Community Based F delivery Flashcards
(37 cards)
effect of F dentally
systemic Vs topical effect
Original belief
- Beneficial effect of F- was its systemic pre-eruptive effect (strengthening enamel during tooth development)
BUT
Dental caries
dynamic process of demineralisation and remineralisation
- Therefore – constant supply of fluoride in oral cavity is most important factor to inhibit demineralisation and encourage reminerlisation
now recognised as primary mode of action of F
in reducing dental caries = post-eruptive
i.e. topical effect
vehicles for F delivery (7)
water
salt
milk
varnishes/gels
rinses
supplements i.e. drops/tablets
toothpaste
Fluoridated salt
First introduced - Switzerland (1955)
- Subsequently used in France, Colombia, Spain & Hungary + others (1960’s onwards)
Switzerland
(90mgF/kg) -> 25% caries reduction after 12 yrs
Hungary
(250-350 mgF/kg) -> 53-68% caries reduction after 10 yrs use
Previously considered most important community F- delivery system, other than water F-
- 2nd to water-F- as means of ensuring ingestion of F-
Caries-preventive effect comparable to that of water fluoridation
- Requires little conscious action by the individual
0 Provides element of choice/ but public health effectiveness diminished
disadvantages of F salt community strategy
In communities with small levels of water F- need for varying levels of F- in salt
- (? Logistics – manufacturers + distributors)
Mixed messages from health professionals
- risk of cardiovascular disease
F milk
Some public health programmes carried out (Mainly school-children)
Glasgow : 1976-1981 (1.5mg in 200ml)
- 48% diff. Mean DMFS between cases and controls
N.W. England: 1997-2001 (0.5mg in 189ml)
- No caries reduction in primary dentition (children aged 3-5 yrs) and only small reduction in permanent dentition up to 8 yrs of age (not clinically significant)
potential factors influencing results of Fluoridated Milk schemes (6)
Age at commencement
Population
F- concentration
Frequency of use
Distribution system
Compliance/drop out rate
advantages of F milk (3)
Natural healthy drink for children
Important part of child’s diet – rich in nutrients
Enables fluoride to be targeted to those who would benefit most
disadvantages of F milk
Distribution delayed until nursery/school age
Not all children drink milk
Distribution system/shelf life/cost issues (higher than water F-)
? lack of long term benefit
APF gels
acidulated phosphate fluoride gels
APF gels application
Professionally applied (or self-applied under supervision)
operator-applied fluoride gels use trays and self-applied gels use either a tray or a toothbrush
Time consuming to apply (approx. 30 mins) – up to x2 / year
Special equipment necessary, i.e. custom-made trays
High cost per tooth surface saved (£11)
APF gels F concentration
12,300 ppm
Fluoride gels must be differentiated from some fluoride toothpastes,
The ‘classical’ fluoride gels do not contain abrasives, their fluoride concentration is usually much higher than that of a fluoride toothpaste, and they are applied at relatively infrequent intervals
Acute toxicity risk
- if ingested - causes sickness (not uncommon = not recommended for young children)
probable toxic dose (PTD) of 100 mg of fluoride for a 20 kg (5-6 year-old) child is contained in only 8 ml volumes of these gels.
- Approximately 5 ml of gel is used in a topical application of APF gel in a tray
representing a potential exposure of 61.5 mg of fluoride ion
F mouth rinses
Early studies (1960’s-1970’s) effectiveness in caries reduction.
Since caries decline (1970’s), doubts about marginal benefit + cost effectiveness
Reasonable to use F- mouthrinsing in high-caries-risk populations. Benefit doubtful in low-risk groups
Not recommended for <7 yr. olds
F supplements (tablets/drops)
In use since 1940’s
Originally used :
birth to 6 yrs (previous belief in importance of systemic effect).
Later :
Proven post-eruptive topical cariostatic benefits in school-aged children > 5.5 yrs old
Systemic effect much less important than topical effect
therefore appropriate to advise continuation beyond 6yrs old for at-risk children (with additional needs / special care requirements)
F supplement dosage in Area with water F- <0.3 ppm fluoride
Age mg F- per day 0 - 6 months 0 6 months - 3 yrs 0.25 3 yrs - 6 yrs 0.50 6 yrs and over 1.00
F supplements advice now
Agreed now :
Pop. level - Tends to be poor compliance
not suitable as public health measure (Best results in school-based programmes)
- Should be directed towards “at-risk” children only
- Careful assessment of risks and benefits for children <7yrs old, i.e. risk of fluorosis
F varnish
designed to hold F- in close contact with tooth for a period of time
Proven efficacy in caries prevention via systematic reviews
(Marinho : dmfs PF = 33% in primary teeth)
PF = Incidence in Exposed – Incidence in Unexposed.
F varnish evidence
Cochrane Review 1 (Marinho et al. 2002)
- F Varnish effective for preventing decay – in patients and communities
But, more research needed
Cochrane Review 2 (Hiiri et al. 2010)
- F Varnish vs Fissure sealants
- Ltd evidence
Cochrane Review 3 (Marinho et al 2013)
- substantial caries inhibiting effect of FV in both permanent and primary teeth.
- quality of evidence moderate
SDCEP guidance on managing and preventing dental caries in children
F varnish application
professionally applied
Need to be reapplied at regular intervals
Emerging consensus re. optimum application frequency (2-4/year depending on caries risk)
- ? Cost-effectiveness
Major component of Childsmile
F toothpaste
Most widely used fluoride delivery vehicle in the world
500m of world’s pop. use F- toothpaste
Considered as single most important factor in caries decline
- Caries decline - late 70’s/early 80’s
- Sale of F- toothpaste - <5% in 1970 to >95% in 1977.
Fluoride toothpaste/brushing factors (4)
(A) Concentration (amount) of fluoride
(B) Frequency of brushing
(C) Age at commencement of brushing
(D) Post-brushing rinsing
[age, specific guidance – children / adults]
Concentration of F in toothpaste
Evidence of dose-response relationship re. caries-preventive effect
Findings : Each additional 500ppmF- over & above 1000ppmF = a cumulative 6% reduction in caries increment.
Evidence from Systematic Reviews -
- Cochrane Review (2001) : - 8% increase in DMFS prevented fraction per 1000ppmF-
- Swedish Review (2003): - Mean diff. in DMFS prevented fraction between 1500ppm & 1000ppm of 9.7%
PF = DMFS Incidence in Exposed - Unexposed
Limited evidence for caries-preventive effect of toothpaste with = 550ppmF-
Colgate children’s toothpaste + Macleans Milk Teeth
- traditionally 500ppmF-.
- more recently 1000ppmF-
Controversy re. F- dose for young children
- tendency to swallow toothpaste so risk of fluorosis
BUT - Loss of caries-preventive efficacy with 500ppmF- and lower
- Balance risk of fluorosis with benefit in caries reduction
Current evidence (no water F-) : - 1500ppmF- toothpaste & limit to pea-sized amount or smear
amount of F toothpaste on dry toothbrush
smear 0-2 (half brush length smear)
pea size 2+
frequency of brushing with F toothpaste
Good evidence from Systematic Reviews
= Morinho et al (2010) Cochrane Review
that effect of F- toothpaste inc with higher freq. of use
(i.e. 14% increase in DMFS ‘prevented fraction’ with twice-daily brushing as opposed to once daily).
Current advice = brush at least twice daily
- Pre-school children using 1500ppmF-
- Regulate quantity of toothpaste to smear or pea-sized amount
- Parental help/supervision to avoid swallowing
