Submitted to: Department of Pedodontics, SSDCH.

Submitted by: Jashanpreet Jawanda (1736) Final year.

Introduction
Fluoride in the Environment
Metabolism of Fluorides
Mechanism of Action of Fluoride
Water Fluoridation
School Water Fluoridation
Salt Fluoridation
Milk Fluoridation
Dietary Fluoride Supplements
Topical Fluorides
Sodium Fluoride
Stannous Fluoride
Acidulated Phosphate Fluoride
Newer Topical Fluoride
Fluoride Varnish
Fluoride Dentrifices
Fluoride Toxicity
Recent Advances in Fluoride
The greatest contribution of last century to the improvement of oral health is
perhaps the discovery and utilization of fluoride as a caries preventive measure.
Fluoride is one of those remarkable elements, which have not only notable
chemical qualities but also physiological properties of great interest and
importance for human health.
Fluoride has been described as an essential nutrient in the Federal Register of
United States Food and Drug Administration (1973) and World Health Organization
(WHO) expert committee on trace elements and human health.
They have also included fluoride in the list of 14 elements recognised to be
physiologically essential for the normal development and growth of human beings.
Derived from a Latin word Fluore meaning to flow
Atomic no. Is 9, atomic weight is 19.
Lithosphere:
In rock and soil
1. Fluorspar (fluorite CaF )
2. Fluorapatite {Ca10F2 (PO4)6}
3. Cryolite (Na3AlF6)
In Soil, the fluoride concentration increases with
depth ie from 0-7.5cm there is 20-500mg of
Fluoride/kg while from 0-30 cm, there is 20-
1620mg of fluoride/kg, according to WHO Expert
Committee (1994).
Atmosphere:
Dusts of fluorides-containing soils
Gaseous industrial waste
Domestic burning of coal fires
Gases emitted in areas of volcanic activity
Biosphere:
Normal level of fluoride in plants is about 2-20 mg/g or dry weight.
Tea has one of the highest concentrations of fluoride i.e. 100 ppm.
Hydrosphere :
crust, all water contains fluoride in various
concentrations
For example, Negligible in rain water, high in lakes and well, fluoride in sea water- 0.8-1.4
mg/L and in water- 0.5mg/L
Lake Nakuru (Kenya): 2800 ppm ie highest content of fluoride in water.
In Foods And Beverages:
Unprocessed foods -low (0.1-2.5 mg/kg).
In plants - 2-20mg/g of dry weight.
Leafy vegetables -11-26 mg on dry weight basis.
Fish -20-40 ppm on dry weight basis.
It depends upon physical form of dose, presence of food in stomach, gastric pH,
gastric motility, and concurrent oral administration
Plasma concentration: 0.7-2.4 m
Kidney: 4.16 ppm
Bone: 99%
Enamel: 2,200-3,200 ppm
Dentin: 200-300 ppm
Cementum: 4,500 ppm
Pulp: 100-650 ppm
Improved crystallinity
Void theory
Acid solubility
Enzyme inhibition
Suppressing the flora
Antibacterial action
Lowering free surface energy
Desorption of protein and bacteria
Alteration in tooth morphology
Improved crystallinity:
Fluoride increases the crystal size and produces less strain in crystal lattice. It takes place
through conversion of amorphous calcium phosphate into crystalline hydroxyphosphate.
Void theory:
Voids in the crystals decrease the stability and increase chemical reactivity. If fluoride fills
these voids in the hydroxyapatite crystal it will attain a stable form with formation of more
and stronger hydrogen bonds. Greater stability will lead to lower solubility and hence
greater resistance to dissolution in acids.
Acid solubility:
(FAP vs HAP) Fluorapatite or fluoridated hydroxyapatite (solubility constant of 10.50) is
less soluble than hydroxyapatite (10.55) therefore has greater stability.
Enzyme inhibition:
Fluoride has enolase inhibition effect, and it also inhibits glucose transport.
Enolase is a metalloenzyme that requires a divalent cation for its activity, fluoride
due to its increased reactivity forms a complex with this cation, thus inhibiting the
enzyme. It also inhibits nonmetalloenzymes like phosphatases, thus leading to
reduced acid production.
Suppressing the flora:
Stannous fluoride is a potent suppressor of the bacterial growth because it oxidizes
the thiol group present in bacteria, thus inhibiting bacterial metabolism
Antibacterial action:
The concentration of fluoride above 2 ppm in solution progressively decreases the
transport of uptake of glucose into cells of oral streptococci and also reduces ATP
synthesis.
Lowering free surface energy:
Fluoride incorporated in enamel by substitution of hydroxyl ions reduces the free
surface energy and thus indirectly reduces surface energy and thus reduces the
deposition of pellicle and subsequent plaque formation.
Desorption of protein and bacteria:
Hydroxyapatite crystals are amphoteric with both positive and negative receptor
sites. Acidic protein group binds to calcium site and basic to phosphate site.
Fluoride inhibits the binding of acidic protein to hydroxyapatite, thereby
displaying its beneficial effects
Alteration in tooth morphology:
Dentition in fluoridated communities showed a tendency toward rounded cusps,
shallow fissures due to selective inhibition of ameloblasts
The study of relationship between fluoride concentration in drinking water,
mottled enamel and dental caries was given an impetus by the decision of Dr
Clinton T Messner, Head of US Public Health service, to assign a young Dental
Officer Dr H Trendley Dean to pursue full time research on mottled enamel.

geographical distribution of mottled enamel in USA

He sent a questionnaire to the secretary of every local and state dental society in
the country and asked if mottled enamel existed in their areas, if so, how
extensive and also enquired about the water resources.
Out of 1197 questionnaires, 632 replies were received.
As a result of investigation, Dean reported 97 localities in the country where
mottled enamel was said to occur and this claim has been confirmed by the field
survey.
Dean conducted a survey in 22 cities in 10 states of USA, on total of 5,824 children
and gave a report.
Dean and his collegues conducted a door-to-door survey (which involved a lot of

His aim was to find out the minimal threshold of fluoride- the level at which fluoride
began to blemish the teeth.
He showed conclusively that the severity of mottling increased with increasing
fluoride concentrations in the drinking water
He gave the following observations:
Water concentration was 4 ppm or more- signs of discrete pitting
Water concentration was 3 ppm or more- mottling was widespread
Water concentration was 2-3 ppm- teeth had dull chalky appearance
Water concentration was <1 or equals to 1- no mottling of any esthetic significance
He also reported that the incidence of caries in these teeth was less as compared to
non fluoridated teeth
The term mottled enamel gave way to the more exact term- dental fluorosis
Thus in 1934, Dean developed a standard system for classification of dental
fluorosis-
Systemic fluorides Topical fluorides

Water Fluoridation Gels

School water fluoridation Dentrifices
Salt Fluoridation Mouth rinses
Milk Fluoridation Varnish
Fluoride tablets and vitamins
Fluoride drops
It is defined as the upward adjustment of the concentration of fluoride ion in public
water supply in such way that the concentration of fluoride ion in water may be
consistently maintained at one part per million (ppm) by weight.
Fluoridated water has fluoride at a level that is effective for preventing caries. This
can occur naturally or by adding fluoride.
Community water fluoridation is the process of adjusting the amount of fluoride in
a community water supply to an optimum level for the prevention of dental caries.
History dates back many years when Fredrick McKay and Trendley H. Dean
began their initial research, but the most significant change took place in 1942
during Grand Rapids- Muskegon study.
During many previous researches, it was noted that fluoride decreased the
incidence of caries, crucial step was to see if dental caries would be reduced in a
community by adding fluoride at 1 ppm to water supply
US public health service in December 1942 began this study in two cities Grand
Rapids and Muskegon. They came to a conclusion that 1 ppm fluoride was not only
best for caries control but was also well within limits of safety
On January 25, 1945, sodium fluoride (NaF) was added to water supply for the first
time.
Fluoride compounds used in Water Fluoridation:
Fluorspar
Sodium fluoride
Silicofluorides
Sodium silicofluoride
Hydrofluorosilicic acid
Ammonium silicofluoride
Optimum level of Fluoride:
Based on extensive research, the United States Public Health Service (USPH) (1986),
established the optimum concentration for fluoride in the water in the range of 0.7-1.2
ppm.
This range effectively reduces tooth decay, with minimal chances to cause dental
fluorosis.
The water intake of individuals varies widely and is influenced significantly by climate.
Galagan and Vermillion (1957) developed an empiric formula for estimating the
amount of daily fluid intake based on body weight and climatic conditions using
the mean annual maximum daily air temperature as follows:
ppm F= 0.34/E
E= -0.038 + 0.0062 ×T
E- Estimated daily water intake of children in oz/lb of body weight
T- Mean maximum daily air temperature in degree Fahrenheit of the area
Advantages of Water Fluoridation:
Large number of people are benefited
Consumption is regular
Fluoridated drinking water not only acts systemically during tooth formation to make dental enamel more
resistant to dental decay but also has topical effect through the release in saliva after ingestion
Fluoridation of community water is the least expensive and most effective way to provide fluoride to a large
group of people.
Disadvantage of Water Fluoridation:
Interfere with human rights
Other modes are not considered
Common source of water supply may not be present.
Equipment for Water Fluoridation:
There are three systems for water fluoridation:
1. Saturator system
2. Dry feeder system
3. Solution feeder system
System Principle Factors limiting Recommendation
utilization
Saturator system 4% saturated solution of Need to clean gravel bed Suitable for small towns
NaF is produced and used for water filtration with a total requirement
injected at the desired of less than 3.8 million
concentration in the litres per day
water distribution source
with aid of a pump
Dry feeder NaF or silicofluoride in Care in handling Suitable for medium
the form of powder is fluoride, obstruction of sized towns with a total
introduced into a pipes, and compacting of requirement of 19 million
dissolving basin with the fluoride while stored in litres per day
aid of an automatic humid atmosphere
mechanism
Solution feeder Volumetric pump The equipment must be Suitable for medium
permitting the addition of resistant to the attack of sized and large towns
a given quantity of hydrofluosilicic acid, with a total requirement
hydrofluosilicic acid in necessitating of 7.6 million litres per
proportion to the amt of construction using day
water treated polyvinyl chloride or
another plastic
This program helps in limiting caries in school children who are our prime concern.
School water fluoridation is a suitable alternative where community water fluoridation
is not feasible
The amount of fluoride added in school drinking water should be greater than normal
because children have to stay in school for a short time of the day and to compensate
for holidays and vacations
This procedure was first started in 1954 in St Thomas US Virgin Islands by US Public
Health Service Division
The current recommended regimen for school water fluoridation is adding 4.5 times
more fluoride
There has been around 25-40% decrease in dental caries with this program. Simple
fluoridators particularly that employ the Venturi system are most suitable, because they
require almost no maintenance and can be utilized effectively in small installations of
small-or medium-sized schools.
Advantages:
Good results in reducing caries
Minimal equipment
Not expensive
Disadvantages:
Children do not receive the benefit until they go to school
Not all children go to school in poor countries like India
Amount of water drunk cannot be regulated.
As a dietary vehicle for ensuring adequate ingestion of fluoride, domestic salt comes
second to drinking water
Wespi in 1955 introduced salt fluoridation in Switzerland
Initially, the concentration of fluoride was 90 miligram of F per kg salt but has been
recently made 200-350 mg F/kg.
In 1982,WHO and FDI recommended that salt fluoridation starts as soon as possible in
all countries. The procedure of salt fluoridation can be either by spraying concentrated
solutions of NaF or KF on salt on a conveyor belt or by mixing bulk PO4 carrier salt and
then adding to the main bulk.
Till now, salt fluoridation has been tried in Columbia, Hungary, Mexico, and Switzerland,
with Switzerland being the oldest.
A study conducted by Toth, in Hungary after 8 years of use of fluoridated salt, showed a
reduction of 39% in deft in 6-year-old children.
Advantages:
Fluoridated salt is safe
Theoretically fluoridated salt prevents dental caries both systemic as well topical action
No supervision of set up or distribution system
Low cost
Depends on individual acceptance and rejection.
Disadvantages
No precise control over-indicated consumption, since salt intake varies greatly among
people
International efforts to reduce sodium uptake
Fluoridated salt consumption is lowest when the need for fluorides is greatest: in the early
years of life.
Ziegler in 1956 was the first person to mention milk fluoridation as a method of
systemic fluoridation
The concentration of fluoride in 250ml milk bottle was 0.625 mg
It targets the fluoride directly to the children, and this could be less expensive than
water fluoridation. But considerable number of children in most countries will not
drink milk for one or another reason
The amount of fluoride to be added depends upon the age of the child and the
fluoride concentration in water. This is further complicated by the fact that different
children consume varying quantities of milk per day.
Compounds used for Milk Fluoridation:
Calcium fluoride
Sodium fluoride
Disodium monofluorophosphate (MFP)
Disodium silicofluoride.
Feasibly of Milk Fluoridation in India:
Controversy concerning the binding of fluoride with calcium and potassium, hence
unavailable for its anticariogenic action, though Ericsson (1985) proved that
fluoride from milk is available for 4 hours after consumption (same as water)
In India, majority of children cannot afford milk daily
No centralised milk supply system
Variation of intake and quantity of milk
When introduced dietary fluoride supplements were perceived to be a reasonable
alternative where water fluoridation was not possible. But supplements need co-
operation to a high degree and so these should be directed only to needy
population for whom caries or its treatment may be difficult
Some examples of supplements are Fluoride drops, Fluoritab liquid, Vi Daylin/F
ADC Drops, Pediaflor Drops, etc
The dosage will depend upon the age of the child and the concentration of fluoride
in the area. American Academy of Pediatrics recommends that fluoride
supplements can be started 2 weeks after birth and continue till 16 years of age.
Dietary fluoride supplementation schedule
Fluoride in Birth to 24 25 to 36 months 37 months to 16
water (ppm) months years
0.3 or less 0.25 mg 0.5 mg 1.0 mg
0.3- 0.7 0.0 mg 0.25 mg 0.5 mg
Prenatal Supplements:
Prior to 1969, fluoride was prescribed in prenatal supplements for potential caries prevention in teeth whose
development began before birth.
It was assumed that fluoride would cross the placental barrier and that it would be acquired by the developing teeth
sufficiently to provide caries protection.
The United States Food and Drug Administration concluded that sufficient endence did not exist to support claims of
efficacy of prenatal fluoride supplements therefore in 1966 the Food and Drug Administration banned advertising, but
it did not ban their sale by prescription.
Topical Effects of (F) Supplements:
Fluoride supplements extend its cariogenic effect by acting both locally and systemically. For its local or topical effect,
fluoride must either contact the tooth surface before it is swallowed or pass through the circulation and be secreted in
saliva.
Factors to be considered before determining proper fluoride dosage:
Concentration of (F) in the drinking water
Total amount of bioavailable fluoride
Age of the child
Dosage forms commercially available.
Dosage Forms of Fluoride Supplements:
Fluoride supplements are available as drops tablets and lozenges, fluoride vitamin
preparations and oral rinse supplements.
It is recommended that a child consume no >1 mg of fluoride per day from fluoride
supplements and from the drinking water
In 1974,Ripa recommended that the appropriate marketed dosage forms may be
given full strength of half strength, depending upon the patient's age and level of
fluoride in the drinking water. The American Academy of Pediatrics has
subsequently adopted this approach.
Dean proved that individuals continuously living in a fluoride-rich area had less
caries as compared to the individuals who had lived in the same Fluoride rich
areas during calcification of teeth but had shifted to non-fluoride areas thereafter.
In 1940s, it was demonstrated that extracted teeth when exposed to dilute solutions
of fluoride for a few seconds were found to have completely bound fluoride on the
enamel surface.
Hence the idea of topical application of fluoride solution of dental caries
prevention was put forth.
In 1941, the first clinical study of topical fluoride was carried out by Bibby using a
0.1% NaF solution.
Subsequently, various other topical fluoride agents have been evolved such as
SnF2 (1947), APF (1963), Na MPP (1963), amine fluoride (1965), and varnish-
containing fluoride (1968)
Topical fluorides can be divided into:

Professionally applied Self-applied

Neutral NaF Tooth brushing dentrifices
Stannous fluoride Tooth brushing solutions
Acidulated phosphate Tooth brushing prophylaxis
fluoride pastes
Amine fluoride Mouth rinses
Fluoride varnishes
Fluoride gels
Milestone studies were conducted by Bibby in 1941 and Knutson in 1942, which varied not only
concentration of NaF used but also in number of applications per year.
Knutson and Feldman (1948) recommended a technique of four applications of 2% NaF at weekly
intervals in a year at 3, 7, 11 and 13 years.
Properties of Sodium Fluoride:
Neutral pH
9200 ppm of F
Caries reduction in first year was 45% and in second year was 36%
Method of preparation:
20% NaF solution can be prepared by dissolving 20g of NaF powder in 1L of distilled water in a
plastic bottle.
It is essential to store fluoride in plastic bottles as the fluoride ion of solution can react with silica
of glass forming SiF2, thus reducing the availability of free active fluoride for anticaries action.
Method of application -Knutson Technique
Mechanism of Action:
When sodium fluoride solution is applied on the tooth surface as a topical agent, it reacts with the
hydroxyapatite crystals in enamel to form calcium fluoride which is the main end product of the
reaction.
As a thick layer of calcium fluoride gets formed, it interferes with the further diffusion of fluoride
from the topical fluoride solution to react with hydroxyapatite and blocks further entry of fluoride
ions.
This sudden stop of the entry of fluoride is termed as "Choking off effect". Fluoride then slowly
leaches from the calcium fluoride.
Thus calcium fluoride acts as a reservoir for fluoride release (It is for this reason that after each
application of sodium fluoride on to the tooth surface, it is left to dry for 4 minutes).
The calcium fluoride formed reacts with the hydroxyapatite crystals to form fluoridated
hydroxyapatite.
The hydroxyapatite thus formed increases the concentration of fluoride on enamel surface, which
in turn makes the tooth surface resistant against caries attack through the action of fluoride.
Advantages:
Chemically stable
Acceptable taste
Non irritating to gingival tissues
Does not discolor the teeth
Cheap and inexpensive
Disadvantages:
Continuous application for 4 minutes
Patient has to make four visits in a short time
Follow-up is difficult
Stannous fluoride in the early 1950s occupied a central role in the saga of preventive dentistry.
After the discovery of NaF, a wide variety of other fluoride compounds were tried like potassium,
lead, silicon, tin, and zirconium
All yielded some cariostatic benefit, but SnF2 was found to be three times more effective than NaF
Dudding and Muhler in 1957 tried single annual application of 8% SnF2 and reported 32%
caries reduction.
Method of preparation:
Stannous fluoride solution has to be freshly prepared before use each time (stannous form of tin
gets oxidized to stannic form, thus making the SnF2 inactive for anticaries action), as it has no
shelf life
For convenient preparation number "o", gelatin capsules are priorly filled with 0.8 g powdered
SnF2 and are stored in airtight plastic containers.
Just before application, the content of one capsule is dissolved in 10 mL of distilled water in a
plastic container, and the solution thus prepared is shaken briefly. The solution is then applied
immediately.
Method of application:
Each tooth surface is cleaned with pumice or other dental cleaning agent
for 5 to 10 seconds
Unwaxed dental floss is passed between the interproximal areas
Teeth are isolated and dried with air
Stannous fluoride is applied using the paint-on technique and the
solution is kept for 4 minutes.
Repeat applications are every 6 months or more frequently if the patient
is susceptible to caries
Mechanism of Action:
Mechanism of Action:
When stannous fluoride is applied in low concentration, stannous
hydroxyphosphate is formed which gets dissolved in oral fluids and is responsible
for the metallic taste after topical application of stannous fluoride.
At very high concentrations, calcium tri-fluoro stannate gets formed along with
stannous tri-fluorophosphate.
The stannous tri-fluorophosphate is responsible for making the tooth structure
more stable and less susceptible to decay.
Calcium fluoride is also the end product both at low and high concentrations.
The calcium fluoride so formed further reacts with hydroxyapatite and a small
fraction of fluorhydroxyapatite also gets formed.
Advantages:
Using an 8% stannous fluoride solution at 6 to 12 months intervals conforms to the
-recall system
Administrative difficulties, particularly in public health programs, created by the need to
arrange four appointments (as for sodium fluoride applications) are avoided.
Disadvantages:
Should be prepared freshly
Low pH
Metallic taste due to stannous hydroxyl phosphate
Causes gingival irritation
Produces discoloration of teeth
Causes staining on margins of restorations
The idea of acidulated phosphate fluoride as a topical agent in the prevention of
dental caries emerged with the in vitro investigation by Bibby in 1947, which
reported that as the pH of the NaF solution was lowered, fluoride was absorbed into
enamel more effectively.
Brudevold et al. did systematic investigation to find out an optimal fluoride acid
solution which would provide maximal fluoride deposition, while causing minimal
demineralization
They concluded that semiannual application of 1.23% APF for 4 minutes is helpful
in reducing caries by 28%
One of the practical difficulties of doing the topical application is that the teeth
must be kept wet with solution for 4 minutes and, moreover, APF solution is acidic
and sour and bitter in taste, so repeated applications are often difficult.
Method of preparation:
It is prepared by dissolving 20 g of NaF in 1 L of 0.1 M phosphoric acid. To this, 50%
hydrofluoride acid is added to adjust the pH at 3.0 and fluoride concentrations at
1.23%
For the preparation of APF gel, a gelling agent like Methylcellulose or
Hydroxyethyl cellulose is to be added to the solution and the pH is to be adjusted
between 4 and 5
Method of application:
After thorough prophylaxis, the teeth are isolated with cotton rolls on both lingual
and buccal sides
For the application of gel, position the patient upright and provide saliva ejector.
Place enough gel to fill one third of the trough area of tray so
that it is sufficient to cover dental arches
Place loaded tray over the arch and squeeze the buccal and
lingual surfaces forcing gel between them and allow tray to
remain in mouth for 4 minutes
Instruct the patient to expectorate immediately and avoid
drinking and eating for the next 30 minutes
Recommended frequency of APF topical application is
semiannual.
Mechanism of Action:
When APF is applied on the teeth, it initially leads to dehydration and shrinkage in the
volume of hydroxyapatite crystals.
Hydrolysis and formation of intermediate product
Formation of Dicalcium phosphate dihydrate (DCPD)
This DCPD is highly reactive with fluoride leading to formation of fluorapatite. The
amount and depth of fluoride deposited as fluorapatite would be dependent on the
amount and depth at which DCPD gets formed
Since the conversion of whole DCPD so formed into fluorapatite, deeper penetration
and continuous supply of fluoride is required, so APF has to be applied every 30
seconds and the teeth be kept wet for 4 minutes
Advantages:
Has acceptable taste
No staining
No gingival irritation
Stable with long shelf life
Cheap
Disadvantages:
Teeth have to be kept wet for 4 minutes
Solution is acidic, sour and bitter in taste
Characteristics Sodium fluoride Stannous fluoride APF
Percentage 2% 8% 1.23%
Fluoride 9,200 19,500 12,300
concentration (ppm)
pH Neutral 2.4- 2.8 3.0
Frequency 4 at weekly intervals Biannually Biannually
at 3, 7, 11 & 13 yrs
Adverse effects No Tooth pigmentation No
Gingival irritation
Caries reduction 30% 32% 28%
Amine Fluoride:
In 1957, Muhlemann and co workers of the University of Zurich first studied effects of
Amine fluoride on enamel solubility in vitro.
Amine fluoride is superior to inorganic fluorides in reducing enamel solubility because
of chemical protection by fluoride and physicochemical protection by organic portion
In addition to their ability to reduce enamel solubility, the amine fluorides have other
properties that enhance their potential as cariostatic agents.
Some of them are also surface active because they hold fluoride on enamel surface for
longer time.
They also have antibacterial properties. Their antibacterial effects appear to be greater
than those that can be accounted for by the presence of fluoride alone and have been
attributed to the organic portion of the molecule. Reduced plaque formation and
antiglycolytic activity have both been reported with these compounds, although not all
studies have been positive.
For the prevention of dental caries in humans, amine fluorides have been tested in
dentifrices, mouthrinses and topical gels, where they have been either brushed on
the teeth or appled with a tray. While the caries inhibiting potential of amine
fluoride preparations appears to be good, despite their surfactant and antibacterial
properties, it is not known if they are superior to the other currently available
fluoride agents.
Stannous Hexafluorozirconate:
Researchers at Indiana University have developed SnZrF6 effective in reducing the
solubility of enamel and in preventing dental caries.
It was first developed by Schimdt in Europe in 1964.
Increase the time of contact between enamel surface &
topical fluoride agents and favors the deposition of
fluorapatite & fluorhydroxyapatite.
The two most commonly used varnishes are Duraphat and
Fluor protector
DURAPHAT: It is a viscous yellow material, containing 22,600
ppm fluoride suspended in an alcoholic solution of natural
organic solution
FLUORPROTECTOR:It is a colorless, polyurethane laquer
containing 7,000 ppm fluoride from difluorosilanfluoride. It
is dissolved in chloroform and is dispensed in 1ml ampules
each ampule.
Technique:
After prophylaxis teeth are dried but are not isolated with cotton rolls since varnish
sticks to cotton
A total of 0.3-0.5 ml of varnish is required to cover full dentition
Application is done first done on lower arch then upper arch, using single tufted
small brush, starting with proximal surfaces
After application, the patient is made to sit with mouth open for 4 min before
spitting.
Patient is asked to not rinse or drink anything for one hour and advised liquid diet
till next morning.
Have been proved effective anticaries agents since
1955.
Today in industrialized countries, their sales have
dominated the major part of the market of dentrifices.
The most commonly evaluated fluoride dentrifices are
Sodium fluoride, stannous fluoride, sodium
monofluorophosphate and amine fluoride.
Sodium fluoride and Stannous fluoride dentrifices:
NaF was the first fluoride compound to be added as an
active ingredient, but its efficacy was very limited. FDA
proposed rules for NaF dentrifice are 0.188- 0.254% with
available fluoride ion concentration of 650 ppm
In 1955, SnF2 was introduced in dentrifices but failed to
get desired results as it caused staining of teeth,
pigmentation of hypoplastic areas and it has a metallic,
astringent taste.
Amine Fluoride Dentrifices:
First tested for its cariostatic potential in Zurich, Switzerland (1963)
Showed organic fluorides to have antibacterial and anticariogenic properties,
which were superior to inorganic fluorides and demonstrated significant reduction
in caries rate.
Marketed only in Europe.
MFP:
Monofluorophosphate is preferred chemical form of fluoride in most of the major
commercial fluoridated tooth pastes used throughout the world ever since 1969.
Dentrifices containing MFP at a concentration of 0.76%, 0.1% F with sodium
metaphosphate as abrasive, which led to variable reductions in caries rates
ranging from 17% for unsupervised brushing and about 34% for supervised
brushing in non fluoridated areas
FDA proposed rules for MFP dentrifice is 0.564-0.884% with available fluoride
concentration of more than and equal to 800 ppm
Mechanism of Action:
First mode is Fluoride effect given by Ericcson (1963)
Second mode given by Ingram (1972)
Advantages:
Neutral pH (6.5)
Greater stability to oxidation and hydrolysis
Longer shelf life
Increased availability of fluoride
No staining of teeth (as occurs with SnF2)
Acute toxicity was found to be half than that of NaF
Fluoride Tooth Pastes: Recommended dentrifices by ADA or FDA
Europe: Extra strength Aim, Colgate, Aquafresh
India: Pepsodent, Colgate total, Stolin-R
Recommendations for use of Fluoride Dentrifices
Below 4: not recommended
4-6 years: Once daily with fluoride paste and twice without paste
6-10 years: Twice daily with fluoride paste and once without paste
Above 10: Thrice daily with fluoride paste
Fluoride is often called as a double-edged sword
Fluoride can be very harmful if large amounts are ingested in a single dose or over
a period of time.
Prior to introduction if water fluoridation as a public health measure, the principal
use of fluoride known to a layman was that of pesticide.

Fluoride Toxicity

Acute Toxicity Chronic Toxicity

Rapid, excessive ingestion of large doses of fluoride at one time.
Signs and Symptoms:
Nausea, vomiting
Abdominal pain, diarrhea
Excess salivation and mucosal discharge
Generalized weakness and carpopedal spasms
Weak thready pulse, fall in blood pressure
Depression of respiratory center
Decreased plasma calcium level, increased potassium level
Cardiac arrhythmia
Coma and death.
To prevent accidental poisoning of an infant weighing as little as 10 kgs (or 22
pounds), the Council on Dental Therapeutics if the American Dental Association
(ADA) recommended that no more than 264 mg of fluoride be dispensed at any
one time.
Certainly Lethal Dose (CLD): 32- 64 mg of F/kg body weight
Safely Tolerated Dose (STD): 8-16 mg of F/ kg body weight
Immediate Aimed at reducing fluoride absorption
Induce vomiting
Fluid replacement
Monitoring levels of plasma ca++ and k+
<5 mg/kg fluoride ingested Give milk
Induce vomiting
>5 mg/kg fluoride ingested Give milk
Induce vomiting
5% calcium gluconate
Hospitalization
>15-mg/kg fluoride ingested Induce vomiting
Hospitalization
Cardiac monitoring
Slow administration of 10% calcium gluconate
Maintain urinary output-supportive measures for
shock
 Ingestion of variant doses of fluoride over a prolonged period of time.
It has two types: (1.) Dental and (2.) Skeletal Fluorosis

Effect Dosages Duration

Dental fluorosis >2 times optimal Until 5 years
Skeletal fluorosis 10-25 mg/kg 10-20 years
Dental fluorosis is a developmental disturbance of dental enamel, caused by
successive exposures to high concentrations of fluoride during tooth development,
leading to enamel with lower mineral content andincreased porosity.
It can be hypoplasia or hypomaturation of tooth enamel or dentin
Both primary and permanent teeth will be affected, can be transferred from a
pregnant mother to her developing fetus through placenta.
Fluorosis occurs symmetrically within the dental arches; the premolar is usually
affected first, followed by second molar, maxillary incisor, canine, first molar and
mandibular incisors.
Causes for dental fluorosis:
Excessive fluoride in water
Nonprescribed use of fluoride supplements
Ingestion of topical fluoride
Clinical features:
The first signs of dental fluorosis are thin white striae across the enamel surface. These fine lines follow
the perikymata pattern and can best be distinguished by drying the surface of the tooth. Even at this
stage of dental fluorosis, the cusp tips, incisal edges, or marginal ridges may appear opaque white, the
"snow

In slightly more affected teeth, the white lines are broader and more pronounced. Occasional merging
of several lines occurs to produce smaller, irregular, cloudy, or paper-white areas scattered over the
surface

With increasing severity, the entire tooth surface exhibits distinct, irregular, opaque, or cloudy white
areas. Frequently, the cervical enamel appears more homogenously opaque, and the mesioincisal part
of the maxillary incisors may exhibit varying degrees of brownish discoloration. Such brown stains are
a result of posteruptive staining

The next degree of severity manifests as irregular opaque areas which merge so that the entire tooth
surface appears chalky white. When such surfaces are probed vigorously, part of the surface enamel
may flake off

In even more severe stages, the tooth surface is entirely opaque with focal loss of the outermost enamel.
Such small enamel defects are usually designated "pits." With increased severity, these pits merge to
form horizontal bands

Ultimately, the most severely fluorotic teeth exhibited an almost total loss of surface enamel whereby
the normal tooth morphology is severely affected. The loss of enamel maybe so extensive that only a
cervical rim of intact, markedly opaque enamel is left. The remaining part of the tooth often exhibits a
dark brownish discoloration. The discoloration is entirely dependent on such post eruptive
environmental conditions as dietary habits, and the degree of discoloration should, therefore not as
used as an indication of severity of fluorosis as death.
 Dental fluorosis indices: Dean Fluorosis Index, Thylstrup and Fejerskov Index,
Horowitz Index, Moller Index, FDI Index
Dean Index: Given by Trendly H Dean (1934)
Rating Public health Characteristics
significance
0 Normal The enamel shows the usual translucency. The surface is smooth,
shiny, and usually of a pale, creamy white to gray white color
0.5 Questionable The enamel shows slight aberrations ranging from a few white flecks
to occasional white spots
1 Very mild Small, opaque, paper white areas scattered irregularly over tooth but
not >25%
2 Mild Opaque, paper white areas ie more extensive, >25% but <50%

3 Moderate All enamel surfaces are affected and show attrition

4 Severe All enamel surfaces are affected, hypoplasia and discrete pitting with
brown spots present
Also k/a Osteofluorosis
Water fluoride levels over 4 ppm causes a mild variants but levels over 8 ppm
cause severe skeletal fluorosis
Signs and symptoms:
Severe pain in back bones, joints, hips, stiffness in joints and spine
Outward bending of legs and hands in advanced stages, hence called knock knee
syndrome
Pregnant lactating mothers and children are the most vulnerable group. Fluoride can also
damage a foetus if mother consumes excess fluoride during pregnancy.
Fluoride may lead to blocking and calcification of blood vessels causing cardiac
problems
In its severest form, crippling fluorisis, the spine becomes rigid and the joint stiffens,
virtually immobilizing the patient
The fluoride dosage necessary to produce pathological skeletal fluorosis is
estimated at 20 to 80 mg fluoride/day for a period of 10 to 20 years
In India, it is most commonly seen in Punjab.
Classification: (Teotia et al)
Clinical: mild, moderate and severe
Radiological: mild, moderate and severe
Intraoral fluoride releasing devices
Use of fluoride complexes
Use of fluoride containing polyelectrolytes
Role of surface active agents on fluoride-
enamel interactions
Additive protective effects of combination
of fluoride and Chlorhexidine
Laser curing and fluoride application
Copolymer Membrane Device
Fluoride Glass Device
Bio-adhesive devices: tablets, capsules and
erosols.