fluoride therapy for caries prevention/control

Question 1

“_______/________ remains the most prevalent chronic disease in both children and adults, even though it is largely ________.”

• ___________ and __________

Answer 1

“Dental caries (tooth decay) remains the most prevalent chronic disease in both children and adults, even though it is largely preventable.”

-National Institute of Dental and Craniofacial Research

Question 2

caries is a _______ infectious disease

primary modifying factors: (8)

secondary modifying factors: (7)

Answer 2

caries is a multifactorial infectious disease

primary: tooth anatomy, saliva, biofilm ph, use of fluoride, diet specifics, oral hygiene, immune system, genetic factors

secondary: socioeconomic status, education, life style, environment, age, ethnic group, occupation

Question 3

what four categories make up the inner circle for caries in the absence of protective factors and if other risk factors are present

Answer 3

host, time, fermentable carbohydrates, and cariogenic bacteria

Question 4

describe the process of demineralization

3 bacteria
4 carbs
=

Answer 4

cariogenic bacteria such as S. mutans, S. sobrinus, and Lactobacilli

combine with fermentable carbohydrates such as sucrose, glucose, fructose, or cooked starch

and create organic acids that penetrate enamel and dentin and dissolve tooth minerals

Question 5

describe the process of remineralization

Answer 5

calcium in tooth water/saliva

+ phosphate in tooth water/saliva

= remineralization: builds on existing crystal remnants; new mineral is less soluble; fluoride speeds up remineralization

Question 6

pH

• ranges from:
• lower number =
• higher number =
• neutral ph =
• when does demineralization occur

Answer 6

0 (acidic) - 14 (alkaline)

lower number = more acidic

higher number = more alkaline/basic

neutral = 7

demineralization occurs at 5.5 or less!

Question 7

demineralization/remineralization

______ process

demineralization starts with _______: the ph drops to ____

how long does it take for ph to return to normal

what plays a key role in neutralizing acids

remineralization occurs when ph _______ and minerals are available for ______

imbalance of _______ results in caries

Answer 7

ONGOING process

demineralization starts with CARBOHYDRATE ATTACKS: the ph drops to 5.5 OR LESS

how long does it take for ph to return to normal: 30-60 MIN

what plays a key role in neutralizing acids: SALIVA

remineralization occurs when ph NEUTRALIZES and minerals are available for UPTAKE

imbalance of PATHOGENIC FACTORS results in caries

Question 8

think of a see saw

pathologic factors balancing protective factors

Answer 8

pathologic: (caries)
- acid producing bacteria
- frequent consumption of fermentable carbohydrates
- subnormal salivary flow/function

protective: (no caries)
- high saliva flow and components
- fluoride: remineralization
- antibacterials: chlorhexidine, xylitol

Question 9

risk factors for caries (9)

Answer 9

• med/high S. mutans and lactobacilli counts
• visible heavy plaque
• frequent snacking between meals
• deep pits/fissures
• Recreational drug use
• Inadequate salivary flow
• Saliva-reducing factors (medications)
• Exposed roots
• Orthodontic appliances

Question 10

caries protection factors (8)

Answer 10

• Drinks fluoridated water
• Uses fluoride toothpaste at least twice daily
• Uses fluoride mouthrinse daily
• Had fluoride varnish/topical applied in the last 6 months
• Use of prescribed chlorhexidine
• Use of xylitol gum or lozenges
• adequate salivary flow

Question 11

Fluoride: _____ occurring element in many ____, ____, ______

Fluoride can have a dramatic caries _____ and ________ effects

Answer 11

Fluoride: NATURALLY occurring element in many WATER, FOODS, AND MINERALS

Fluoride can have a dramatic caries PREVENTIVE and REPARATIVE effects

Question 12

what are the 3 mechanisms of action for fluoride

Answer 12

1. inhibits demineralization
2. enhances remineralzation
3. inhibits plaque bacteria

Question 13

DEMINERALIZATION
- ________ metabolism
- Rapid ___ in plaque pH
- Diffusion of acids into _____
- ________ and ______ dissolve
- Carious lesion formation

REMINERALIZATION
- _____ pH of oral environment
- ______ flow
- Re-deposition of minerals
- _____ of carious lesions

Answer 13

DEMINERALIZATION
- Carbohydrate metabolism
- Rapid drop in plaque pH
- Diffusion of acids into enamel
- Calcium and phosphate dissolve
- Carious lesion formation

REMINERALIZATION
- Neutral pH of oral environment
- Salivary flow
- Re-deposition of minerals
- Repair of carious lesions

Question 14

mechanism 1: inhibits demineralization

• fluoride flows into ______
• _______ acidic environment
• reduces the _____ of tooth material

Answer 14

• fluoride flows into TOOTH SURFACE
• NEUTRALIZES acidic environment
• reduces the SOLUBILITY of tooth material

Question 15

mechanism 2: enhances remineralization

• Presence of ___ is mandatory
• Allows for influx of _____, ______, ______ onto tooth surface
• _______ bond formed: ______ than original tooth structure
• Remineralized lesions are less susceptible to _________

Answer 15

• Presence of SALIVA is mandatory
• Allows for influx of CALCIUM, PHOSPHATE, AND FLUORIDE onto tooth surface
• FLUORAPATITE bond formed: STRONGER than original tooth structure
• Remineralized lesions are less susceptible to FUTURE DEMINERALZATION

Question 16

mechanism 3: inhibits plaque bacteria

• Fluoride in biofilm is taken up by ________
• Interferes with ____ production

Answer 16

Fluoride in biofilm is taken up by acid-producing bacteria

Interferes with acid production

Question 17

COMMUNITY WATER FLUROIDATION

defined as:

• most common ________
• i_____
• e______
• s____

Answer 17

defined as: The adjustment of the natural fluoride ion content in a municipal water supply to the optimum physiologic concentration that will maximize caries prevention and limit enamel fluorosis

• most common FLUORIDE DELIVERY SYSTEM
• INEXPENSIVE
• EFFECTIVE
• SAFE

Question 18

what is the number 1 way to prevent dental decay

Answer 18

community water fluroidation

Question 19

statistics from CWF

first communities fluoridated in ___

in ___, ___% of the US population served by _____ water systems received fluoridated water (CDC)

Healthy People 2030 goal: ___% of people receive fluoridated water

Starting in ____, the Public Health Service recommended fluoride level in water to be ___ppm

Answer 19

first communities fluoridated in 1945

in 2020, 72.7% of the US population served by PUBLIC water systems received fluoridated water (CDC)

Healthy People 2030 goal: 77% of people receive fluoridated water

Starting in 2015, the Public Health Service recommended fluoride level in water to be 0.7ppm

Question 20

Benefits of community water fluoridation (4)

Answer 20

• reduces cost of dental treatment
• no licensed professional needed
• client compliance
• caries reduction among children and adults!

Question 21

prescription fluoride supplements

Forms:

Warnings:

concentrations:

who is it for

Answer 21

Forms:
- drops for children 6months-3years
- tablets/lozenges for ages 4+, chew or let dissolve in mouth at bedtime

Warnings:
- avoid milk: calcium interferes with fluoride by binding to it in the digestive system and reducing the fluoride absorption

concentrations:
- 0.25mg
- 0.50mg
- 1.0mg

who is it for
- children with high caries risk and don’t receive enough or any fluoridated water (below 0.7ppm)

Question 22

FLUORIDE SUPPLEMENT DOSE SCHEDULE (less than .3ppm, 0.3-0.6ppm, greater than 0.6ppm)

0-6months
6months-3years
3-6 years
6-16 years

Answer 22

0-6months: 0, 0, 0

6months-3years: .25mg, 0 , 0

3-6 years: .50mg, .25 mg, 0

6-16 years: 1mg, .5mg, 0

Question 23

TOPICAL FLUORIDE

Low-concentration (_____) products are applied ______

High-concentration (_______) products are applied ___ frequently

3 forms:

Answer 23

Low-concentration (LOW POTENCY) products are applied FREQUENTLY

High-concentration (HIGH POTENCY) products are applied LESS frequently

3 forms:
- self applied OTC
- self applied prescription
- professionally applied presciption

Question 24

self applied fluoride mouthrinses

_____ NaF - ___ppm fluoride

__ potency, ___ frequency

adjunct to _____

_____% reduction in caries

EX: 2

USE:
- pour dose according to instructions
- swish for __ then spit
- once or twice a day
- do not eat for __ after

Answer 24

0.05 NaF - 220 ppm fluoride

low potency, high frequency

adjunct to toothpaste

30-35% reduction in caries

EX: act, listerine total care

USE:
- pour dose according to instructions
- swish for 60 sec then spit
- once or twice a day
- do not eat for 30 min after

Question 25

SELF APPLIED DENTIFRICES Other than _________, dentifrices are the most widely used fluoride Dentifrices in the United States contain _______ ppm fluoride Most dentifrices contain one of the following: (3) Brushing ___ daily with fluoride-containing dentifrice is effective for _______ Do not _____ afterward

Answer 25

Other than DRINKING WATER, dentifrices are the most widely used fluoride Dentifrices in the United States contain 1000-1100 ppm fluoride Most dentifrices contain one of the following: STANNOUS FLUORIDE (SnF2), SODIUM FLUORIDE (NaF), or SODIUM MONOFLUOROPHOSPHATE (NaMFP) Brushing TWICE daily with fluoride-containing dentifrice is effective for PREVENTING DECAY Do not RINSE afterward

Question 26

SELF APPLIED DENTIFRICES Recommended for ___ patients no matter their caries risk Foundation for all patients ______ regimens Look for _____ ____ concentrations of fluoride Promotes enamel ________ Higher concentrations available by _________

Answer 26

Recommended for ALL patients no matter their caries risk Foundation for all patients FLUORIDE regimens Look for ADA SEAL LARGE concentrations of fluoride Promotes enamel REMINERALIZATION Higher concentrations available by PRESCRIPTION

Question 27

SELF APPLIED PRESCTIPTION DENTIFRICES Prescription dentifrice with ____ fluoride concentration is more effective for _______ patients ____ ppm Available in the _____ office Examples: (2)

Answer 27

Prescription dentifrice with HIGH fluoride concentration is more effective for HIGH-RISK patients 5000 ppm Available in the DENTAL office Examples: - Clinpro 5000 - PreviDent 5000 plus

Question 28

SELF APPLIED FLUORIDE GELS _____ use Brushed on teeth after brushing with fluoride _______ Keep in mouth for __ then expectorate Types: (3)

Answer 28

DAILY use Brushed on teeth after brushing with fluoride DENTIFRICE Keep in mouth for 1 MIN then expectorate Types: - stannous fluoride (SnF2) with 1000ppm (OTC) - sodium fluoride (NaF) with 5000ppm (Rx) - acidulated phosphate fluoride (APF) with 5000ppm (Rx)

Question 29

FLUORIDE AND CHILDREN Involve the client’s ____ or _____ Emphasize key information: - Importance of _____ of children when brushing their teeth - Limit the _____ of _______ - younger than __ (grain-sized) - ages ___ (pea-sized) - No _____ or _____ prior to age __ - Importance of _________ - Store products out of the ______ of children

Answer 29

Involve the client’s parent or caregiver Emphasize key information: - Importance of SUPERVISION of children when brushing their teeth - Limit the AMOUNT of DENTIFRICE - younger than 3 (grain-sized) - ages 3-6 (pea-sized) - No MOUTHRINSE or GELS prior to age 6 - Importance of SPITTING/EXPECTORATING - Store products out of the REACH of children

Question 30

NaF gel/foam: neutral/7ph form concentration application mode/frequency notes

Answer 30

FORM: 2% gel or foam CONCENTRATION: 9050ppm .9% F ion APPLICATION: tray (4 min)/no currently recommended interval; most commonly applied every 3-6 months NOTES: do not overfill

Question 31

Acidulated phosphate: 3.5 ph form concentration application mode/frequency notes

Answer 31

form: 1.23% gel or foam concentration: 12300ppm 1.23% F ion application mode/frequency: tray (4min)/at least every 3-6 months notes: do not overfill

Question 32

NaF (varnish): neutral/7ph form concentration application mode/frequency notes

Answer 32

form: 5% varnish concentration: 22600ppm 2.26% F ion application mode/frequency: apply thin layer with a soft brush (1-2min)/at least every 3-6 month notes: sets up to a hard film

Question 33

SDF: ph 8-10 form concentration application mode/frequency notes

Answer 33

form: 5-5.9% Fluoride concentration: 44800ppm 4.48% F ion application mode/frequency: apply thin layer with a microbrush (1min and let dry, then rinse with water)/at least every 6-12 months notes: goes on clear, becomes black/gray upon application to cavitated areas

Question 34

NaF GEL ____% NaF Sometimes called ____ NaF due to neutral pH of __ _____ ppm fluoride ion __-minute tray application Most commonly applied every 3-6 months

Answer 34

2.0% NaF Sometimes called Neutral NaF due to neutral pH of 7 9,050 ppm fluoride ion 4-minute tray application Most commonly applied every 3-6 months

Question 35

APF gel ___% APF ___ pH increases fluoride uptake Uptake greatest during the first __ minutes _____ ppm fluoride ion __-minute tray application Apply every ___ months Not indicated for patients with ___, _____, or _______ because it may etch the materials

Answer 35

1.23% APF Low pH increases fluoride uptake Uptake greatest during the first 4 minutes 12,300 ppm fluoride ion 4-minute tray application Apply every 3-6 months Not indicated for patients with porcelain, composites, or sealants because it may etch the materials

Question 36

foams ___% NaF or ____% APF __-minute tray application Limited evidence to support effectiveness in ______

Answer 36

2.0% NaF or 1.23% APF 4-minute tray application Limited evidence to support effectiveness in CARIES PREVENTION

Question 37

procedure for topical gel/foam PATIENT: determine need based on ______ assessment (not for children under __), pick a fluoride (__/__, data supports ___ gel), seat pt ____, explain procedure and duration (__ min), instruct pt not to ____, tilt head ______ slightly TRAY COVERAGE: choose right ___, must cover full dentition and areas of ______ (if unable to cover root surfaces, use _______) PLACE GEL/FOAM: use _____ amount of product, fill tray __ w/ gel. Fill ______ will foam but do not ____ DRY TEETH: use saliva ejector and dry teeth before insertion of trays starting with ______ teeth then ____ (facial, occlusal, lingual) INSERT TRAY: place both filled trays in mouth, may need to do one tray at a time, if doing a 2-step procedure, pt can not ___ in between but should ____ ISOLATION: use a ____ ejector with max suction ATTENTION: do not leave pt ______ TIMING: use a ___, do not _____ (4min). 2 step takes __ min COMPLETION: tilt head _____ for tray removal, have pt ___ several times without swallowing, wipe excess fluoride off teeth, instruct pt to not eat, drink, or brush teeth for ___ min

Answer 37

PATIENT: determine need based on caries risk assessment (not for children under 6), pick a fluoride (APF/NaF, data supports APF gel), seat pt upright, explain procedure and duration (4 min), instruct pt not to swallow, tilt head forward slightly TRAY COVERAGE: choose right size, must cover full dentition and areas of recession (if unable to cover root surfaces, use varnish) PLACE GEL/FOAM: use minimum amount of product, fill tray 1/3 will gel, fill completely will foam but do not overfill DRY TEETH: use saliva ejector and dry teeth before insertion of trays starting with maxillary teeth then mandibular (facial, occlusal, lingual) INSERT TRAY: place both filled trays in mouth, may need to do one tray at a time, if doing a 2 step procedure, pt can not rinse in between but should spit ISOLATION: use a saliva ejector with max suction ATTENTION: do not leave pt unattended TIMING: use a timer, do not estimate (4min). 2 step takes 8 min COMPLETION: tilt head forward for tray removal, have pt spit several times without swallowing, wipe excess fluoride, instruct pt to not eat, drink, or brush teeth for 30 min

Question 38

NaF varnish __% NaF _____ ppm Higher concentration of fluoride than __ or ___ ___ amount used Only _______ topical fluoride application for children under __

Answer 38

5% NaF 22600 ppm Higher concentration of fluoride than gel or foam less amount used Only professional topical fluoride application for children under 6

Question 39

BENEFITS OF NAF VARNISH (12)

Answer 39

Prolonged exposure Safe Ease of application Short delivery time Good for children Acceptable taste Cost effective Small amount needed Can eat and drink immediately after application Can apply over demineralized lesions Ortho patients Decreases caries and hypersensitivity

Question 40

SILVER DIAMINE FLUORIDE Contains ____ and ______ Mechanisms of action: - ________ biofilm pH - Reduces ______ demineralization - Fluoride-aids in ______ - Creates an ___ and ______-resistant tooth - _____-_____ action

Answer 40

Contains SILVER and FLUORIDE Mechanisms of action: - Increases biofilm pH - Reduces dentin demineralization - Fluoride-aids in remineralization - Creates an acid and abrasion-resistant tooth - Silver-Antimicrobial action

Question 40

SILVER DIAMINE FLUORIDE FDA APPROVAL - 2014: - 2016: CARIES ARREST FOR: (3)

Answer 40

FDA APPROVAL - 2014: dentinal hypersensitivity - 2016: granted breakthrough therapy designation for preventing and arresting caries CARIES ARREST FOR: - pediatric - adolescents - special needs

Question 41

SILVER DIAMINE FLUORIDE ___% concentration Can be applied to _____ caries ________ carious lesions in primary and permanent dentition Procedure: - _____ area and thoroughly ___ - Apply ____ amount to indicated surface - Apply ______ to the rest of the mouth No special instructions: - Routine brush and floss ___ times per day -Use fluoridated _____

Answer 41

38% concentration Can be applied to dentinal caries Arresting carious lesions in primary and permanent dentition Procedure: - Isolate area and thoroughly dry - Apply small amount to indicated surface - Apply NaF varnish to the rest of the mouth No special instructions: - Routine brush and floss 2-3 times per day -Use fluoridated mouth rinse

Question 42

benefits (4) VS adverse effects (2) of SDF

Answer 42

benefits - cavitated and noncavitated caries arrest and prevention - dentinal caries arrest - inexpensive - no reported systemic effects adverse effects - pulpal and soft tissue irritation - permanent black dental stain

Question 43

chronic fluoride toxicity: skeletal fluorosis ___-term intake of ____ amounts Osteosclerosis: ___ painful joints ______ in later years Elevation in bone _____ __+ years of excessive intake ____ppm fluoride in water Never a concern in the ____

Answer 43

LONG-term intake of EXCESSIVE amounts Osteosclerosis: STIFF painful joints CRIPPLING in later years Elevation in bone DENSITY 10+ years of excessive intake 8-10ppm fluoride in water Never a concern in the US

Question 44

chronic fluoride toxicity: dental fluorosis _____ of excess fluoride in ___ _________ of the enamel Only during _________ of the crown Greatest risk: _____ years old No _______ symptoms Protection against _______

Answer 44

ingestion of excess fluoride in water Hypo-mineralization of the enamel Only during the development of the crown Greatest risk: 0-16/18 years old No systemic symptoms Protection against dental caries

Question 45

acute fluoride toxicity ____ intake, over a _____ period of time rare occurs within __min of ingestion may last up to ____ hours

Answer 45

Rapid intake, over a short period of time Rare Occurs within 30 minutes of ingestion May last up to 24 hours

Question 46

acute fluoride toxicity symptoms GI symptoms: (3) Blood symptoms: (1) CNS symptoms: (3) Cardiac symptoms: (1)

Answer 46

GI symptoms: - nausea, vomiting - increased salivation - abdominal pain Blood symptoms: - hypocalcemia CNS symptoms: - hyperreflexia - convulsions - paresthesia Cardiac symptoms: - cardiac failure

Question 47

acute fluoride toxicity TREATMENT - induce ______ - call 911 - administer ___/______, why? - support ______

Answer 47

- induce VOMITING - call 911 - administer MILK/MILK OF MAGNESIA: calcium interferes with fluoride by binding to it in the digestive system and reducing the fluoride absorption - support RESPIRATION

Question 48

FLUORIDE DOSING CERTAINLY LETHAL DOSE (CLD) - ___g NaF at once for adults - _____g NaF at once for children SAFELY TOLERATED DOSE - __ of CLD - ________g of NaF for adults - age 2: CLD and STD - age 4: CLD and STD - age 6: CLD and STD - age 8: CLD and STD - age 10: CLD and STD - age 12: CLD and STD - age 14: CLD and STD - age 16: CLD and STD - age 18: CLD and STD

Answer 48

CERTAINLY LETHAL DOSE (CLD) - 5-10g NaF at once for adults - .5-1g NaF at once for children SAFELY TOLERATED DOSE - 1/4 of CLD - 1.25-2.5g of NaF for adults - age 2: 320mg and 80mg - age 4: 422mg and 106mg - age 6: 538mg and 135mg - age 8: 655mg and 164mg - age 10: 771mg and 193mg - age 12: 931mg and 233mg - age 14: 1206mg and 301mg - age 16: 1338mg and 334mg - age 18: 1382mg and 346mg