5mg 8 drops= 1mg
Prescribe no more than 30ml per household
Sodium fluoride, drops-  5mg/ml fluoride Drops 1 drops= 0.25mg
2 drops= 0.5mg 4 drops= 1mg
Prescribe no more than 23ml per household
Sodium fluoride, rinse 0.2mg/ml fluoride Rinses 1mg  fluoride / teaspoonful (0.2mg fluoride/ml) swished for 1 min then swallowed Prescribe no more than 500ml per household
Sodium fluoride tablets and lozenges- 0.25mg fluoride tablets and lozenges 1 tablet or lozenge per day taken with water or juice and dissolved in mouth or chewed Prescribe no more than 480 tablets or lozenges per household
Sodium fluoride tablets and lozenges- 0.5mg fluoride tablets and lozenges 1 tablet or lozenge per day taken with water or juice and dissolved in mouth or chewed Prescribe no more than 240 tablets or lozenges per household
Sodium fluoride tablets and lozenges- 1mg fluoride tablets and lozenges 1 tablet or lozenge per day taken with water or juice and dissolved in mouth or chewed Prescribe no more than 120 tablets or lozenges per household
Adverse effects and precaution
  • Ingestion of fluoride of quantities as low as 1mg/day have been shown to produce mild fluorosis.
  • Chronic fluoride toxicity or skeletal fluorosis, may occur after years of daily ingestion of 20-80mg of fluoride.
  • Accidental ingestion of fluoride, >120mg in form of fluoride supplements and mouthrinses or >260mg in toothpaste can cause gastrointestinal disturbances such as excessive salivation, nausea, vomiting, abdominal pain and diarrhoea.
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