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Pedo lec.# 4 Dr.

Abeer Al Najjar
‫بسم الله الرحمن الرحيم‬
Fluoride 2
Dental fluorosis

The Dr insisted on the oral hygiene instructions and she wanted them to be
written (actually printed ) and before u give it to the patient u should show it
to the Dr to get mark on it .. you also should do the diet analysis and give diet
instruction these two things are a requirement of the pedo clinic …

Fluoride topic is really so wide .. I (Dr ) tried to summarize it in two lectures

… you should really focus on the concentration of fluoride in the materials that
we use … today we are going to talk the toxicity which can result in from the
excessive fluoride intake , the toxicity could be acute or chronic … acute
means .. that the patient has ingested big amounts of fluoride at once .. and
the acute symptoms appearing straight away on the patient .. chronic toxicity
is when the patient is taking smaller amounts of fluoride for a long period of
time , and this can have other effects on the teeth such as fluorosis …

More fluoride is not necessarily better , bcoz there is a toxic effect of

fluoride , then the Dr showed us a pic for a fluorosis teeth ..

So dental fluorosis is irreversible condition , that means when you have

fluorosis the fluoride becomes part of the tooth structure so we can’t separate
it .. its cozed when we do excessive exposure on the developing tooth .. so in
order to have fluorosis the tooth should be developing inside the jaw , if its
partially erupted it might affect the part that being developing like roots for
examples and we will have excessive fluoride in the cementum .. so erupted
tooth will not be affected by fluorosis at least the erupted part … coz they
have already finished there formation , so irreversible fluorosis cozed by the
exposure of unerupted or developing tooth to big amount of fluoride and this
fluoride what makes a mineralization defects in the tooth in the enamel not in
Pedo lec.# 4 Dr. Ola
Abeer Al Najjar
the dentine , its a mineralization defect not a hypoplastic defect , so it’s a
hypomineralization defect …

Hyperplasia means a defect in quantity in the enamel , so it means that the

quantity of enamel is less ….

Hypomineralization means the mineralization defect of enamel , the dr

talked about a pic in the slides showing teeth for a 8-9 years old living in
oakland which is a city in neusiland so we need to know the amount of
fluoride that leads to fluorosis , we know that the fluoride is found in the water
from 0.7 – 1.2 if its above 1.2 its toxic , but if I’m in a cold area if you got more
than 1.2 you got fluorosis , but if you are in a hot area you have to stay in 0.7-
0.8 range so its according to the climate , so if the patient is drinking too much
water the fluoride amount in this water is high then he can get fluorosis , some
times its not very easy to predict who will got flourosis and who will not …

Clinical appearance :

1- Bilateral opaque white area’s in enamel is opaque and chalky and white ,
bcoz it’s a systemic condition so it has to be bilateral its happening a
very where in the jaw , so if you only see its unilaterally you exclude
fluorosis from your diagnosis .

2- They become mottled and/or pitted w increase level of fluoride ingested .

3- The fluorosis teeth are still fully functional .. the patient can still eat with
them , they don’t have reduced function or wearing in the teeth and they
are more resistant to acid attack than normal teeth coz there is fluoride
in the tooth (coz when we do acid etching we are demineralization the
tooth so if the tooth is already hypomineralized so what the acid can do ..
not much)

4- Coz enamel is more porous it may be stained easily , some cases are
yellowish and some are brownish especially in sever fluorosis and they
become more prone to fracture and wearing coz the enamel is brittle ,
and easily going out ..
Pedo lec.# 4 Dr. Ola
Abeer Al Najjar
5- You might have dental caries , coz you have porous and the bacteria may
perforate and coz caries ..

Generally speaking fluorosis cozes the teeth to be resistant to acid etching

and dental caries but in very sever form bcoz of these pitted and the porous
surface so we will have caries ..

Fluorosis can be very mild , mild , moderate , sever …

- Very mild : very small white pits on the surface of the enamel and it
involves less than 25% of there surface ..

- Mild : opaque area involving about 50% of the tooth ..

Moderate type : 50% or more or the whole enamel surface is affected and you
can notice some discoloration ..

- Sever : enamel is grossly affected and pitted and worn out ..

Fluorosis patient mainly from esthetics otherwise they will have no caries
risks (except for the sever case )

The dr started showing us pic and define them to the fluorosis classification
and the dr started talking about the table which tells us the dates of eruption
and enamel formation and we should memorize it …. And from this table we
can tell at which age the child started the fluoride exposure …

You have to know when the enamel formation begins and when root
formation ends , and when the tooth erupts , so in this case (I don’t know
exactly which one )the central incisor developing is a little pit delayed than the
six’s and they start formation at 3 – 4 months after birth .. so we can tell from
the incisal edge which are affected by fluorosis by fluorosis that this defect
was their when the patient was 3-4 months old , the laterals start formation10-
12 months and they are affected so it did continue tell the patient is 10-12
months , canine starts formation 4-5 months , premolar 1.5-2 years , so we can
tell that this patient was exposed to fluoride from 2 months up to 2 years
(these are permanent teeth .. I mean we are talking about permanent teeth
formation) , how did he got the fluoride ?? could be by breast milk ….
Pedo lec.# 4 Dr. Ola
Abeer Al Najjar
So as the Dr said you should ask where the patient was living and what’s the
fluoride concentration in that area and you should be able to estimate at which
age these teeth subjected to fluoride …

How do we restore these teeth ??? by composite or veneers (the sever cases
that got caries )we do acid itching but not with phosphoric acid maybe with
sodium hypocloride…

The stain on the fluorolized tooth : that happens coz the tooth is so porous so
its like a sponge it absorbs any stains ..

Another way to detect fluorosis by fluorosis is by histopathological if you

take a section of the tooth and you look at the layers you will find a well
mineralized layer at the top of the surface and a much porous surface
underneath , so the superficial layer is well mineralized and more resistant to
dental caries but once this surface has been removed the surface underneath
is very porous so it can get dental caries ..

So you will see pitted enamel showing surface porosity below a well
mineralized surface , but how this surface become well mineralized ?? bcoz of
post eruption maturation at least , and coz of fluoride gel and dental past that
makes it mineralized …

So the porosity cozes the white appearance of the enamel , the well
mineralized surface zone is normal , its normally mineralized so you got
normal enamel which is translucent but the white discoloration that you see its
not from this layer its actually from the layer underneath which is porous ..

With increase severity of the fluorosis the porosity extends towards the
dentino-enamel , and this what cozes the pitted enamel appearance . so why
do we see it in sever forms ..?? coz the fluoride was extended to the dentino-
enamel junction where the enamel and dentine meet , so this layer is affected
here then you see some pitting in the surface , some areas where enamel and
dentine are not well adherent ..

The pathogenesis of fluoride : actually happens at the microbiological level or

a very very microscopic level so you have to understand the stages of enamel
Pedo lec.# 4 Dr. Ola
Abeer Al Najjar
formation . we know that enamel goes into 4 phases (the Dr said 2 but she
mentioned 4) :

Presecretory , secretory , maturation , post eruption maturation .

Now we will discuss what happens in each stage …

- Presecretory : when the cells are preparing them selves for the secretory
stage , the cells become more elongated they become columnar , the
nucleus become prominent , the cytoplasm become more stained all of the
structures that are involved in the secretory stage become prepared ..

- Secretory : when the protein is synthesized (amylogenin , enamelin) all of

these that are incorporated in enamel start being secreted , and then some
mineralization occur (very early mineralization) .

Mineralization actually occur after that in a separate stage where there is

initial mineralization as I said (initial removal of the minerals and the
proteins ) and then incorporation of the minerals from the blood into the
matrix .. (I didn’t understand this )

- Maturation : means if there is any protein remains then its removed and
minerals are incorporated in the surface .

- Post eruption maturation : is where the process continues after eruption of

tooth ..

So in presecretory phase the dental lamina differentiate into amyloblast and

these differentiate into polar cells and high fluoride at this level really affects
the cells differentiation and perforation , so there is an effect of the fluoride
on this stage but it still minimal .

Secondary in the secretory phase there is secretion of the organic matrix as

we said and protein synthesis , protein become hydrolyze , so the cells
hydrolyze the protein and removes them (normal situation)..
Pedo lec.# 4 Dr. Ola
Abeer Al Najjar
Early maturation the amyloblast secrets proteinases these are enzymes that
suppose to remove the protein degrade them .

Now with high fluoride level at this stage there is an inhibited protein
secretion and there for the fluoride increases in the matrix ..

The protein is increased , not removed probably from the matrix and the
fluoride will be in high amounts ..

Why does the fluoride inhibits it ?? coz fluoride is a very good enzyme
inhibitors , remember with bacteria it inhibits glycolsis and the H+ pump ..
and inhibits the ATP some times and now its working on the proteinases
enzyme it inhibits the protein degradation so if you put fluoride with any
enzyme it will inhibit it …

The fluoride affects the tooth when its in the maturation phase more that if
its in the secretory phase .. but when we have the fluoride in both stages it
sure has a higher risk of having fluorosis

At maturation level which is a very important stage and the fluoride affects it
very very much more them the secretory phase ..

What happens here is the matrix is removed and the minerals are deposited
now this is called cycle , when the protein is synthesis then proteinases
remove it and then the minerals get deposited now this is a whole cycle these
cycles are called zone refinement hypothesis , what fluoride do is decreases
the number of these cycles , which means it decreases the protein removal and
the deposition of minerals .

So the matrix will become high protein and less minerals so the enamel
becomes mushy and soft .

So there is a change in the size of the crystal and the morphology of the
enamel and we will have increase in the fluoride and magnesium levels .

So what really I should know is .. the time(age of the patient) of exposure to

fluoride .. the duration of the exposure and the a amount that’s ingested ..

First thing .. the does of fluoride threshold is 0.1 mg/kg and a later study said
its 0.03-0.1 mg/kg.
Pedo lec.# 4 Dr. Ola
Abeer Al Najjar
Critical period for fluoride exposure is late secretory or first maturation
period , but maturation stage is more sensitive that the secretory , the
permanent incisors and canines they are affected at age 1.5-2.5 permanent
posterior teeth can be affected up to age 6 (now I’m confused by these num
but I think now she is talking about the maturation but we should look to the
table and memorize it and remember this is what the Dr said)

Characteristics of dental fluorosis : its endemic so if you have group of people

living in one area for a long time it should affect every body in that area ,some
times its geographic distribution , here in Jordan here in Jordan , the Jordan
valley they have high number of fluorosis in compare to other areas in Jordan
like irbid , so if a person with a full developed teeth moved to high fluoride
area he wont get it coz his teeth fully developed .

Permanent teeth are affected but deciduous teeth are less affected , and in
primary dentition the most affected teeth are the E’s , coz there develop is
later than the others , and when affected mainly in the gingival third (the
latest part to be developed)

The risk increase the longer you exposed to fluoride and that’s what is called
chronic exposed , if the child swallow a tooth past then this is acute exposure
he will not get fluorosis but he will got acute symptoms of fluoride toxicity .

Most of the risks comes from increase the exposure to fluoride thinking its
better and when the water is fluoridated they will also get fluoride supplement
and then it causes fluorosis , and now we are very conscious in describing
fluoride supplement coz we have fluoride in food and tooth past .

How do you differentiate between fluorosis and enamel hypoplasia they are
similar in appearance some times , the first thing you will be asked about is
fluoride history , where do they live is it fluoridated area or not ?? any history
of trauma ?? why?? bcoz of trauma permanent tooth will be affected by this
trauma and it will cause an enamel hypoplasia on the permanent tooth ,
history of fluoride intake ?? some people take tooth past or supplement or
other source then you might think of fluorosis is it localized or generalized
defect ?? why?? Coz fluorosis is bilateral its not in a localized area ..

A student asked .. if the histopathological feature of fluorosis is like the

enamel hypoplasia ?? generally speaking is yes .. both has a well mineralized
Pedo lec.# 4 Dr. Ola
Abeer Al Najjar
then a porous layer but in fluorosis the fluoride concentration is higher .. and
yes enamel hypoplasia yellowish some times ..

What’s the problem of fluorosis is the esthetics defects there is too much
chipping of the teeth especially the molars we place crowns on them in
anterior teeth we do esthetics management such as composites resin veneers
specially during childhood and then when the patient grows up

we put porcelain veneers , it might require microabrasion and its only on the
very mild cases to clean the defects …

Recently tooth mousse has been used by walsh 2007 (not sure about the
name)you will be taking about in the chemotherapeutic agents its cream which
is made of calcium and phosphate its actually derived from cazyeen (not sure
about the name) ?? which is a protein found in milk and cheese , you put in on
the tooth and it will mineralized it by the ca+ and phosphate content of it ..

From you clinical experience you will know that the mousse in some cases will
remove it totally others will have minimal effect and in others it will be
moderate ..

Fluoride toxicity you have to know the toxic level of fluoride , the certainly
lethal does is the dose when you will see certainly die , and this does for the
adults its 32-64 mg/kg according to body weight and this does results in death
within 2-4 hours if first aid is not applied immediately so they conclude that
CLD for a 70 kg is 5-10 g .

From that lower limit of 32 mg/kg the estimated equivalent CLD for a child is
320 mg ..

Probably toxic dose (PTD )is the dose where toxic symptoms appear .. it will
do toxicity and some times it could kill and it should trigger immediate
therapeutic intervention and hospitalization .

Its approximately 5 mg f/kg so for a 10 kg child 50 mg is enough to cause

toxicity , it does not mean that a dose less than that will cause nothing , so
even if only 5 mg f /kg is ingested assume that as an emergency condition and
immediate treatment and hospitalization required .

PTD for 2 years child with average weight 11.3 is 57 g ….

Pedo lec.# 4 Dr. Ola
Abeer Al Najjar
How did they calculated it ?? simple its 5 (PTD)multiplied by the weight 11.3 ..

Now what 57 g of fluoride means ??

- It means a tube of tooth past of 1000 ppm fluoride dentifrice at once ..

- It’s a 38 mg tube of tooth past 1500 dentifrice at once .

- Or its 24 ml of sodium fluoride mouth rinse .

- Or it can be 57 mg of fluoride tablets , they become in a bottle each one

of them can be 1.0 mg .

- Or it can be only 4.6 ml of a 1.23 % of APF gel .. this means swallowing

the fluoride that we apply to the child in the clinic that’s why we place a
suction when we do fluoride application .

These exposures to fluoride causes acute affects not chronic , so within 2

hours the symptoms will occur …

The question was if the fluoride is related to cancer ?? ingestion of

fluoride suggested to cause cancer however , American cancer society
stated that scientific studies show no connection between cancer rate in
humans and adding fluoride to drinking water , several reviews have also
concluded that there is no relationship between fluoridation and cancer ..

The symptoms of fluoride toxicity are related to the GI system coz its
ingested and they are:

- Nausea

- Vomiting

- Hypersalivation

- Diarrhea & abdominal pain due to irritation of GI through the formation

oh hydro florid acid .

Management of toxicity :
Pedo lec.# 4 Dr. Ola
Abeer Al Najjar
- Recommendation to induce vomiting ..

- Administer syrup of ipecac (vomiting inducing agent) or milk as an

antidote to help bind the fluoride ion .

Death reported due to F toxicity : 3 reported cases in children in

literature ..

- Age 3 yrs ..male , swallowed SnF rinse .

- Age 27 months , male , ingested 100 F tablets ..

- Age 3 yrs , male , ingested 200 F tablets ..

These calculations are for you at home , I just want you to know how do
they calculate the amount of fluoride ..

The first two of these conversation factors you have to know by heart

1 ppm (part per million ) = 1 mg /l

1% = 10000 ppm

So 1.23 % APF in clinic = 12.300 ppm

F content is estimated by (atomic weight of F / molecular weight (mw)of the

whole compound)

1st ex .

You take the weight of fluoride which is 19*2 then divide it by 119 (the mw
for sn+ the mw for F)

That’s how we estimate the fluoride content..

What I want you to memorize is the F concentration like ..

Pedo lec.# 4 Dr. Ola
Abeer Al Najjar
In SnF2 its : 0.24 %

In Na2Po3F its : 0.13 %

In NaF its : 0.45%

AFP it’s the only product that u got 1% of AFP and that’s mean1% of F
concentration ..

The rest are examples for you to do at home ;-)

ThE eNd

Actually this was a very boring lec im sorry but its not my fault , allah y3nene w
y3enkom 3aleha ;-)

With all the best :

Abeer Al Najjar