Fluoride therapy

From Wikipedia, http://en.wikipedia.org/wiki/Fluoride_therapy

Fluoride therapy is the delivery of fluoride to the teeth

topically or systemically in order to prevent tooth decay (dental
caries) which results in cavities. Most commonly, fluoride is applied
topically to the teeth using gels, varnishes, toothpaste/dentifrices or
mouth rinse. Systemic delivery involves fluoride supplementation
using water, salt, tablets or drops which are swallowed. Tablets or
drops are rarely used where public water supplies are fluoridated.

Contents

1 Benefits
2 Mechanism
3 Delivery
3.1 Water fluoridation
3.2 Toothpaste
3.3 Mouth rinses
3.4 Gels/foams
3.5 Varnish
3.6 Slow-release devices
3.7 Dietary supplements
3.8 Indications for fluoride
therapy
4 Health risks
4.1 Overdose
4.2 Fluorosis
5 Fluoride conversion chart
6 References
7 Further reading

1
1. Benefits

Fluoridation is widely, but not universally, accepted by

dentists as being useful.[1] The U.S. Center for Disease Control lists
water fluoridation as one of the "ten greatest public health
achievements of the 20th century."[2] It is therefore understandable
that fluoride therapy would be commonly practiced and in many
modalities. Many types of fluoride therapies are known, ranging from
at-home therapies (use of fluoridated toothpaste) to professionally
administered, such as topical fluorides provided by dental offices, to
publicly sponsored fluoridation of water or other commonly ingested
materials such as salt. At-home therapies can be further divided into
over-the-counter (OTC) and prescription strengths. The fluoride
therapies, whether OTC or PATF, are categorized by application –
dentifrices, mouthrinses, gels/ foams, varnishes, dietary fluoride
supplements, and water fluoridation.

2. Mechanism

All fluoridation methods provide low concentrations of fluoride

ions in saliva, thus exerting a topical effect on the plaque fluid.
Fluoride combats the decay primarily by the formation Fluorapatite
via remineralization of enamel. The fluoride ions reduce the rate of
tooth enamel demineralization, and increase the rate of
remineralization of the early stages of cavities.[3] Fluoride exerts its
major effect by this demineralization and remineralization cycle.
Fluoride also affects the physiology of dental bacteria,[4] although its
effect on bacterial growth does not seem to be relevant to cavity
prevention.[5] Fluoride has minimal effect on cavities after it is
swallowed.[6] Technically, fluoride does not prevent cavities but
rather controls the rate at which they develop.[7] Although fluoride is
the only well-documented agent with this property, it has been
suggested that also adding some calcium to the water would reduce
cavities further.[8]

3. Delivery

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 3.1. Water fluoridation

Main article: Water fluoridation

Water fluoridation is the controlled addition of fluoride to a

public water supply in order to reduce tooth decay.[9] Its use in the
U.S. began in the 1940s, following studies of children in a region
where water is naturally fluoridated. It is now used for about two-
thirds of the U.S. population on public water systems[10] and for
about 5.7% of people worldwide.[11] Although the best available
evidence shows no association with adverse effects other than
fluorosis, most of which is mild,[12] water fluoridation has been
contentious for ethical, safety, and efficacy reasons,[11] and
opposition to water fluoridation exists despite its support by public
health organizations.[13] As mentioned, fluoride primarily only helps
teeth when it is in the mouth. After it is swallowed, it has minimal
effect.

A 2000 systematic review of water fluoridation's effectiveness

found that fluoridation was associated with a decreased proportion
of children with cavities (the median of mean decreases was 14.6%,
the range −5% to 64%), and with a decrease in decayed, missing,
and filled primary teeth (the median of mean decreases was 2.25
teeth, the range 0.5 to 4.4 teeth). A more comprehensive 2007
review which used the 2000 review for its water fluoridation efficacy
conclusions affirmed this result.[12]

3.2. Toothpaste

Most toothpaste today contains 0.32% (1450 ppm) fluoride,

usually in the form of sodium fluoride or sodium
monofluorophosphate (MFP); 100 g of toothpaste containing 0.76 g
MFP equates to 0.1 g fluoride.

Prescription strength fluoride toothpaste generally contains 1.1%

(4,950 ppm) sodium fluoride toothpaste. This type of toothpaste is
used in the same manner as regular toothpaste. It is well established
that 1.1% sodium fluoride is safe and effective as a preventive of
caries. This prescription dental cream is used up to three times daily
in place of regular toothpaste.

3
 3.3. Mouth rinses

The most common fluoride compound used in mouth rinse is

sodium fluoride. Over-the-counter solutions of 0.05% sodium fluoride
(225 ppm fluoride) for daily rinsing are available for use. Fluoride at
this concentration is not strong enough for people at high risk for
caries.[citation needed]

Prescription mouth rinses are more effective for those at high

risk for caries, but are usually counterindicated for children,
especially in areas with fluoridated drinking water. However, in areas
without fluoridated drinking water, these rinses are sometimes
prescribed for children.

3.4. Gels/foams

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

The gel or foam is applied through the use of a mouth tray,

which contains the product. The tray is held in the mouth by biting.
Application generally takes about four minutes, and patients should
not rinse, eat, smoke, or drink for at least 30 minutes after
application.

Some gels are made for home application, and are used in a manner
similar to toothpaste. The concentration of fluoride in these gels is
much lower than professional products.

3.5. Varnish

Fluoride varnish has practical advantages over gels in ease of

application, a non-offensive taste, and use of smaller amounts of
fluoride than required for gel applications. Varnish is intended for
the same group of patients as the gels and foams. There is also no
published evidence as of yet that indicates that professionally
applied fluoride varnish is a risk factor for enamel fluorosis. The
varnish is applied with a brush and sets within seconds.

4
 3.6. Slow-release devices

Devices that slowly release fluoride can be implanted on the

surface of a tooth, typically on the side of a molar where it is not
visible and does not interfere with eating. The two main types are
copolymer membrane and glass bead. These devices are effective in
raising fluoride concentrations and in preventing cavities, but they
have problems with retention rates, that is, the devices fall off too
often.[14]

3.7. Dietary supplements

Dietary fluoride supplements in the form of tablets, lozenges, or

liquids (including fluoride-vitamin preparations) are used primarily
for children in areas without fluoridated drinking water. The
evidence supporting the effectiveness of this treatment for primary
teeth is weak. The supplements prevent cavities in permanent teeth.
A significant side effect is mild to moderate dental fluorosis.[15]

3.8. Indications for fluoride therapy

The individual's risk factors and the reason for treatment will
determine which method of fluoride delivery is used. Consult with a
dentist before starting any treatment.

• white spots
• Moderate to high risk patients for developing decay
• Active decay
• Orthodontic treatment
• Additional protection if necessary for children in areas without
fluoridated drinking water
• To reduce tooth sensitivity
• Protect root surface
• Decreased salivary flow
• Institutionalized patients

5
4. Health risks

Consumption of large amounts of fluoride can lead to fluoride

poisoning and death, but the amounts of fluoride amount to several
ounces for an adult. Chronic intake and topical exposure may cause
dental fluorosis, and excess systematic exposure can lead to
systemic effects such as skeletal fluorosis. Young children are at risk
for receiving excess fluoride, and the ADA has recently issued an
interim guidance on their fluoride consumption.[16]

4.1. Overdose

In 1974 a 3-year old child swallowed 45 milliliters of 2% fluoride

solution, estimated to be triple the fatal amount, and then died. The
fluoride was administered during his first visit to the dentist, and the
dental office was later found liable for the death.[17]

4.2. Fluorosis

See main article Dental fluorosis.

Most fluorosis is mild and cosmetic, but the chance of more

severe fluorosis increases with exposure. A recent report by National
Research Council (NRC) states that severe dental fluorosis can be
considered a "toxic effect" which increases the prevalence of caries
(106), but fluorosis this severe is not expected with the normal use
of fluoride therapy.

5. Fluoride conversion chart

APF (10)(%)(1000) ppm

1.0% 10,000
1.23% 12,300
NaF (4.5)(%)(1000) ppm
0.05% 225

6
 0.20% 900
0.44% 1,980
1.0% 4,500
1.1% 4,950
2.0% 9,000
5.0% 22,500
SnF2 (2.4)(%)(1000) ppm
0.40% 960
0.63% 1,512

6. References
1. ^ "ADA.org:A-Z Topics: Fluoride and Fluoridation". American
Dental Association.
http://www.ada.org/prof/resources/topics/fluoride.asp.
Retrieved 11 August 2009.[dead link]
2. ^
http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm
3. ^ Pizzo G, Piscopo MR, Pizzo I, Giuliana G (2007). "Community
water fluoridation and caries prevention: a critical review".
Clin Oral Investig 11 (3): 189–93. doi:10.1007/s00784-007-
0111-6. PMID 17333303.
4. ^ Koo H (2008). "Strategies to enhance the biological effects
of fluoride on dental biofilms". Adv Dent Res 20 (1): 17–21.
doi:10.1177/154407370802000105. PMID 18694872.
5. ^ Marquis RE, Clock SA, Mota-Meira M (2003). "Fluoride and
organic weak acids as modulators of microbial physiology".
FEMS Microbiol Rev 26 (5): 493–510. doi:10.1016/S0168-
6445(02)00143-2. PMID 12586392.
6. ^ Featherstone JD (1999). "Prevention and reversal of dental
caries: role of low level fluoride". Community Dent Oral
Epidemiol 27 (1): 31–40. doi:10.1111/j.1600-
0528.1999.tb01989.x. PMID 10086924.

7
 7. ^ Aoba T, Fejerskov O (2002). "Dental fluorosis: chemistry
and biology". Crit Rev Oral Biol Med 13 (2): 155–70.
doi:10.1177/154411130201300206. PMID 12097358.
http://cro.sagepub.com/cgi/content/full/13/2/155.
8. ^ Bruvo M, Ekstrand K, Arvin E et al. (2008). "Optimal drinking
water composition for caries control in populations". J Dent
Res 87 (4): 340–3. doi:10.1177/154405910808700407.
PMID 18362315.
9. ^ Centers for Disease Control and Prevention (2001).
"Recommendations for using fluoride to prevent and control
dental caries in the United States". MMWR Recomm Rep 50
(RR-14): 1–42. PMID 11521913.
http://cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm.
10.^ Ripa LW (1993). "A half-century of community water
fluoridation in the United States: review and commentary". J
Public Health Dent 53 (1): 17–44. PMID 8474047.
11.^ a b Cheng KK, Chalmers I, Sheldon TA (2007). "Adding
fluoride to water supplies". BMJ 335 (7622): 699–702.
doi:10.1136/bmj.39318.562951.BE. PMID 17916854.
PMC 2001050.
http://www.bmj.com/cgi/content/full/335/7622/699.
12.^ a b National Health and Medical Research Council (Australia)
(2007). "A systematic review of the efficacy and safety of
fluoridation" (PDF).
http://www.nhmrc.gov.au/PUBLICATIONS/synopses/_files/eh41.
pdf. Retrieved 2009-02-24.[dead link] Summary: Yeung CA (2008).
"A systematic review of the efficacy and safety of
fluoridation". Evid Based Dent 9 (2): 39–43.
doi:10.1038/sj.ebd.6400578. PMID 18584000. Lay
summary – NHMRC (2007).
13.^ Armfield JM (2007). "When public action undermines public
health: a critical examination of antifluoridationist literature".
Aust New Zealand Health Policy 4: 25. doi:10.1186/1743-
8462-4-25. PMID 18067684. PMC 2222595.
http://anzhealthpolicy.com/content/4/1/25.
14.^ Pessan JP, Al-Ibrahim NS, Buzalaf MAR, Toumba KJ (2008).
"Slow-release fluoride devices: a literature review". J Appl Oral
Sci 16 (4): 238–46. doi:10.1590/S1678-77572008000400003.
PMID 19089254. http://www.scielo.br/scielo.php?
script=sci_arttext&pid=S1678-
77572008000400003&lng=en&nrm=iso&tlng=en.
8
 15.^ Ismail AI, Hasson H (2008). "Fluoride supplements, dental
caries and fluorosis: a systematic review". J Am Dent Assoc
139 (11): 1457–68. PMID 18978383.
http://jada.ada.org/cgi/content/full/139/11/1457.
16.^ ADA. (2006). Interim Guidance on Fluoride Intake for Infants
and Young Children
17.^ New York Times. (1979). $750,000 Given in Child's Death in
Fluoride Case: Boy, 3, Was in City Clinic for Routine Cleaning.
NYT archive, free full-text available at NYT here.

Further reading

• Committee on Fluoride in Drinking Water, National Research

Council. (2006). Fluoride in Drinking Water: A Scientific
Review of EPA's Standards. National Academies Press.
• government guidelines
• Fluoride History History of fluoride therapy including early
patents
• Clark CD. Appropriate use of fluorides in the 1990s. J Canad
Dent Assoc. 1993;59:272-279.
• Hawkins R, Locker D, Noble J, Kay EJ. Prevention. Part 7:
Professionally applied topical fluorides for caries prevention.
British Dental J. 2003: Vol. 195, No 6: 313-317.
• Moran R, Saemundsson S. Fluoride Varnish: An alternative to
traditional topical fluoride therapy. Department of Pediatric
Dentistry, University of North Carolina 1996
• Stookey GK. Review of fluorosis risk of self-applied topical
fluorides: dentifrices, mouthrinses and gels. Community Dent
Oral Epidemiol. 1994;22:282-286