PEDO Journal Review

CONTENT
1. Introduction 2. Fluoride toxicity 3. The Caries Process

Fluoride in Caries Prevention

2003/08/19

4. Fluoride Mechanism of Action 5. The Role of Low Levels of Fluoride 6. Clinical Implications 7. Policy on the use of fluoride

1. Introduction
Caries continues to be a major problem Need an improved approach to prevention & therapy Major contributor to reductions in decay during the last 20 years universal use of fluoride (F) products
(Featherstone JD, 1999) Featherstone JD. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol 27: 3131-40, 1999.

1. Introduction
BUT BUT
Parents of Fluoride Poisoned Children (PFPC) Fluoride Issues New York State Coalition Opposed to Fluoridation (NYSCOF) STOP fluoridation USA ...stop fluoride poisoning

1. Introduction

1. Introduction
Fluoride
Safety? Efficacy of caries prevention? How to use?

( , , 2002/07/31) 2002/07/31)

2. Fluoride toxicity
Fluoride
Inhibit a variety of enzymes G protein activator

2. Fluoride toxicity
In most of the situations, the investigators have not proved that AlAl-F complexes are present in vivo AlAl-F complexes have clinical implications only if they are available to the biological tissues
Li L. The biochemistry and physiology of metallic fluoride: action, mechanism, mechanism, and implications. Crit Rev Oral Biol Med 14(2):10014(2):100-14, 2003.

AlAl-F complexes
Usually formed in routine laboratory solutions, cell culture media, and body fluid Play physiological or pathological roles in bone biology, fluorosis, neurotoxicity, and oral disease
Li L. The biochemistry and physiology of metallic fluoride: action, mechanism, mechanism, and implications. Crit Rev Oral Biol Med 14(2):10014(2):100-14, 2003.

2. Fluoride toxicity
Methods
Research on effects on bone published since the 1991 National Health and Medical Research Council report on water fluoridation was reviewed

2. Fluoride toxicity
Conclusion
Fluoride at up to 1ppm does not have an adverse effect on bone strength, strength, bone mineral density or fracture incidence

Results
33 studies were identified The majority of animal studies showed no effect or a beneficial effect of low fluoride doses
Demos LL, Kazda H, Cicuttini FM, Sinclair MI, Fairley CK. Water fluoridation, osteoporosis, fractures recent developments. Aust Dent J 46:(2):8046:(2):80-7,2001.

Demos LL, Kazda H, Cicuttini FM, Sinclair MI, Fairley CK. Water fluoridation, osteoporosis, fractures recent developments. Aust Dent J 46:(2):8046:(2):80-7,2001.

2. Fluoride toxicity
Dental fluorosis

2. Fluoride toxicity

2. Fluoride toxicity
Dental fluorosis
Enamel fluorosis is caused by the long-term ingestion of fluoride during tooth development Effects of fluoride on enamel formation Causing dental fluorosis Cumulative, rather than requiring a specific threshold dose Depending on the total fluoride intake from all sources & the duration of fluoride exposure
Aoba T, Fejerskov O. Dental fluorosis: chemistry and biology. Crit Rev Oral Biol Med 13(2):155 13(2):155170, 2002.

2. Fluoride toxicity
Dental fluorosis
Water fluoridation and use of F dentifrice are the most efficient and costcost-effective ways to prevent dental caries; other modalities should be targeted toward highhigh-risk individuals Care should be exercised in prescribing other modalities of F delivery before age 6, & especially before age 3, because of the risk of dental fluorosis.
Levy SM. An update on fluorides and fluorosis. J Can Dent Assoc 69(5):286 69(5):28691, 2003.

2. Fluoride toxicity
Symptoms of overdose
GI, CNS; death in 4 hr

2. Fluoride toxicity
Treatment
< 8 mg F/kg: F/kg: milk, observe6 hr, refer if symptoms develop 8 mg F/kg: F/kg: syrup of ipecac, followed by milk; refer immediately Unknown dose: dose: asymptomatic: asymptomatic: treat as <8 mg F/kg symptomatic: symptomatic: give milk, refer immediately Poison control center: center: gastric lavage, IV calcium gluconate

Probably toxic dose 5 mg F/kg Certainly lethal dose 16~32 mg F/kg (Hodge & Smith) 15 mg F/kg (Whitford)

3. The Caries Process

3.1. The nature of tooth mineral Enamel & dentin: millions of tiny mineral crystals embedded in a protein/lipid matrix Tiny gaps or pores between the crystals
filled with protein, lipid & water allow the passage of small molecules (lactic acid) and ions (hydrogen and calcium)

3. The Caries Process

3.1. The nature of tooth mineral Remineralized enamel mineral
more resembling a blend of hydroxyapatite & fluorapatite much less soluble than the original mineral

Featherstone JD. The science and practice of caries prevention. JADA 131(7): 887887-99, 2000.

3. The Caries Process

3.2. The demineralizationdemineralization- remineralization cycle

3. The Caries Process

3.3. The caries balance Caries progression vs reversal is a delicate balance between pathological factors (bacteria & carbohydrates) & protective factors (saliva, calcium, phosphate, fluoride)

Featherstone JD. The science and practice of caries prevention. JADA 131(7): 887887-99, 2000.

3. The Caries Process

3.4. Driving force for remineralization Degree of supersaturation of mineralizing fluid (saliva in the mouth) Fluoride concentration in the oral fluids

4. Fluoride Mechanism of Action

Any prepre-eruptive benefit due to ingestion of fluoride during tooth development is now believed to be relatively unimportant Primary mode of action of F is topical PostPost-eruptive benefit is cumulative
Limeback H. A rere-examination of the prepre-eruptive and postpost-eruptive mechanism of the antianti-caries effects of fluoride: is there any antianti-caries benefit from swallowing fluoride? Community Dent Oral Epidemiol 27: 6262-71,1999.

4. Fluoride Mechanism of Action

ReRe-examining the literature used in support of a prepre-eruptive mechanism
Water fluoridation studies Fluoride supplement studies

4. Fluoride Mechanism of Action

4.1. Inhibits of demineralization F surrounding the carbonated apatite crystals is much more effective at inhibiting demineralization than F incorporated into the crystals at the levels found in enamel F incorporated developmentally into the normal tooth mineral is insufficient to have a measurable effect on acid solubility
Featherstone JD. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol 27: 3131-40, 1999.

'Systemic topical' fluoride (or local prepre-eruptive fluoride)

Limeback H. A rere-examination of the prepre-eruptive and postpost-eruptive mechanism of the antianti-caries effects of fluoride: is there any antianti-caries benefit from swallowing fluoride? Community Dent Oral Epidemiol 27: 6262-71,1999.

4. Fluoride Mechanism of Action

4.1. Inhibits of demineralization If F is present in the plaque fluid at the time that the bacteria generate acid it will travel with the acid down into the subsub-surface of the tooth, adsorb to the crystal surface and protect it against being dissolved

4. Fluoride Mechanism of Action

4.2. Enhances remineralization The saliva is "supersaturated" with calcium & phosphate providing a driving force for mineral to go back into the tooth The partially dissolved crystals act as "nucleators" for remineralization

Featherstone JD. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol 27: 3131-40, 1999.

Featherstone JD. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol 27: 3131-40, 1999.

4. Fluoride Mechanism of Action

4.2. Enhances remineralization Fluoride acts to speed up this remineralization process by adsorbing to the surface & acting to bring calcium and phosphate ions together, together, & is preferentially included in the chemical reaction that takes place, producing a lower solubility endend-product

4. Fluoride Mechanism of Action

4.3. Inhibits plaque bacteria F from topical sources is taken up by the bacteria when they produce acid, thereby inhibiting essential enzyme (enolase) activity

Featherstone JD. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol 27: 3131-40, 1999.

Featherstone JD. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol 27: 3131-40, 1999.

5. The Role of Low Levels of Fluoride in Saliva & Plaque Fluid

Small increases in the background level of F in saliva & plaque fluid could provide important caries protection via enhancement of remineralization When levels of 0.03 ppm F or higher were incorporated in the mineralizing solution (artificial saliva in the model) remineralization was enhanced
Featherstone JD. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol 27: 3131-40, 1999.

5. The Role of Low Levels of Fluoride in Saliva & Plaque Fluid

F can be retained at concentrations in the saliva between 0.03 & 0.1 ppm for 2-6 hours depending on the product and the individual subject Children with high individual salivary F (0.075 ppm) ppm) were more frequently caries free (p<0.02)

6. Clinical Implications
6.1. Maximizing benefit and minimizing risk Maximize antianti-caries efficacy
F present in oral cavity as long as possible ( concentration & frequency of application)
Product
Dentifrice

6. Clinical Implications
Fluoride Formulation
1500ppm (1.5mg/g) 1000ppm (1.0mg/g) 500ppm (0.5mg/g) Rinse Tablets Daily(0.05%) (0.23mg/ml) Weekly(0.20%) (0.97mg/ml) 0.25mg 0.5mg 1.0mg Fluoridated milk water 2.65ppm (0.5mg in 189ml) 1ppm (1mg/l)

Probable toxic dose=5mg/kg Fluorosis dose=0.1 mg/kg 1 y/o (10kg) 5-6 y/o (20kg) 1 y/o (10kg) 5-6 y/o (20kg)
33 g 50 g 100 g 217 ml 52 ml 200 tab 100 tab 50 tab 100 cartons (18.9 litres) 50 litres 66 g 100 g 200 g 434 ml 104 ml 400 tab 200 tab 100 tab 200 cartons (37.8 litres) 100 litres 0.67 g 1.0 g 2.0 g 4.3 ml 1.0 ml 4 tab 2 tab 1 tab 2 cartons 1 litres 1.33 g 2.0 g 4.0 g 8.7 ml 2.1 ml 8 tab 4 tab 2 tab 4 cartons 2 litres

Minimize fluorosis
F ingested & absorbed as little as possible ( dose = concentration x amount)

Frequent Amounts Concentration

6. Clinical Implications
6.2. HomeHome-based methods of delivery F toothpaste (caries incidence 25) F tablets & supplements (primary dentition 50~80; F mouthrinses ( 30) F varnishes ( 38)

6. Clinical Implications
6.2. HomeHome-based methods of delivery F toothpaste
Frequency & time of application Amount applied peapea-sized sized / 5mm long Rinsing behaviour

permanent dentition dentition 20~40)

6. Clinical Implications
6.2. HomeHome-based methods of delivery F tablets & supplements

6. Clinical Implications
6.2. HomeHome-based methods of delivery F mouthrinses
NaF 0.05% (220ppm) for daily use NaF 0.2% (900ppm) for weekly use Not be used by children under 7 years due to risk of swallowing excessive F

6. Clinical Implications
6.2. HomeHome-based methods of delivery F varnishes
Duraphat (23000 ppm F)

6. Clinical Implications
6.3. CommunityCommunity-based fluoride delivery Water fluoridation ( 40~70) Fluoridated milk drinks Fluoridated salt

6. Clinical Implications
6.3. CommunityCommunity-based fluoride delivery Water fluoridation
Small amounts of F are delivered throughout the day, helping to maintain intraintra-oral F levels Reduction is usually greatest in young children Use of F tablets in fluoridated areas should be strongly discouraged, discouraged, as this combination is associated with a high risk of cosmetically disfiguring fluorosis

6. Clinical Implications
6.3. CommunityCommunity-based fluoride delivery Water fluoridation

7. Policy on the use of fluoride

1.Endorses & encourages water fluoridation 2.Whenever water fluoridation is not feasible, endorses F supplementation 3.Inform medical peers of potential hazard of enamel fluorosis when F supplements are given in excess of recommended amounts

7. Policy on the use of fluoride

4.Continued research on dental fluorosis 5.Not 5.Not support use of prenatal F supplements 6.Recommends an individualized patient cariescaries-risk assessment to determine the use of FF-containing products 7.Encourages continued research on safe & effective F products including restorative materials
American Academy of Pediatric Dentistry 2003

American Academy of Pediatric Dentistry 2003

SUMMARY
1. Introduction 2. Fluoride toxicity 3. The Caries Process 4. Fluoride Mechanism of Action 5. The Role of Low Levels of Fluoride 6. Clinical Implications 7. Policy on the use of fluoride