FLUORIDES

INTRODUCTION

Fluorine is a member of the halogen family with a relative atomic weight of l9 and an atomic number 9. The word Fluorine is derived from latin term "Fluore", meaning, "to flow". At room temperatures Fluorine is a pale, yellow-green gas. It is the most electronegative and reactive of all elements and thus, in nature, is rarely found in its elemental state.

The WHO Expert Committee on Trace Elements has included Fluorine as one among the l4 physiologically essential elements for the normal growth and development of human beings.

Combined chemical!y in the form of fluorides, fluorine is the seventeenth in order of frequency of occurrence of the elements, representing about 0.06% to 0.09% of the earth's crust. In rock and soil, fluorine may occur in combined form in a wide variety of minerals, such as Fluorspar [CaF2], Fluorapatite (Ca10(PO4)O6F2) and Cryolite (Na3AlF6). Fluorspar is the principle fluoride containing mineral and the theoretical fluoride content is 48.5%.

Fluoride ions have a strong tendency to form complexes with heavy metal ions in aqueous solutions. The range of fluoride levels in water varies in different parts of the world

HISTORICAL EVOLUTION OF FLUORIDES

The history of fluoridation started with the arrival of Dr Fredrick McKay in Colorado Springs, Colorado, USA in 1901. He noticed many of his patients had an apparently permanent stain on their teeth, known to the locals as Colorado Stain. McKay called the stain mottled enamel

ln theyear 1916, McKay along with Dr. G. V. Black conducted studies on individuals living in 26 different communities in various parts of USA They concluded that an unidentified factor was responsible for the mottling of enamel. They assumed that this unknown factor might have been present in the water consumed by the individuals during the period of tooth calcification.

In 1931, the element fluoride was identified as the "mysterious factor" responsible for mottled enamel. Fluoride was established as the causative factor for mottling of enamel through the historical studies conducted by Trendley H. Dean, known as the "Shoe Leather Survey"

Dr. Trendley H Dean conducted a survey among 22 cities in ten states of USA on a total population sample of 5,824 children and gave the following report on mottling of enamel at various concentrations of fluoride.

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A high concentration of fluoride in water is directly related to the severity of enamel mottling. Enamel mottling was widespread in areas with water having fluoride content of 3 ppm Mottling with discrete pitting of enamel was noticed at fluoride content of 4ppm. Mottling was less in case of fluoride levels of 2.5 ppm to 3 ppm, with a dull chalky white appearance of teeth No mottling or any other enamel changes were observed in areas with water containing 1ppm fluoride

The term mottled enamel gave way to the more exact term dental fluorosis and in 1934 Dean developed a standard system for classification of dental fluorosis- the mottling index. Another feature observed was that mottled enamel did not develop dental caries compared to normal enamel, which was highly susceptible to caries.

SOURCE OF FLUORIDE FOR ADULTS

The greater part of the fluoride intake in man originates from food and water ingested each day. Fluoride is also derived from certain plants, marine animals and even dust particles. The fluoride concentration in various foods reflects the fluoride concentrations in the water used in food processing

SOURCE OF FLUORIDE FOR INFANTS

In infants, the feeding pattern i.e.; breast milk or formula feeding determines the dai!y fluoride intake. Fluoride concentration of human milk ranges from 6- l2 mg/ml

ESTIMATED DAILY INTAKE OF FLUORIDES BY MAN

Daily intake of fluoride by individuals vary from country to country. A total intake of between 0.05 and 0.07 mg of fluoride per kilogram body weight has been found to be the optimum intake for humans.

RETENTION AND DISTRIBUTON OF FLUORIDE IN THE BODY

The retention of fluoride in the body is due entirely to the capacity of apatite, the mineral form assumed by over 99% of the skeleton's mineral phase, to bind and perhaps to incorporate fluoride ion as an integral part of the crystal lattice.

Fluoride concentration in soft tissue is very low and transient. Concentrations in the mineralized tissues vary considerably and depend on a wide variety of factors:

- The level of fluoride intake - Duration of exposure - Stages of mineralised tissues development - Its rate of Growth - Vascularity - Surface area of tissue and of mineral crystallites - Porosity - Region and type of tissue sampled for analysis.

In the body, fluoride is present as inorganic fluoride and usually as the ion F-. Any fluoride present at low pH in the stomach, exists almost totally in the undissociated form as Hydrofluoric acid (HF). In blood, saliva and tissue, fluoride is present in the fully ionized form as F- .

CONCENTRATION OF FLUORIDE IN BONE

Approximately 99% of all the fluoride in the human body is found in calcified tissues. During the active bone formation, when crystals are growing, the overall rate of fluoride uptake is high. Bones of the mature animals take up less fluoride than those of the younger ones.

There is also a correlation in individual bones between metabolic activity and fluoride uptake. Thus the metabolically active metaphyseal cortex and periosteal bone take up more fluoride than the mid cortical compact bone. In general, cancellous bone incorporates more than the cortical compact bone.

CONCENTRATION OF FLUORIDE IN ENAMEL

The accumulation of fluoride by enamel seems largely restricted to the surface region and the fluoride conc. is therefore always relatively higher at the enamel surface compared with the interior.

CONCENTRATION OF FLUORIDE IN THE DENTIN

Dentin and Cementum have collagenous matrices. The apatite crystallites are considerably smaller than those of enamel. Their surface area and their capacity to take up fluoride is consequently much larger. The fluoride concentration is more in dentin than in enamel.

CONCENTRATION OF FLUORIDE IN THE CEMENTUM

From analysis carried out, it was concluded that the fluoride concentration of cementum was higher than that of any skeletal or dental tissue. This is because, the tissue is very thin and all of it is therfore, near to the tissue surface and so accessible to the fluoride present in blood. Fluoride concentration generally decreases from surface to interior. Total fluoride content in cementum increases with age.

MECHANISM OF ACTION OF FLUORIDES IN CARIES REDUCTION

The mechanisms by which fluoride increases caries resistance may arise from both systemic and topical applications of fluoride. The proposed mechanisms that have been identified and which are assumed to work simultaneously are as follows:

Increase enamel resistance (OR) Reduction in enamel solubility Increased rate of post eruptive maturation Re-mineralization of incipient lesions Interference with plaque microorganisms Modification in tooth morphology

Increased enamel resistance / Reduction in enamel solubility

Dental caries involves dissolution of enamel by acids from bacterial plaque and that dissolution is inhibited by the presence of fluoride. Because fluoride forms fluorapatite, which is a less soluble mineral, it has been thought that the anticaries effect of fluoride is the result of reduced solubility.

A high level of fluoride acquired prior to eruption is more effective in slowing enamel dissolution in vitro than the same level acquired topical!y.

Increased rate of post eruptive maturation

Newly erupted teeth have hypomineralized areas that are prone to dental caries. Fluoride increases the rate of mineralization or post eruptive maturation of these areas.

Re-mineralization of incipient lesions

Fluoride also plays a critical role in reducing dental caries by enhancing remineralization. Re mineralization which is the deposition of minerals into previously damaged areas of the tooth is a dynamic process that results in reduced enamel solubility. Fluoride enhances the re-mineralization process by accelerating the growth of enamel crystals that show demineralization resulting in larger crystals which are more resistant to acid attack

Fluoride as an inhibitor of demineralization

In vitro studies have shown that the presence of fluoride reduces the rate of demineralization of enamel

Interference with micro organisms

Fluoride has been known to inhibit bacterial enzymatic processes involved in carbolydrate metabolism. Fluoride interferes with oral bacteria in two ways. In high concentrations, fluoride is bactericidal thus probably helping reduce plaque. In lower concentrations, fluoride is bacteriostatic. It helps control the growth of bacteria without destroying them. Fluoride lodges in plaque and inhibits bacterial enzymes responsible for acid metabolism.

Modification in tooth morphology

There is a direct relationship between the amount of fluoride ingested during tooth development and the incidence of dental caries. If fluoride is ingested during tooth development, there is some evidence to suggest the formation of a more caries resistant tooth slightly smaller with shallow fissures.