Prevention and controlling of dental caries

( Fluoride in dentistry )
 Introduction
 Without doubt, the repeated use of fluorides is of
critical importance for the control and prevention of
dental caries in both children and adults.
 It has also been described as an essential nutrient in
the Federal Register of United States Food and
Drug Administration (1973) and also by WHO
expert committee.
 Fluoride is found in abundance in the nature and is
distributed in the lithosphere, biosphere,
hydrosphere and the atmosphere.
 The caries-preventive effect of fluoride has been
known since the 1930s, when the differences in
caries prevalence between communities were
attributed to naturally occurring fluoride levels in
the drinking water.
 Some studies have been proven that water
fluoridation has reduce dental caries by about 50%.
 Due to its safety, efficacy and cost-effectiveness in
preventing caries the fluorides are widely used in different
forms thus remains cornerstone of most caries prevention
programs.
 It is well documented that fluoride can have both beneficial
and detrimental effects on the dentition.
 As a basic principle, the beneficial effects on dental caries
are due primarily to the topical effect of fluoride after the
teeth have erupted into the oral cavity. In contrast, the
detrimental effects of fluoride are due to its systemic
absorption during tooth development, resulting in dental
fluorosis.
 Fluoride content is commonly expressed in parts
per million (ppm)
 (ppm) which is equivalent to 1mg fluoride per
kilogram or liter of water. Thus,1ppm fluoride
equal to 1mg fluoride per liter of water
 Distribution of
fluoride in nature
 Fluoride in the Lithosphere

 Fluoride though is considered as a trace element from

the biologic point of view is present in abundance in
the earth’s crust and presents as 13th among them.

 In the lithosphere, the fluoride is present as inorganic

fluoride in:
- Siliceous igneous rocks
- Alkalic rocks
- Geothermal waters and hot springs
- Volcanic gases and fumaroles
 In the Biosphere

 Some plants accumulate more fluoride and hence are the

rich source of this mineral.

 The normal concentration of fluoride in leaves ranges

between 2-20 ppm (parts per million).

 Few plants like tea plants actively accumulate fluoride and

the fluoride concentrations reach several hundred ppm.

 The fluoride level in the soil directly influences the

fluoride concentration of the plants grown in such a soil.
 Concentration of fluoride tea leaves is on the average 98
ppm, leafy vegetables such as cabbages, and lettuce
contain about 11-26 μg fluoride on a dry weight basis.

 Washing leafy vegetables reduces the intake of fluoride

by about 1/2 to 1/3

 Plants grown in acidic soils have a higher fluoride

content than those grown in lime-containing basic soils.
 In the Hydrosphere

 River contains fluoride in the free form but complex

fluoride increases with increasing salinity, reaching 50-
60% in sea water.

 47% of which are present as MgF.

 Sardines, salmon, mackerel and other fish contain about

20 ppm of fluoride on a dry weight basis.

 Seafood is rich in fluorine since the oceans contain about

1 ppm of fluorine.
Fluorides in Water
 By virtue of dissolution, fluorides occur in most springs,
wells, seawaters, and plants.

 Fluorides are present in trace quantities in all surface

and underground waters.

 The concentration of fluorides is negligible in rainwater

and high in some lakes and wells.

 The fluorides contained in drinking water is commonly

the largest single contributor to the daily fluoride intake
 In the Atmosphere

 Fluoride in the atmosphere is maximum near industrial

area who by product is fluoride as seen around the
aluminium factory.

 Fluoride emissions are heaviest in the vicinity of

industries involved in the production of aluminium
from cryolite, phosphate fertilizers, fluorinated
hydrocarbons, plastics, uranium and other heavy metals
and hydrogen fluoride
Fluorides in Pharmaceutical Products
 An increasing number of pharmaceutical products

contain fluorides in organic and inorganic form.

 The products such as sodium fluoride tablets, vitamin

pills, fluoride dentifrice, fluoride gels and solution are

widely used for caries prevention.
 Metabolism of Fluoride
 The significance of fluoride in nutrition is related to
its regular presence in small amounts in foods and in
all tissues of the body.
 The advent of water fluoridation as a public health
measure for partial reduction of caries and the
continued and increasing use of other fluoride
formulations makes it essential that its metabolism
be known.
 By understanding the fate of ingested fluoride it is
possible to quantitate safe and unsafe levels of
ingestion from air, water and foods.
Metabolism of fluoride
 Estimated Daily Intake of Fluoride

 Several estimates have been made of the daily intake of

fluoride from food and water.
 The variation reflects different dietary patterns between
races and countries.
 Two factors that contribute most to the daily intake are
fluoridated water and fluoride-rich foods such as fish.
 The average daily intake of fluoride by adults from dry
food substances is in the range of 0.2–1.8 mg and the
average daily intake from water containing 1.0 ppm
fluoride is about 1.5 mg. The total daily intake for
adults being in the 1.7 – 3.3 mg range
 Absorption of Fluoride

 Most fluorides are absorbed rapidly and transported in

the body and subsequently excreted as the fluoride ion.
 About 86–97% of ingested fluoride is absorbed.
 Absorption of fluoride

The rate and amount of fluoride absorption are determined by

many factors:

 Physical form of the dose: Fluoride in the liquid form is

better and quickly absorbed than in the solid form.

 Presence of food in the stomach: Fluoride absorption is

slow in the presence of food.

 Composition of gastric contents: Certain items such as milk

combine with fluoride and delay or prevent its absorption.
 Gastric pH: Reducing the pH enhances the fluoride
absorption

 Concurrent oral administration of cations like Ca,

Mg, Al: They bind with fluoride thus making it
unavailable for absorption.

 Fluoride is absorbed from the entire

gastrointestinal tract. About 80% of the dietary
fluoride is absorbed and the maximum plasma
concentration is reached within 60 minutes.
 The main factors influencing absorption are species
variation, concentration of fluorides ingested,
solubility and other dietary constituents, such as
calcium, which may form insoluble salts with
fluoride.
 The rate of absorption increases with starvation and
presence of fats.
Distribution of fluoride in the body

Fluoride in Plasma
 It exists in 2 general forms

1. Ionic (also called as inorganic or free fluoride)

2. Non ionic (bound fluoride)
 Together they form the total plasma fluoride and are

about 12 μm/l.
 There is evidence that plasma fluoride levels increase

slightly with age.

 Plasma fluoride levels also increase in the presence of

renal failure
Fluorides in Soft Tissues
 The brain tissue and the adipose tissue accumulate

the least amount while the kidney, heart and lungs

accumulate the maximum amount of fluoride.
Fluorides in Bone
More than 95% of the fluoride in the body is retained in the bones
Accumulation in bones depends on:
 The fluoride intake: Amount of fluoride accumulated is

directly related to the amount of fluoride intake.

 Type of bone: Cancellous bone retains more fluoride than

compact bone.
 Age: Fluoride accumulation is maximum in growing bones.

 Duration of fluoride exposures: Amount of fluoride

accumulated is directly proportional to the duration of exposure
to fluoride.
 Fluorides are deposited in dental tissues in successive
stages during the life of the tooth.
 The initial deposition occurs while the organic and
mineral phases are being laid down.
 Next it is deposited from the tissue fluids during the
pre eruptive maturation phase.
 Finally fluoride is acquired topically during post
eruptive maturation and aging period.
Amount of Fluoride in the tooth
 Outer enamel - 2,200-3,200 ppm

 Dentin - 200-300 ppm

 Cementum - 4,500 ppm

 Pulp - 100-650 ppm

 Excretion of Fluorides

 Excretion through the kidneys forms the major route

for the elimination of fluoride.
 About 30% is excreted within 3 hours and remaining
40-60% is excreted within 24 hours.
 Increase in urine pH increases the fluoride excretion.
 Remaining fluoride is excreted through the feces
(10%), Breast milk (0.001-0.005 ppm), Sweat (10-
25%) and saliva (0.01-0.05 ppm).
Fluoride Transfer by Placenta
 The presence of fluoride in primary teeth that

develop during the intrauterine phase and the rapid

increase in fluoride level of fetal blood when
medications containing fluoride are administered to
pregnant women indicate that fluorides readily
cross the placenta.
 The skeletal fluoride increases with fetal age in

areas that have water supplies of 0.1, 0.5 and 1.0

ppm.
 Toxicity of fluoride

 The term toxicity refers to the symptoms manifested

as a result of over dosage or excessive administration.
 Acute: Due to single ingestion of large amounts of
fluoride.
 Chronic: Due to long-term ingestion of smaller
amounts.
 Acute Fluoride Toxicity

 The acute lethal dose of fluoride for man is probably 5

g. The probable range is 2–10 g.
 Acute fluoride intoxication is rare and is not well
described as the chronic intoxication.

Certainly Lethal Dose (CLD)

 A lethal dose is the amount of drug likely to cause death

 Adult lethal dose = 34–64 mg F/kg body wt.

 Symptoms
 Vomiting, nausea, diarrhoea
 Pain abdomen extremities

 Difficulty in speech

 Thirst

 Perspiration

 Weak pulse

 Coma

 Convulsions

 Cardiac arrhythmia → death.

Death will occur within 4 hours. If the patient survives for

24 hours, the prognosis is good.
 Treatment
 Milk or egg can be given: This serves 2 purposes:
 Protects upper gastrointestinal tract from chemical
burns
 Provides calcium that acts as a binder for fluoride
 Lime water
 Aluminium hydroxide gels
 Vomiting
 Majority of ingested fluoride is expelled.
In an hospital
 Cardiac monitoring.

 Gastric lavage.

 Oral or IV calcium gluconate (10 ml of 10%).

 Urine output to be maintained.

 General supportive measures.