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BDS3 Caries Symposium > The role of fluoride in caries prevention > Flashcards

The role of fluoride in caries prevention Flashcards

1
Q

What is ‘upstream’ prevention?

A
  • What we do at a population level
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2
Q

What is ‘downstream’ prevention?

A

What we do at an individual level

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3
Q

What are community examples of fluoride therapy? (3)

A
  • Water
  • School based brushing
  • Varnish (possibly SDF)
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4
Q

What are clinic examples of fluoride therapy? (3)

A
  • Varnish (possibly SDF)
  • Gels & foams
  • Slow release
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5
Q

What are at home examples of fluoride therapy? (3)

A
  • Toothpaste
  • Mouthwash
  • Tablets
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6
Q

Hoe does fluoride prevent caries? (6)

A
  • Fluoride present in fluid at the plaque/tooth interface promotes remineralisation
  • The fluoro-apatite formed is less susceptible to demineralisation
  • Topical effect greater than synthetic effect
  • Fluoride may also have an effect on bacteria and metabolic pathways resulting in less acid being produced
  • Maintain elevated oral levels of fluoride for as long as possible (little and often)
  • Fluoride most effective on early lesion
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7
Q

What type of effect of fluoride is more effective: topical or systemic?

A
  • Topical effect is greater
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8
Q

Which type of lesion is fluoride most effective on?

A
  • Early lesions
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9
Q

Is the oral reservoir for fluoride large or small?

A
  • Small
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10
Q

What is a negative of fluoride in toothpaste in relation to the oral reservoir?

A
  • The fluoride from toothpaste disappears quickly
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11
Q

What are the 2 broad types of fluoride in oral reservoirs?

A
  • Mineral deposits (CaF2 in saliva and fluid phase of plaque)
  • Biologically/bacterially bound calcium-fluoride
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12
Q

The aim in prevention is to maintain cariostatic levels of fluoride in oral fluids. IS this correct?

A

Yes

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13
Q

What are the predominant methods of delivering fluoride in oral care products? (4)

A
  • Toothpaste
  • Mouth rinses
  • Varnishes and gels
  • Tablets
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14
Q

What is the general level of fluoride in a community water supply?

A
  • 0.8-1.0ppm
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15
Q

Does Scotland have water fluoridation?

A
  • No
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16
Q

If fluoride action is topical, is water fluoridation relevant ?

A
  • Simple - when you ingest the water and the fluoride in that water it does become incorporated into saliva so saliva will contain very low and frequent concentrations of fluoride
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17
Q

How are fluoride tablets most effective?

A
  • Using the ‘swish and ‘swallow’ procedure - linking to the topical effect rather than the systemic effect
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18
Q

What is the dosage of fluoride tablets for 6m-3YO?

A

0.25mg

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19
Q

What is the dosage of fluoride tablets for 3-6yrs?

A

0.5mg

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20
Q

What is the dosage of fluoride tablets for >6yrs?

A

1.0mg

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21
Q

Are fluoride tablets are topical or systemic method of delivery?

A
  • Systemic
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22
Q

What is the risk-benefit balance like for fluoride tablets?

A
  • Poor risk-benefit balance
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23
Q

Fluoride mouthrinses are commonly available for home use. What are the 2 concentrations available?

A
  • Daily (0.05% 227ppmF)

- Weekly (0.2% 909ppmF)

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24
Q

By what % do fluoride mouthrinses reduce caries?

A
  • By around 30%
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25
Q

What is more effective: daily rinsing or weekly rinsing with fluoride mouthrinses?

A
  • Daily rinsing slightly more effective but more expensive
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26
Q

What is important for efficacy of fluoride mouthrinses?

A
  • Swishing around the mouth
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27
Q

Do fluoride mouthrinses have a good or bad benefit to risk ratio?

A
  • Good benefit to risk ratio
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28
Q

How is the compliance for fluoride tablets?

A
  • Poor compliance
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29
Q

How is the compliance for fluoride mouthrinses?

A
  • Generally good compliance
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30
Q

IS the cost benefit ratio for fluoride mouthrinses high or low?

A
  • Low
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31
Q

Give an example of a fluoride varnish?

A
  • Duraphat
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32
Q

Fluoride varnish has a high fluoride concentration. What is it?

A
  • Sodium fluoride 50mg/ml = 22600 ppm F-
33
Q

Since fluoride varnishes are painted onto the tooth in a varnish form. What does this allow?

A
  • Sustained contact with the tooth
34
Q

How do fluoride varnishes work?

A
  • Colophony resin hardens in contact with saliva to maintain contact of fluoride with the tooth
35
Q

What are the kinetics of fluoride absorption? (3)

A
  • Rapid absorption on tooth surface (enamel and dentine)
  • Increase in fluoride content of enamel up to 77% after a single application
  • Progressive release of fluoride over several months
36
Q

How does calcium fluoride work?

A
  • During an acid attack the pH falls
  • Fluoride products have a greater bioavailability the lower the pH
  • Therefore as the pH lowers you will get a release of fluoride ions into the oral environment
  • The presence of the fluoride ions helps to drive the process of remineralisation
37
Q

What are acidulated mouthrinses and how do they work?

A
  • Low pH mouthrinse
  • Stimulated mild demineralisation on tooth surfaces
  • P r esence of fluoride remains
  • Effective means of getting fluoride into teeth
  • More so than non acidulated rinses (because of the low pH)
38
Q

Give an example of fluoride boosters?

A
  • Casein Phosphopeptide - Amorphous Calcium Phosphate (CPP-ACP) - not suitable for those with milk allergies
39
Q

Fluoride boosters (e.g. CPP-ACP) are not suitable for people with what allergy?

A
  • Milk allergies
40
Q

Where can fluoride boosters be used?

A
  • At home or in office in trays
41
Q

Fluoride boosters are useful in which markets?

A
  • Markets with no access to high fluorides (no access to licenced high fluoride products such as Duraphat)
42
Q

Some dental materials are able to facilitate fluoride release. Give an example of these?

A
  • Glass ionomer/resin modified
43
Q

There is an ‘early washout’ of fluoride from GI/RMGI. What does this mean?

A
  • Fluoride is gone around 4 weeks from surface layer
44
Q

What actual amount of fluoride in GI/RMGI is very small but sustained. What does this help us achieve?

A
  • Helps us meet the little but often goal
45
Q

What is a ‘slow release device’?

A
  • Devices that are attached to the oral environment b the cementing to the tooth surface or by incorporating into an appliance that is worn where fluoride can be released in a controlled manner over a period of time
46
Q

What is the historical view of the effect of fluoride at the tooth surface?

A
  • The role of fluoride was around the incorporation of fluoride into the apatite crystal structure during amelogenesis and the resultant fluorapatite being more resistant to acid solution and demineralisation
47
Q

What is the contemporary philosophy of the effect of fluoride at the tooth surface?

A
  • Centres more around the presence of fluoride during the caries process and how it impacts and interferes with the demineralisation/remineralisation dynamic on the tooth surface
48
Q

What does the principle mechanism of fluoride in caries control rely upon? (3)

A
  • Fluoride in saliva
  • Fluoride at plaque fluid and tooth interface
  • Fluoride in fluids around lesion mineral crystals
49
Q

The oral reservoir of fluoride is small but it can be optimised by…? (2)

A
  • Delivery of fluoride to tooth surface, plaque and plaque fluid - fluoride boosting
  • Maintaining fluoride levels (frequency of exposure)
50
Q

What are the factors that determine the anticaries activity of fluoride toothpaste? (4)

A
  • Fluoride concentration
  • Frequency of application
  • Rinsing behaviours
  • When brushing takes place
51
Q

Studies have shown that the more you increase the F- conc entration in toothpaste the netter effect it has. What is the % reduction in caries for every 500ppm F increase in F concentration?

A
  • 6-7% reduction in caries

use of low fluoride formulations provide less anticaries benefit

52
Q

Does frequency of application of fluoride has an impact on caries activity?

A
  • Yes, more frequent brushing results in lower caries increments
53
Q

What will happen if a patient rinses after brushing but with a small volume of water?

A
  • Will remove excess fluoride

- But maintains fluoride reservoir in the mouth

54
Q

What will happen if a patient rinses after brushing with a large volume of water?

A
  • Removes excess fluoride

- But also reduces the volume of fluoride in the oral reservoir in the mouth

55
Q

What are the characteristics for optimal toothbrushing? (3)

A
  • Twice daily
  • Not rinsing with water
  • 1500ppm F toothpaste
56
Q

What are the characteristics for sub-optimal toothbrushing? (3)

A
  • Once daily
  • Rinsing with water
  • 1000ppm F toothpaste
57
Q

IS the quantity of toothpaste applied to the teeth strongly associated with efficacy?

A
  • No
58
Q

What is the issue with using fluoride?

A
  • If fluoride is swallowed there is a risk of developing fluorosis
59
Q

Acute toxicity of fluoride is very rare. In which population is this a potential problem?

A
  • In very young children
60
Q

What can chronic toxicity of fluoride cause?

A
  • Developmental defect of enamel
61
Q

How much fluoride do young children need to swallow to risk fluorosis?

A
  • General consensus is around 0.1mg f/kg body weight
  • 1mg per day for 1 year old
  • 2mg per day for 5/6 year old
62
Q

Is it still possible to develop fluorosis at the recommended daily intakes of 0.05-0.07 mg f/kg?

A
  • Yes
  • There is no lower limit below which fluorosis does not occur
  • There appears to be a dose response between fluoride exposure and fluorosis severity
63
Q

How much of a 1500 ppm F toothpaste does a 1YO need to swallow to risk fluorosis?

A

0.66g

64
Q

How much of a 1500 ppm F toothpaste does a 5-6YO need to swallow to risk fluorosis?

A
  • 1.33g
65
Q

How much of a 500 ppm F toothpaste does a 1YO need to swallow to risk fluorosis?

A

2.00g

66
Q

How much of a 500 ppm F toothpaste does a 5-6YO need to swallow to risk fluorosis?

A

4.00g

67
Q

How many 1mg fluoride tablets does a 1YO need to swallow to risk fluorosis?

A

1 tablet

68
Q

How many 1mg fluoride tablets does a 5-6YO need to swallow to risk fluorosis?

A

2 tablets

69
Q

How much 1mg/l fluorinated water does a 1YO need to swallow to risk fluorosis?

A

1 litre

70
Q

How much 1mg/l fluorinated water does a 5-6YO need to swallow to risk fluorosis?

A

2 litres

71
Q

How much of a fluorinated mouth rinse does a 1YO need to swallow to risk fluorosis?

A
  • Not recommended for children less than 6 years
72
Q

How much of a fluorinated mouth rinse does a 5-6YO need to swallow to risk fluorosis?

A
  • Not recommended for children less than 6 years
73
Q

Is the quantity of topical fluoride applied to a tooth strongly associated with efficacy?

A
  • No

- Efficacy is primarily concentration, not dose dependent as oral fluid reservoir is small

74
Q

Why is brushing after meals the most effective time?

A
  • Most effective time of cariogenic challenge/less readily absorbed
  • This is where the pH is lower and stomach is full so more fluoride is available and if it is swallowed it is less readily absorbed
75
Q

Why is it good to brush your teeth before bedtime ?

A
  • Salivary flow rate is reduced/increased oral retention
76
Q

Is anti caries benefit topical or systemic?

A
  • Topical
77
Q

Is increased risk of developing fluorosis topical or systemic?

A
  • Systemic

methods favouring topical delivery whilst minimising ingestion will have the best risk/benefit profile

78
Q

What can we do to maximise caries benefit but reduce fluorosis risk in young children? (8)

A
  • Keep toothpaste out of reach of young children
  • Brush frequently (twice daily; evening and one other time)
  • Supervise brushing by young people
  • Use a small amount (pea/smear) of paste
  • Discourage swallowing
  • Brush after meals to minimise effect of fluoride ingestion
  • Encourage spitting out, remove slurry; avoid excess rinsing
  • Use a lower fluoride formulation if low caries risk, maximise fluoride concentration in relation to risk
79
Q

Where is there community level caries prevention for children?

A
  • Schools, nureries, play groups
  • Community groups, housing estates, local authority…
  • Community health professionals, local GMP surgery, health centres, shops, shopping centres

BDS3 Caries Symposium (7 decks)

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