Fluoride and childhood

caries
Nutritional Management of
Periodontal Disease
Dr. Susan Yanga-Mabunga

Dental Public Health Section

Department of Health Policy and Administration
College of Public Health , University of the Philippines Manila

SEAMEO-TropMed Regional Centre for Public Health,

Hospital Administration, Environmental and Occupational
Health
By the end of the session, the
students should be able to

Discuss the role of fluoride in the
prevention of dental caries

Identify nutritional considerations in
the prevention and management of
periodontal disease
Fluorides in dentistry

What are fluorides?

Why do we use fluoride in
dentistry? How does it work?

How should we use fluoride to
prevent dental caries?

What is fluorosis
What are fluorides?

Fluoride is a mineral

Fluoride ion comes from the element
fluorine
 Fluorine is 17th most abundant element in the
earths crust
 Never encountered in its free state in nature
 Exits only in combination with other elements
as a fluoride compound
How does it work?

Changes the crystalline structure of
enamel to make it less soluble.

Suppresses cariogenic bacteria in
dental plaque.

Acts on the enamel surface to inhibit
bacterial adhesion
Changes the
crystalline structure of
enamel to make it less
soluble.
Nature of tooth mineral

{{ Ca
Ca10-x(Na)
10-x (Na)xx
(PO
(PO4 ))6-y
4 6-y
(CO
(CO3 ))
3 zz (OH)
(OH)
2-u(F)
2-u(F)u}
u}
Highly
Highly substituted
substituted carbonated
carbonated apatite
apatite
Most
Most soluble
soluble

Ca
Ca1010(PO
(PO44))66(OH)
(OH)22
hydroxyapatite
hydroxyapatite(less
(lesssoluble)
soluble)

Ca
Ca1010(PO
(PO44))66(F)
(F)22==fluoroapatite
fluoroapatite
Least
Least soluble
soluble
 Mechanism of action
OLD
OLD concept
concept ::

Recent
Recent evidences
evidences That
That major
major inhibitory
inhibitory
shows
shows that
that the
themain
main effect
effect was
was thought
thought to to
effect
effect of
of fluoride
fluoride in
in be
be due
due to
to its
its
caries
caries prevention
prevention are
are incorporation
incorporation in in tooth
tooth
 POST
POSTERUPTIVE
ERUPTIVE
mineral
mineral during
during the
the
 Through development
development of of the
the
ThroughTopical
Topical
effect tooth
tooth prior
prior to
to eruption
eruption
effect
Mechanism of action

Fluoride
Fluoride incorporated
incorporated 
Fluoride
Fluoride incorporated
incorporated
during
during mineral
mineral developmentally
developmentally into into
development
development at at the
the normal
normal tooth tooth
normal
normal levels
levels of
of 20-
20- mineral
mineral isis insufficient
insufficient
100
100 ppm
ppm doesdoes not
not to
to have
have aa measurable
measurable
alter
alter the
the solubility
solubility of
of effect
effect on
on acid
acid
the
the mineral.
mineral. solubility
solubility
Mechanism of action

Only
Only when when fluoride
fluoride is is
concentrated
concentrated into into aa new new
crystal
crystal surface
surface during
during Re Re
mineralization,
mineralization, is is itit sufficient
sufficient
to
to alter
alter solubility
solubility beneficially.
beneficially.
 Mechanism of action

IfIf fluoride
fluoride isis present
present inin the
the plaque
plaque
fluids
fluids atat the
the time
time that
that bacteria
bacteria generate
generate
acids,
acids, itit will
will travel
travel with
with the
the acid
acid down
down
into
into the
the subsurface
subsurface of of the
the tooth,
tooth, adsorb
adsorb
to
to the
the crystal
crystal surface
surface and
and protect
protect itit
from
from being
being dissolve.
dissolve.
Source: Featherstone , 1999
Fluoride inhibits
plaque bacteria.
Fluoride inhibits plaque
bacteria

Fluoride can not cross the cell wall and
membrane in its ionized form(F-) but can rapidly
travel through the cell wall and into the
cariogenic bacteria in the form of HF.

Once inside the cell ,the HF dissociates again
acidifying the cell and releasing fluoride ions that
interfere with enzyme activity in the bacterium.

Interferes with glycolysis
 HF H+

H+ + F - HF F-

Bacterial Cell

pH 7 H+ + F- HF

pH 4.5 H+ + F- HF

Acts on the enamel
surface to inhibit
bacteria adhesion
Sources of fluoride

Natural foods 
Dentrifices
 Tea, sea foods, 
Professionally applied
 Water 
Fluoride supplements

Fortified
 Milk
 Salt
Sources of fluoride

Milk formulas ( .05 to .35 ppm)

Soy Beans Formula ( 0.17 to 0.38 ppm)

Bottled Mineral

In beverages :
 Tea ( raw tea leaves 400 ppm)
 Brewed tea ( 0.1 to 4.2 ppm_
 Daily consumption of 1 cup (200 ml) would yield 0.6
mg F/day
Sources of fluoride

Fish and seafood products
 Dried seafoods (can contain 290 ppm)
 Canned seafoods ( can contain 40 ppm)

Chicken products (0.6 to 10.6 ppm)

Salt with Fluoride, Sugar with Fluoride
Sources of fluoride

Dental Products
 Dentifrices
 Fluoride mouth rinse
 Professional applied fluorides
 Dietary fluoride supplements
 Fluoride metabolism and
excretion
Fluoride in •50 % of the
Food, water absorbed
fluoride will be
associated
75 to 90 % absorbed with calcified
from the alimentary tissue
tract, more from liquids
than solids (10 to 25% •50% excreted
excreted via feces) in urine

50:50 distribution is shifted strongly in favor of retention

in the very young, greater excretion in later years of life
Fluoride Toxicity

Acute fluoride toxicity
 5.0 mg per kg or more
 Very rare

Most recorded fatalities are suicides

Dental related fatalities are very rare
 Accidental swallowing of fluoride supplements

Chronic Fluoride toxicity
Fluoride Toxicity
PTD: Probable Toxic Dose

minimum dose that would cause toxic
signs and symptoms including death and
should trigger treatment management
and hospitalization.

5 mg fluoride/kg (Whitford,1987)
Acute Fluoride Toxicity
Accidental poisoning with

Toothpaste with Fluoride

Mouthwash with Fluoride
“usual cases reported are due to accidental
ingestion of fluoride rinses and tables-
usually by very young children”
Fluorosis

Skeletal Fluorosis

Dental Fluorosis
Chronic Fluoride Toxicity
Chronic Toxicity:
“other than dental fluorosis, there are no
known adverse effects of ingesting fluoride
in a chronic basis at levels associated with
drinking water concentrations of 4 p.p.m or
less.”
Things you should know

Skeletal fluorosis 
Osteosarcoma
 Confined to individuals
exposed to very high
 Studies have
fluoride failed to identify
 Usually associated with
any correlation
industrial situation or with fluoride
unusually very high
fluoride level in drinking history
water of 10mg/l
Dental Fluorosis

Will only affect teeth which are exposed to
obove optimal levels of fluoride during
enamel maturation

Once the tooth has erupted, dental fluorosis
can not take place.
 Types of Fluoride Used in
Dentistry

Water fluoridation

School Water fluoridation

Dietary fluoride supplements

Self applied fluorides

Dentifrices with fluorides

Professionally applied fluoride
How to avoid Fluoride Toxicity
1. Parental supervision of the use of the
product that are used by children at home.
2. Teach children at an early age to
expectorate the product.
3. Keeping the product out of reach of
children
How to avoid Fluoride Toxicity
Manufacturer:
1. Decreasing the level of fluoride
concentration for children.(???)
2. Encouraging the use of pea size amount
3. Equip product containers with tops that are
difficult to open ( child proof)
Issues
1. Instituting regular tooth brushing drills will
fluoride toothpaste in all school
2. The monitoring of fluoride content in toothpaste?
3. Is there a need for lower fluoride content
toothpastes for children?
4. Dental professionals are not fully informed about
fluorides and fluorosis.
Nutritional management of
Periodontal diseases
Periodontium
 Gingiva
Gingiva
 Alveolar Bone
Alveolar Bone
 Cementum
Cementum
 Periodontal
Periodontal
Ligaments
Ligaments
 Connective Tissue
Connective Tissue
PERIODONTAL DISEASE

DISEASES OF THE GUMS

DISEASES RELATED TO THE
PERIODONTIUM
 Nutrition
(modifiable variable
Host response and
susceptibility
to infection)

Host

Environment
Pathogens
Microorganism
 Periodontal disease

Delicate balance between host, environmental and
bacterial factors

Complex interaction between pathogenic bacteria
and host response to infection

Primary etiology is bacterial (anaerobic) but
susceptible host is necessary for disease initiation

Nutrition is a modifiable factor that impacts on
host immune response and the integrity of the
hard and soft tissues
Three main nutritional
considerations

Integrity of the oral mucosa

Maintenance of the hard tissues

Maintenance of the immune
response
 1. Integrity of the oral mucosa
Vitamin B Co factor for Energy Metabolism, and
needed in DNA, RNA synthesis
Tissue maintenance and new cell
production
Healing
Most common sx of vit b deficiency:
loss of integrity of the oral mucosa
Stomatitis, angular cheilitis,glossitis
 Integrity of the oral mucosa
C Prevents oxidative cell damage, aids in the
(Ascorb maintaining the integrity of the oral mucosa.
ic acid) Maintains microvasculature of the sulcus
Vit c def: Bleeding (increase permeability of
bld vessels)
Hydroxyline formation(stabilizes the
structure of collagen by cross linking) ,
collagen formation,

 Citrus fruits, dark and leafy green

vegetable, potatoes, cantaloupe
 Integrity of the oral mucosa
Vitamin A DNA and RNA replication
Zinc Transcription of RNA
Translation of protien necessary
for new cell growth

Early sign of vit a def: decrease in

the rate of proliferation of
epithelium
Wound healing
 Integrity of the oral mucosa
Minerals Collagen Supplementation
metabolism of minerals above
RDA is not
Boron recommended
Copper Cross-linking of Zinc, copper and
collagen and elastin iron all compete for
Manganese absorption so must
be balanced for
Silicon optimum wound
Zinc Protien synthesis healing
2. Maintenance of Calcified
Tissues

Vitamins A, D,C,K

Zinc, Magnesium,Phosporus and Calcium
 Maintenance of Calcified
Tissues
Vit Regulates the absorption of
D calcium from the GIT to maintain
calcium balance
Fortified
milk, eggs Inadequate Ca intake, Vit D
liver stimulates osteoclastic activities,
mobilizes calcium stored in bone
Collagen synthesis and
accumulation of mineralized bone are
dependent on adequate levels of Vit
D and Calcium
 Maintenance of Calcified
Tissues
Vit Bone density and strenght
K Anti coagulant theraphy (group at
risk)
Green, leafy vegetables,liver
 Vitamin C deficiency

Goetzl, Wasserman , Gilgi and Austen
(1974) : Vit C enhances the motility of
polymorphonuclear leukocytes

Sandler , Gallin, Vaughan (1975):decreases
host immune response
National Health and Nutrition
Examination Survey

Sample of 12,419 adults

Ages 20 to 90 years

Dental Measurements

Dietary assessment

Demographic and medical histories
 NHANES III results

OR of having

Smokers, and former
periodontal disease is smokers with low
1.2 times greater in vitamin C intake are
those with low dietary at 1.6 times greater
Vitamin C intake risk of having
periodontal disease
Nishida, Grossi, Dunford, Ho,
Trevisan and Genco (2000)

“…dietary Vit C intake was weakly but
statistically significantly associated with
periodontal disease…

There is no clear evidence that supplementary vit.
C and possible other anti-oxidant will improve
periodontal health and response to therapy in
current and former smokers”
Boyd and Lampi (2001)

… “ megadoses of vitamin C have not
been shown to have a strong effect in
the healing response in initial
periodontal therapy and therefore
pharmacological doses should not be
recommended”
 Maintenance of hard tissue
(Bone remodeling)
Minerals
Calcium Milk products, tofu fortified with
calcium, legumes, fortified breakfast
cereal, orange juice
Copper
Boron
Magnesium
 NHANES III results

Risk of periodontal 
27% greater for
disease was 59%
those taking less
greater in women
with less than than 800 mg/day
500mg/day of
Calcium
 Boyd and Lampi (2001)


However it remains unclear how calcium
supplements might impact the course of
periodontal disease
3. Maintenance of Host
Immune Response

Nutritional deficiencies quickly
alter immune cell function and
increases the risk of infection
Maintaining host immune
response

Proteins:

Antioxidants
 Vitamin A, C, E
 Minerals : Zinc, Copper, Iron, and Selenium
 3. Maintenance of Host Immune
Response

Protiens Mild protein malnutrition decreases

effectiveness of the inflammatory
response to invading pathogens
Neutrophil functioning
Collagen synthesis