538 prev caries

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.

SESSION PLAN

TEXT

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

SESSION OUTLINE

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.

TEXT

GOALS OF FLUORIDE (F) ADMINISTRATION

Do no harm

Prevent decay on in tact dental surfaces

F

F

Arrest active decay

Remineralize decalcified teeth

1.

2.

3.

4.

F

Fluorosis or toxicity

Do not harm the patient

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.)

1.

TEXT

POTENTIAL HARM

5 mg F / kg body weight

20 kg 6 year old, PTD= 100 mg F

10 kg 2 year old PTD = 50 mg F

230 mg F/ tube toothpaste

ACT91-97 mg F/ container of F mouthrinse

Symptoms:

1. Vomiting

2. Excess salivary and mucous discharge

3. Cold wet skin

4. Convulsion at higher dose

Probable toxic dose:

Topical F, 12,300 ppm F pH= 3.5

61.5 mg F/ 5 ml

F

Ca

F

Ca

Counter Measures:

1. Emetics

2. 1% calcium chloride

3. Calcium gluconate

4. milk

Divalent cations like Ca cause precipitation, of F and prevent absorbtion in the intestine.

F Ca

F

Ca

F Ca

FCa

FCa

FCa

A serious systemic consequence is binding of F to Ca which needed for heart function.

POTENTIAL HARM

F Ca

FCa

FCa

FCa

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.

Do Not Harm the Patient

2.

TEXT

10

9

8

7

6

5

4

3

2

FLUOROSIS

0.0 0.5 1.0 2.0 3.0 4.0

DMFT

PPM F IN DRINKING WATER

slight

severe

moderate

mild

F in excess of 0.1mg/ kg body weight = fluorosis

POTENTIAL HARM

FLUOROSIS

F

F

Excess F affects mineralization of developing teeth

Up to age 6 is the critical age for fluorosis. After age 8, risk is past.

Enamel prism

FLUOROSIS

F in excess of 0.1mg/ kg body weight = fluorosis

Maxium safe dose for a 5 year old = 2 mg F / day

Maxium safe dose for a 2 year old = 1 mg F / day 1 2 3 4 mg F

supplements toothpaste

fluids food

DW Banting JADA 123:86,1991

Daily F intake of a 20 kg 4 year olds with different water F

0.5 ppm water F

1.2 ppm water F

FLUOROSIS

Children under 2 years swallow 50% of toothpaste

5 year olds swallow 25% of toothpaste

Toothpaste = 1 mg F / gram (1000 ppmF)

1 to 3 grams

“pea” size amount (0.5g) is recommenred for fluorosis susceptible children.

moderate

severe

mild

pitting

Prevention of Caries

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).

1.

TEXT

MECHANISMS OF F PROTECTION

F F F F F F

F F F F F

F

Saliva (S)

Plaque (P)

Tooth (T)

DEPOSITION

Increase FHA levels maximally in intact dental surfaces.

Theory:

Topical F is the best method for deposition.

F

F

F

F

F

FF

FCa

PO4

PO4

Ca

Neutral pH

remineralization

DEPOSITION OF F

F

F

FHA

FHA

FHA

HA

pH 5.0

Ca

P

FHA is more acid resistant than HA

H+

H+

CO3

Mg

H+

H+

Mg and CO3 do not repreci-pitate

F

F

F

F

This has better F uptake due to more porosity

DEPOSITION OF F

Best F uptake is late pre-eruption and early post-eruption

FF

F F

FF

FFFF

FFFF

F

F

F

F

Mature enamel

Surface build-up of F

F

F

F

Enamel fluid

Young enamel

Drinking water

Permanent teeth

Primary teeth

F 3000 900

No F 2000 600

Maximal F levels of in outer 5 microns

3000

2000

1000

PPM Fluoride

outer 2 microns = 6000 ppm fluoride (max. uptake)

Fluoride uptake is higher in a decalcified area

F

5 um

DEPOSITION OF F

CaCa CaCaCaF F

F

As fluoride reacts strongly with calcium it does not penetrate far into the tooth.

3000 ppm F

1500 ppm F

F

DEPOSITION OF F:

Maxium uptake can not be exceeded. (3000 to 4000 ppm F in outer 5 um)

The F-rich surface can be abraded away.

TOPICAL F STUDIES

Averill JADA 74:990,1987

DePaola JADA 87:155,1973

Downer BritDJ 141:242,1978

Horowitz JDent Child 27:157,1980

Muhler JDent Child 27:1571980

Szwejda JPub Health Dent 32:110,1972

NaF

APF

APF

SnF2

SnF2

APF

Caries reduction100%

Newly erupted teeth Previously erupted teeth

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.


2.

TEXT

BIOAVAILABILITY

F

F

S

P

T F

ACID

SUGAR

Provide continual low level of F to enamel fluid. The benefit occurs at the time of decalcification.

Theory:

MECHANISMS OF F PROTECTION

Water fluoridation is an example of a source.

BIOAVAILABILITY OF F

SUGAR

Low level of F F

S

H+

H+H+

H+

F

F

F

F

SS

saliva

Plaque and enamel fluid

plaque

Intact HA crystals

H+

FDecalcifying HA crystals

J Arends. JDR 69(SI):601,1990

Decalcification of enamel crystals:

F Stable FHA

F Loosely bound or adsorbed F

F

F

F

F

FF F

F

F

F

FFACID

Protection from dissolution

F from plaque fluid

H+

H+


F

F

Loosely-bound F

will eventually

become stable

FHA.


F

F

F F

F

FF

F

Protection only where is

F

H+

H+

H+

H+

H+


F

Ca

PO4

PO4

Ca

FHA with no

Incomplete protection

F

H+

H+

H+

H+

H+

F



FF

F

H+

H+MS

Effect on bacteria:

H+

H+

F

F

F

F

SSH

+

F

H+

H+

The presence of

fluoride at the time of

glycolytic activity will also

inhibit of plaque

acidogenesis.

SOURCES OF BIOAVAILABLE F

1. saliva

0.08

0.02

ppm F in saliva after drinking

1 3 5 h

F F F F

S

P

T

4. RESIDUAL F

ACT

2. Fluoridated water

3. Home care products

Calcium Fluoride

F F F F F

Topical F

CaF2 precipitates in plaque during topical F treatment

FHA

No FHA

No FHA

F F

10 ppm F added to drinking water

LESIONS (mean)

MS

8

30

5

DEPOSITION

BIOAVAILABILITY

Larson RH. Caries Res 10:321, 1976

sugar

BIOAVAILABILITY VERSUS DEPOSITION OF F

Rodent studies:

plus

0

1

2

3

4

5

0.05 0.1 1 5

calcium loss

F ppm in solution

pH

5

4.5

4


pH 5.0

HA

calcium

phosphate

JM Ten Cate. JDR 69(SI):614,1990

Research evidence:

F

F

Add F:

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.


3.

TEXT

FLUORIDE SUPPLEMENTS

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

F in drinking water

F

Academy of Pediatric Dentistry current recommendations

TEXT

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.

SUMMARY OF PREVENTIVE F

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.

Arrest of Active Decay

1.

TEXT

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

2.

TEXT

ARREST OF ACTIVE DECAY

incipiencies

Root caries

Indications:

Cases difficult to treat, i.e., certain ECC cases

Interproximal caries in low or moderate risk patients.


PO4PO4Ca

Ca

MS

LB

1.

2.

3.

Increase topical Ca and PO4 intake.

Encourage beneficial microbial shifts.

4.

Plaque control

Procedure:

Diet control


5. Increase bioavailable F

F

Arrested caries turns dark, is firm and often glossy.

F

F

S

P

T F

ACID

SUGAR

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.

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 of Decalcified Surfaces

1.

2.

TEXT

REMINERALIZATION

Same procedures as for arresting caries.

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

precisely.

White spot

before after

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

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.

1.

TEXT

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.


2.

TEXT

PROFESSIONAL TOPICAL F

2.72% acidulated phosphate F (APF), 1.23% free F, 12,300 ppm F.

2.0% neutral sodium F, 0.9% free F, 9200 ppm F.

8% stannous F (no longer used routinely).

F

0.1 M H3OP4

PO4

Ca

Ca

F

Dissolution of surface layer

Reprecipitation of fluorapatite

1.

2.

3.

APF

Ca

Topical Fluorides:

H+H+

Precipitation of calcium fluoride on enamel surface

Ca

PO4


CaF2

Do not seal teeth immediately after a topical F treatment due to CaF2.

APF will etch glass in filled resins. Use neutral F gel.

T

H+

Plaque acids will release bioavailable F from CaF2.

F

FCa

Ca

resin

Etched glass

H+ H+

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.


3.

TEXT


Recommendations:

1. Determine total F exposure.

2. Administer 0,1,2,3,4 times a year as indicated by caries risk level.

3. Apply for 4 minutes.

4. Use only 2 ml of gel in trays, keep patients from swallowing the gel.

5. No rinsing, drinking or eating for 30 min. afterwards.

caries

Two topical F treatments per year reduced caries by 30% versus placebo gel.

topical

placebo

Fluoride Varnish

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.

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.

1.

2.

TEXT

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

Cavity Shield (OMNI) – 5% NaF

0.40 ml for mixed dentition

0.25 ml for primary dentition

FLUORIDE VARNISH

White spots or other incipiencies

All teeth in the OR

Exposed roots and root caries

Margins of restorations

Erupting teeth

Carious anterior teeth in young children

Indications:

2.

3.

4.

5.

1.

6.

Home Rinses

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.

Indications: 1) High caries risk patients. 2) Exposed root surfaces. 3) School prevention programs.

1.

2.

TEXT

HOME F RINSES

ACT

0.05% NaF, 0.023% free F, 230 ppm F, 2.3 mg F / dose

Daily Rinse:

PHOS-FLOR

0.02% APF, 0.02% free F, 200 ppm F, 2 mg F / dose.

Weekly Rinse

PREVI-DENT

0.2% NaF, 0.091% free F, 910 ppm F, 9.1 mg F / dose.

Indications:

1. High caries risk

2. Exposed roots

3. Prevention programs

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.

TEXT

HOME GELS

GEL-CAM –

0.4% SnF2,

0,097% free F,

970 ppm F, 2-3mg

F/ dose.

PREVIDENT –

1.1% NaF, 0.5% free F, 5000 ppm, 10-25 mg F/ dose.

Indications:

1. Severe caries

2. Root caries

3. Prevention programs

Radiation caries

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.

TEXT

DENTIFRICE (TOOTHPASTE,TP)

Gels:

1. Better interdental penetration

2. More acceptable to children

PastesKey ingredients in TP:

1. F salt

2. Abrasive

DENTIFRICE

1. 0.2% NaF

2. 0.76% sodium monofluorophosphate (MFP)

3. 0.4% stannous F

4. Amine F

1 gram of TP = 1 mg F

Na

FPO4

MFP does not react with calcium abrasives (F is covalently bound) and has better uptake by enamel crystals.

Na

F

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.

F salt (all reach 1000-1500 ppm F)

F salt in TP:

FSn

F

SnF2 exhibits less shelf life and may cause dental staining

F

Amine F is not sold in the US. It adsorbs to enamel and has anti-bacterial properties

Na

DENTIFRICE

Na PO4

CO3

H

Ca

Ca

Ca

PO4

CO3

Ca These can be used with MFP

It is desirable to have

PO4 and Ca and HCO3

as abrasives

H+

Abrasives:

Sodium metaphosphate

Sodium Silica

Na bicarbonate

Acrylic polymer

Dicalcium phosphate

F

2.5.

4.

3.

1.

Na

6. Calcium carbonate

Ca

CO3

CaPO4

PO4

F

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.

Dentifrices

TEXT

F USE CONSIDERATIONS

F

FF

F

F

F

Evidence shows that increased F use and F concentration increases bioavailability in stagnation sites.

(Note: be aware of fluorosis susceptible patients.)

FS

P

T

FS

P

T

F F

F

F

awake

asleep

High salivary flow

Low salivary flow

Brush before bedtime

Rinsing after brushing

reduces F effectiveness by 50%.

Recommendations: Do not rinse after brushing or rinse with a F rinse.

Type of F F salt Free F Brand name

Company F ppm F mg/dose

Professional gel 2.72% APF

1.23% Nupro Dentsply 12,300 24.6-61.5

2.0% NaF

0.9% “ “ 9200 18.4-46

F varnish 5.0% NaF

2.6% Duraflor Pharma Science

26,000 3-6

Daily rinse 0.05% NaF

0.023% Act J&J 230 2.3

0.02% APF

0.02% Phos-Flor Colgate 200 2.0

Weekly rinse 0.2% NaF

0.091% Prevident Colgate 910 9.1

Home gel 0.4% SnF2

0.097% Gel-Kam Colgate 970 1.94-4.85

1.1 NaF

0.5% Prevident Colgate 5000 10-25

Commonly Used F Products

Type of F F salt Free F Brand name

Company F ppm F mg/dose

Supplements

F tablets 2.2% NaF 1.0% Luride Colgate 1000 1

1.1% NaF 0.5% “ “ 500 0.5

0.55% NaF 0.25% “ “ 250 0.25

F drops 1.1% NaF 0.5% “ “ 500 0.25mg per 1/2ml

Dentifrice 0.22% NaF 0.1% 1000 1

0.76% MFP 0.1% 1000 1

Commonly Used F Products

538 prev caries

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