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SESSION PLAN
COURSE # AND TITLE: PEDS 538, Pediatric Dentistry
SESSION # AND TOPIC: # 9 Prevention of Dental Caries-Fluoride
DURATION: Equivalent to 1 hour
FACULTY: Dr. Glenn Minah
GENERAL GOALS: Become familiar with various soft tissue
abnormalities and diseases found in children
SPECIFIC OBJECTIVES: The student should be able to:
1. State goals of fluoride therapy.
2. Understand how optimal benefits of non-
professional administration of fluoride can be
accomplished.
3. Describe rationale and clinical
recommendations for professionally applied
topical gels, fluoride varnish and home rinses
and gels.
SESSION PLAN
SPECIFIC OBJECTIVES: The student should be able to:
4. Describe optimal use of fluoride dentifrice.
5. Know when intensive fluoride therapy is required and
what type should be administered.
METHODOLOGY: Web Lecture
ASSIGNMENT: McDonald RE, Avery DR. Dentistry for the Child
and Adolescent. Mosby, St. Louis, 7th ed. 2000.
Chapter 10, p. 209
EVALUATION: Written exam. Questions will be from the text portion of
this presentation. TEXT
SESSION OUTLINE
A. Goals of fluoride administration
B. Non-professional fluoride administration
1. Systemic
2. Topical gels
3. Rinses
4. Dentifrice
C. Professional administration
1. Topical
2. Varnish
TEXT
Goals of Fluoride (F) Administration
1) Do not harm the patient. 2) Prevent decay on intact dental surfaces. 3) Arrest
active decay. 4) Remineralize decalcified tooth surfaces.
GOALS OF FLUORIDE (F) ADMINISTRATION
1. Do no harm 3. Arrest active decay
F
Fluorosis or
toxicity
2. Prevent decay on in tact
dental surfaces 4. Remineralize
decalcified teeth
F
F
TEXT
Do not harm the patient
1. Probable toxic dose (PTD): The PTD is 5 mg F/kg body weight. For a 20
kg 5 to 6 year old this would be 100 mg and for a 10 kg 2 year old, 50 mg.
F content of dental products or treatments may exceed these values for
young children. For example, a gel tray containing 5 ml of APF contains
61.5mg F (F is absorbed more quickly when in acidic form.), 100ml of 0.2
or 0.4% F mouthrinse contains 91 or 97mg F and a tube of fluoridated
toothpaste contains as much as 230mg F. Sub-lethal toxic symptoms are
manifested quickly after the dose and consists of vomiting, excessive
salivation, tearing and mucous discharge, cold wet skin and convulsions
with higher doses. Counter measures which should be administered
immediately are emetics, 1% calcium chloride, calcium gluconate or milk.
(Calcium reacts with F in the GI tract and prevents its absorption. The
most serious consequences of F toxicity stem from reactions of cationic
electrolytes with systemic F.)
POTENTIAL HARM
Probable toxic dose:
5 mg F / kg body
weight 61.5
mg F/ 91-97 mg
ACT
5 ml F/
container
of F
mouthrinse
Topical F,
12,300 ppm
F pH= 3.5
20 kg 6 year old,
PTD= 100 mg F
Symptoms:
1. Vomiting
2. Excess salivary
and mucous
discharge
230 mg F/
tube 3. Cold wet skin
10 kg 2 year old toothpaste 4. Convulsion at
PTD = 50 mg F higher dose
POTENTIAL HARM
A serious systemic Counter Measures:
consequence is
binding of F to Ca 1. Emetics
which needed for 2. 1% calcium
heart function. chloride
3. Calcium
F gluconate
4. milk
F F
Ca
F Ca
Divalent
cations like Ca Ca
Ca cause
precipitation,
of F and
F prevent F
Ca Ca F absorbtion in Ca Ca F
F F Ca the intestine. F F Ca
Ca Ca
TEXT
Do Not Harm the Patient
2. Fluorosis: Fluorosis occurs when teeth are developing. The most
critical ages are from 0 to 6 years. After 8 years, risk of fluorosis is
essentially past. During the critical ages F intake in excess of
0.1mg/kg body weight/day can lead to fluorosis. This is roughly
1mg/day for a 1 to 2 year old or 1.5 to 2 mg for a 5 year old.
Remember that all forms of F intake comprise the daily
consumption. This includes water intake (up to 1.5mg/day), foods
(0.3 to 1.0mg) and especially significant in young children,
swallowed toothpaste. Children under 2 years swallow 50% of
toothpaste during tooth brushing and at 5years, 25%, both of
which may amount to 1mg F/day.
POTENTIAL HARM
DMFT FLUOROSIS
10
9 severe
8
moderate
7
6
mild
5
4 slight
3
2 0.0 0.5 1.0 2.0 3.0 4.0
PPM F IN DRINKING WATER
F in excess of 0.1mg/ kg body
weight = fluorosis
FLUOROSIS
F
F
Enamel prism
Excess F affects
mineralization of
developing teeth
Up to age 6 is the critical age for
fluorosis. After age 8, risk is past.
FLUOROSIS
Daily F intake of a 20 kg
4 year olds with
Maxium safe different water F
dose for a 2 year
old = 1 mg F / 1 2 3 4 mg F
day
0.5 ppm
water F
1.2 ppm
water F
supplements toothpaste
Maxium safe fluids food
dose for a 5 year
old = 2 mg F /
day
F in excess of 0.1mg/ kg body DW Banting
weight = fluorosis JADA
123:86,1991
FLUOROSIS
5 year olds swallow
25% of toothpaste Children under 2
years swallow 50%
of toothpaste
1 to 3 grams
Toothpaste = 1 mg
F / gram (1000 “pea” size amount (0.5g) is
ppmF) recommenred for fluorosis
susceptible children.
mild moderate
pitting severe
TEXT
Prevention of Caries
1. Deposition of fluorapatite (FHA) in sound tooth structure: Caries
protection results from FHA being more acid resistant than pure
hydroxyapatite (HA). Deposition takes place when F replaces hydroxyl
groups in HA. This can occur pre- or post-eruption at neutral pH, or
post-eruptively at neutral or acidic pH. At low pH, HA dissolves, then
re-precipitates as new crystals which are larger and more acid-resistant
due to higher FHA and lower magnesium and carbonate content.
Deposition of FHA is accomplished both by systemic intake of F during
tooth development, and topical F administration after eruption.
Professional topical F treatments with concentrated acidulated phosphate
fluoride (APF) gels (2.72% APF gel contains 12,300 ppm F), is the most
efficient way to accomplish this, especially when applied to newly
erupted teeth (i.e., age 2 for primary molars; age 6 to 8 for permanent
first molars and anterior teeth; age 11 to 14 for permanent premolars and
second molars).
MECHANISMS OF F PROTECTION
DEPOSITION
Saliva (S) F F F F F
Plaque (P) F
F F F FF F
Tooth (T)
Topical F is
the best
Theory: method for
deposition.
Increase FHA
levels maximally in
intact dental surfaces.
DEPOSITION OF F
F FHA is more acid resistant than
F F HA
F
F
FHA
Neutral pH
H+ PO4 H+
F
PO4 F FHA
F HA
F CO3
Ca Ca
pH 5.0
Mg
F
H+ Mg and P
CO3 do
FHA H+ not Ca
repreci-
remineralization pitate
DEPOSITION OF F
Best F uptake is late pre-
Surface eruption and early post-
F build-up eruption
of F
F F F
F F
F
F F F
F
Mature F
enamel
F F Drinking Permanent Primary
Enamel F
F water teeth teeth
fluid
F F
F F 3000 900
Young enamel No F 2000 600
This has better F uptake due Maximal F levels of in outer 5 microns
to more porosity
DEPOSITION OF F
PPM Fluoride Fluoride uptake is higher in a
decalcified area
3000
2000
1000 5 um
3000 ppm F
1500 ppm F
outer 2 microns = 6000
ppm fluoride (max.
uptake)
F
F
F F
Ca Ca Ca Ca Ca
As fluoride reacts strongly
with calcium it does not
penetrate far into the tooth.
DEPOSITION OF F:
Maxium uptake
F
can not be
exceeded.
(3000 to 4000
ppm F in outer
5 um)
The F-rich surface can be
abraded away.
TOPICAL F STUDIES Caries reduction
100%
Averill JADA 74:990,1987 NaF
DePaola JADA 87:155,1973 APF
Downer BritDJ 141:242,1978 APF
Horowitz JDent Child 27:157,1980 SnF2
Muhler JDent Child 27:1571980 SnF2
Szwejda JPub Health Dent APF
32:110,1972
Newly erupted Previously erupted teeth
teeth
TEXT
Prevention of Caries
2. Bioavailability of F: A second theory of caries prevention asserts that
F in the vicinity of carious activity (in enamel fluid) prevents
dissolution of HA crystals. Although this mechanism requires only
low levels of F (less than 100ppm to as low as 1ppm), F must be
present when the acid challenge takes place and therefore must be
supplied continually. Examples of topical applications which ensure
bioavailability are fluoridated drinking water and fluoridated
dentifrices. A major source of bioavailable F is residual F in plaque
and pellicle. F in plaque minerals such as CaF2 or calculus or in
protein complexes is released during bacterial acid production.
MECHANISMS OF F PROTECTION
BIOAVAILABILITY
Water fluoridation
is an example of a
source.
S F SUGAR
P F ACID
T F
Theory:
Provide continual low level
of F to enamel fluid. The
benefit occurs at the time of
decalcification.
BIOAVAILABILITY OF F
Decalcification of enamel
crystals:
SUGAR S
Low level of F F saliva
H+ S
S
plaque
F F
H+
Decalcifying F Plaque and
F
HA crystals H+ enamel
H+ fluid
F
H+
Intact HA
crystals
J Arends. JDR
69(SI):601,1990
BIOAVAILABILITY OF F
F from plaque J Arends. JDR
fluid 69(SI):601,1990
ACID
F F
F F H+
F F F
F
F F
H+
F
F
F F Protection
from Loosely-bound F
dissolution
will eventually
F Stable FHA become stable
Loosely bound FHA.
F
or adsorbed F
BIOAVAILABILITY OF F
H+ F
FHA with no
F
H+ H+ H+
F F H+
F F
PO4
F F F
PO4
F
H+ H+
H+ F Ca
H+ Ca
Protection only H+
where is
F
Incomplete
J Arends. JDR protection
69(SI):601,1990
BIOAVAILABILITY OF F
Effect on bacteria:
F H+ S
S
F
F F
H+ H+
F H+
H+ F
MS
F
H+
F
The presence of H+
fluoride at the time of
glycolytic activity will also
inhibit of plaque
acidogenesis.
SOURCES OF BIOAVAILABLE F
1. saliva
ACT
2.
Fluoridated 3. Home care products
water
Topical F 4. RESIDUAL F
F F F F F S
ppm F in saliva
after drinking P
F
0.08 F F F T
0.02
Calcium
Fluoride
1 3 5 h
CaF2 precipitates in plaque during
topical F treatment
BIOAVAILABILITY VERSUS DEPOSITION OF F
Rodent studies:
LESIONS (mean)
30
No FHA
MS
plus
8 DEPOSITION
FHA
F F
5
sugar BIOAVAILABILITY
No FHA
10 ppm F
added to
drinking
water Larson RH. Caries
Res 10:321, 1976
BIOAVAILABILITY OF F
Research evidence:
Add F:
F
calcium loss F
5
HA
4
3 pH 5.0
2
1 pH
0 phosphate
0.05 0.1 1 5 calcium
F ppm in solution
JM Ten Cate.
JDR
69(SI):614,1990
TEXT
Prevention of Caries
3. Summary of preventive F procedures and recommendations: The older view
of caries prevention was that FHA deposition in non-carious dental surfaces
should be maximized by systemic F administration during tooth
development, and post-eruptively by topical F treatments. It was believed
that increased FHA provided increased protection against caries. Although
implementation of high FHA deposition has proved beneficial, it does not
afford as much protection as bioavailable F. Moreover, the high doses of F
required, systemically or topically (which often becomes systemic intake)
are partly responsible for the increasing incidence of fluorosis. Current
clinical recommendations for preventive F measures are 1) to determine
total F intake per day from all sources in order to assess over or under F
exposure, 2) determine caries risk, 3) institute a regimen commensurate
with individual caries risk status which emphasizes bioavailability of post-
eruptive topical F (e.g. regular use of F dentifrice and other home products
if indicated), 4) administer professional topical F treatments, the timing of
which should also be gauged to caries risk (This may not be needed in low
risk individuals) and 5) administer systemic topical F if indicated. (The
latter is currently under review. Present Academy of Pediatric Dentistry
recommendations are presented below.
TEXT
FLUORIDE SUPPLEMENTS
F
F in drinking water
AGE <0.3ppm 0.3- >0.6ppm
0.6ppm
6m-3y 0.25 0 0
3-6y 0.5 0.25 0
6-16y 1.0 0.5 0
Academy of Pediatric Dentistry current
recommendations
SUMMARY OF PREVENTIVE F
1. Determine F intake
2. Determine caries risk
3. Devise personalized plan based
on risk level.
4. Stress bioavailability of F.
5. Monitor F intake of young
patients in an effort to prevent
fluorosis.
TEXT
Arrest of Active Decay
1. Mechanisms: Caries arrest means that active lesions become
inactive. This is accomplished clinically by adjusting several
aspects of the oral environment such as by reducing intake of
cariogenic dietary substrates, reducing plaque volume, stimulating
salivary flow, increasing plaque levels of Ca++ and PO4---,
promoting favorable microbial shifts (i.e. reducing acidogenic and
aciduric bacteria and encouraging proliferation of alkalinogenic
bacteria) and increasing bioavailable F. Bioavailable F arrests
caries by 1) inhibiting decalcification by coating enamel crystals,
intact or partially decalcified, with loosely bound F and thereby
preventing further dissolution of crystals, 2) catalyzing
reprecipitation of dissolved enamel crystals and 3) inhibiting
acidogenesis and aciduricity of cariogenic bacteria. Arrested
incipient lesions appear either as dark stained fissures which resist
explorer penetration (Active probing of stained fissures with sharp
explorers is not recommended as it may induce cavitation.), stained
cervical incipient lesions or shiny enamel surfaces covering white
spot lesions. Arrested carious dentin or root surfaces exhibit dark
staining with hard and often shiny surfaces.
TEXT
Arrest of Active Decay
2. Clinical recommendations: 1) Determine total F exposure, 2)
determine caries risk and tailor clinical measures to risk
status, 3) institute dietary and plaque control procedures, 4)
control cariogenic bacteria, if indicated and 5) have patient
maintain continual low level F exposure to decalcified sites.
ARREST OF ACTIVE DECAY
Root caries
Indications:
incipiencies
Cases difficult to treat, i.e.,
certain ECC cases
Interproximal
caries in low or
moderate risk
patients.
ARREST OF ACTIVE DECAY
Ca
PO4 PO4
3. Ca
Procedure:
Diet
control
1. Increase topical Ca
and PO4 intake.
4. LB
MS
2.
Encourage
beneficial
Plaque control microbial shifts.
ARREST OF ACTIVE DECAY
5. Increase bioavailable F
F
S F SUGAR
P F ACID
T F
Arrested caries turns
dark, is firm and often
glossy.
TEXT
Remineralization of Decalcified Surfaces
1. Indications and mechanisms: This clinical manipulation is intended to
restore lost mineral from incipient lesions and reverse appearance of white
spot lesions. (Review notes on remineralization from Cariology course.)
Generally, remineralization procedures are indicated for non-cavitated
carious dental surfaces (enamel or cemental) in individuals who are not in
the high or severe caries risk category. These are the same as caries arrest
procedures with the exceptions that 1) only non-cavitated lesions are
indicated and 2) F, Ca++ and PO4--- exposure are monitored more
carefully.
2. Recommendations: Follow recommendations for caries arrest, above,
along with application of recalcifying solutions (e.g., Enamelon, which
contains F) and/or F to affected sites. Recalcification of white spot lesions
on anterior smooth surfaces require low concentrations of topical F (100
to 250ppm) since higher ones do not penetrate enamel as effectively and
may cause preservation of the white spot by reacting only with the outer
enamel layer.
REMINERALIZATION
Same procedures as for
arresting caries. White spot
Exceptions or additions:
1. Only non-cavitated
lesions can be
remineralized.
2. Not recommended for
severe of high caries risk
patients.
3. Ca, PO4 and F are
administered more
before after
precisely.
TEXT
Clinical Fluoride Products
These include 1) professional topical F, 2) F varnishes 3) home rinses
and gels, 4) dentifrices, 5) supplements and 6) other agents such as
sustained release devices. A detailed summary is presented in Tables at
the end of the presentation.
Professional Topical F
1.
Products and description: The principal products are 2.72% acidulated
phosphate fluoride(APF) gel and 2% neutral sodium fluoride gel.
Stannous fluoride (SnF2) is no longer used routinely for professional
topical applications. APF, pH 3.5, contains 12,300 ppm F and is
formulated from sodium fluoride and 0.1M phosphoric acid. This gel is
intended to dissolve surface enamel which will re-precipitate with
higher FHA content. Neutral NaF gels (9200 ppm F) are indicated when
composite restorations are present since APF will etch glass filler
particles of the composites. This product will not produce comparable
surface FHA deposition, but according to research evidence, achieves
the same caries protection as APF.
TEXT
Professional Topical F
2. Mechanisms of caries protection: The earlier theories
centered on increasing deposition of FHA. Now it is
believed that benefits are derived mainly from residual F
buildup in plaque and other oral surfaces or biofilms in
the form of CaF2, other minerals and protein-bound F.
These reservoirs release F during acidification which acts
as bioavailable F. (Note: sealants should not be placed
immediately after professional topical F treatment due to
instability of the CaF2 layer which precipitates on the
tooth surface. Sealants may be placed after 24 hours.)
When applied every 6 months to children in F deficient
regions, all types of professional topical F agents
achieved roughly 30% caries reduction versus sham
treated controls.
PROFESSIONAL TOPICAL F
Topical Fluorides: APF
Reprecipitation of
fluorapatite
2.72% acidulated
phosphate F (APF), 2. Ca F
1.23% free F, 12,300
ppm F. PO4
2.0% neutral sodium F, F
0.9% free F, 9200 ppm
F. 1.
0.1 M H3OP4
8% stannous F (no longer
used routinely).
Ca 3.
H+
Ca
H+
PO4
Ca Precipitation of
calcium
fluoride on
Dissolution of enamel surface
surface layer
PROFESSIONAL TOPICAL F
CaF2
Do not seal teeth immediately
after a topical F treatment
due to CaF2.
H+ H+ H+ Etched
glass
Ca
F T
Ca F
APF will etch
Plaque acids will glass in filled
release bioavailable F resins. Use resin
from CaF2. neutral F gel.
TEXT
Professional Topical F
3. Recommendations: 1) Determine total F exposure. 2)
Determine caries risk. 3) Administer as indicated by # 1
and 2. (Timing may be monthly, 1, 2, 3 or 4 times a
year or even contra-indicated.) 4) Apply for 4 minutes.
5) Add no more than 2ml to the gel tray and make every
effort to keep patient from swallowing the gel. 6) Have
patient refrain from rinsing, eating or drinking for 30
minutes after application.
PROFESSIONAL TOPICAL F
Recommendations:
1. Determine total F caries
exposure. placebo
2. Administer 0,1,2,3,4 times
a year as indicated by topical
caries risk level.
3. Apply for 4 minutes.
4. Use only 2 ml of gel in
trays, keep patients from
swallowing the gel. Two topical F
treatments per
5. No rinsing, drinking or
year reduced
eating for 30 min.
caries by 30%
afterwards.
versus placebo
gel.
TEXT
Fluoride Varnish
1. Products and use: Application of F varnish is essentially a professional
topical F treatment. Duraflor is currently the only concentrated F varnish sold
in the US (called Duraphat in Europe) and contains 5% NaF. Flor-Protector
contains 0.7% silane F and is used as a cavity varnish. For topical treatments
Duraflor should be applied to, and allowed to dry on all cotton roll-isolated
teeth. Afterwards the patient should not eat for 2 hours. Although the caries
benefits are similar to topical F gels, less total F is released into the oral
cavity during treatment (i.e., only 3 to 6mg ) than from gels.
2. Indications: Apply to: 1) teeth during operating room procedures, 2) enamel
incipiencies, 3) exposed roots, 4) margins of restorations, 5) teeth at risk
which cannot be sealed such as erupting molars or premolars or 6) carious
anterior teeth in very young children.
FLUORIDE VARNISH
Duraflor – 5% NaF,
26,000 ppm F, 3-6 mg F
per dose.
Fluor-Protector –
0.7% silane F. Used
as a cavity varnish
FLUORIDE VARNISH
0.25 ml for
primary dentition
Cavity Shield (OMNI) – 0.40 ml for
5% NaF mixed
dentition
FLUORIDE VARNISH
Indications:
3. Exposed
roots and
root caries
5. Erupting
teeth
1. All teeth in
the OR
2. 6.
4. Carious anterior
White spots or teeth in young
Margins of children
other restorations
incipiencies
TEXT
Home Rinses
1. Products and use: These are available as over-the-counter
(OTC) daily rinses (0.05% NaF, 230ppm F; 0.02% NaF,
200ppm), or as prescription weekly rinses (0.2% NaF, 910ppm
F or 0.4% SnF2, 970ppm F). Patients should rinse 1x/day for 1
minute with 10ml.
2. Indications: 1) High caries risk patients. 2) Exposed root
surfaces. 3) School prevention programs.
HOME F RINSES
Daily Rinse: Weekly Rinse
0.2% NaF, 0.091% free
ACT F, 910 ppm F, 9.1 mg F /
dose.
PREVI-
DENT
0.05% NaF, 0.023%
free F, 230 ppm F, 2.3
mg F / dose
Indications:
1. High caries risk
2. Exposed roots
PHOS 3. Prevention programs
-FLOR
0.02% APF, 0.02%
free F, 200 ppm F, 2
mg F / dose.
TEXT
Home Gels
Products and use: Home gels are available as prescription
1.1% NaF (5000ppm F) and 0.4% SnF2 (1000ppm). These
are self-administered by the exposure of F to teeth than do
rinses.
Indications: 1) High or severe (rampant) caries risk patients.
2) Exposed root surfaces when evidence of caries is present.
3) School prevention programs.
HOME GELS
GEL-CAM – Indications:
0.4% SnF2, 1. Severe caries
0,097% free F, 2. Root caries
970 ppm F, 2- 3. Prevention
3mg programs
F/ dose.
PREVIDENT –
1.1% NaF,
0.5% free F,
5000 ppm, 10-
25 mg F/ dose.
Radiation
caries
TEXT
Dentifrices
Product descriptions: Dentifrices are sold as pastes or gels. The latter theoretically
penetrates retention sites better, and are more acceptable to young children than pastes.
The main ingredients of dentifrices, from a preventive standpoint, are F salts and
abrasives. One of 4 types of F salts are used, i.e., 1) 0.2% NaF, 2) 0.76% sodium
monofluorophosphate (MFP), 3) 0.4% SnF2 or 4) amine F. Amine F is not sold in the US.
Most dentifrices contain 1mg F/gram which amounts to 1mg or 1000ppm F in each tooth-
brushing dose. A few newer products contain up to 1500ppm F. According to trial data, all
F dentifrices reduce caries by 25 to 32% versus control paste without F, when used twice
daily. MFP and NaF are the standard types of F used in the US. SnF2 exhibits a shorter
shelf life and may cause staining of teeth. MFP is formulated with covalently bound
fluoride which improves stability, and can be used with abrasives containing Ca++ which
will react with and inactivate
non-covalently bound F. F is released from MFP in vivo by enzymatic reactions and
supposedly achieves better enamel uptake of the F ion than NaF pastes. Common
abrasives are a) sodium metaphosphate, b) silica, c) sodium bicarbonate, d) acrylic
polymer, e) dicalcium phosphate or f) calcium carbonate. The latter two can only be
used with MFP. The FDA requires that at least 60% of free F ion be available in doses,
over the life of the dentifrice. NaF and MFP dentifrices lose about 20% F availability
within 2 years.
DENTIFRICE (TOOTHPASTE,TP)
Pastes
Key ingredients in TP:
1. F salt
2. Abrasive
Gels:
1. Better
interdental
penetration
2. More
acceptable
to children
DENTIFRICE
F salt in TP: MFP does not react with
Na
calcium abrasives (F is
1. 0.2% NaF PO4 F covalently bound) and has
better uptake by enamel
2. 0.76% sodium crystals.
monofluorophosphate
(MFP)
3. 0.4% stannous F
F F
4. Amine F Sn
F salt (all reach 1000-1500 ppm F) SnF2 exhibits less shelf life
and may cause dental
staining
Na 1 gram of TP = 1 Amine F is not sold in the
mg F US. It adsorbs to enamel
F and has anti-bacterial
F properties
The ADA requires that 60% of free F ion be
available over the shelf life of the TP. NaF
and MFP lose about 20% free F in 2 years.
DENTIFRICE
Abrasives: 4. Acrylic polymer
CO3
1. Sodium metaphosphate
Ca
PO4
H+
Na PO4 F
F
5. Dicalcium PO4
2. phosphate
Sodium Silica Ca
Ca
PO4
Na Ca It is desirable to have
PO4 and Ca and HCO3
as abrasives
3. Na bicarbonate 6. Calcium
carbonate
Na H Ca These can be
CO3 CO3 used with MFP
Ca
TEXT
Dentifrices
Use considerations: Noteworthy concerns are fluorosis from swallowed
toothpaste in children, and the F content of commercial products. The latter
involves toothpaste trial data showing that preventive effects correlate
positively with F content. As a result, commercial products are prepared with
increasing amounts of F, and this may become a fluorosis concern with young
children. Accepted provisions for reducing child intake of F are use of
toothbrushes with small heads to limit paste application, and instructing
parents to use no more than a “pea size” amount of paste (approximately
0.5g) on the toothbrush (High concentration F dentifrice should not be used
before age 7.). Another concern is rinsing after tooth-brushing. Studies show
that 50% of the benefit is lost when this is routinely practiced. No rinsing
after brushing, or rinsing with an OTC F mouthrinse are recommended.
Finally, tooth-brushing should be conducted just before bed-time in order to
take advantage of night-time reduction of oral clearance mechanisms. F
bioavailability will thus be increased.
F USE CONSIDERATIONS
S F
High
P
salivary
T flow
F awake
Brush S
F F F
before
F bedtime P F Low
salivary
F T
F F F flow
asleep
F
Evidence shows that
increased F use and F Rinsing after brushing
concentration
reduces F effectiveness
increases
by 50%.
bioavailability in
stagnation sites. Recommendations: Do
not rinse after brushing
(Note: be aware of
or rinse with a F rinse.
fluorosis susceptible
patients.)
Commonly Used F Products
Type of F F salt Free F Brand Company F F mg/dose
name ppm
Professional gel 2.72% 1.23% Nupro Dentsply 12,300 24.6-61.5
APF
2.0% 0.9% “ “ 9200 18.4-46
NaF
F varnish 5.0% 2.6% Duraflor Pharma 26,000 3-6
NaF Science
Daily rinse 0.05% 0.023% Act J&J 230 2.3
NaF
0.02% 0.02% Phos-Flor Colgate 200 2.0
APF
Weekly rinse 0.2% 0.091% Prevident Colgate 910 9.1
NaF
Home gel 0.4% 0.097% Gel-Kam Colgate 970 1.94-4.85
SnF2
1.1 0.5% Prevident Colgate 5000 10-25
NaF
Commonly Used F Products
Type of F F salt Free Brand Company F F mg/dose
F name ppm
Supplements
F tablets 2.2% NaF 1.0% Luride Colgate 1000 1
1.1% NaF 0.5% “ “ 500 0.5
0.55% 0.25% “ “ 250 0.25
NaF
F drops 1.1% NaF 0.5% “ “ 500 0.25mg per
1/2ml
Dentifrice 0.22% 0.1% 1000 1
NaF
0.76% 0.1% 1000 1
MFP
