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Auxiliary Education Programme

A structured learning programme on oral health for dental professionals presented by:

Figure 2: Professional and Self-Applied fluoride products

Objectives

Module 11 - Topical Fluoride

Agent

Professional: Acidulated Phosphate Fluoride (APF) Sodium Fluoride (NaF) Sodium Fluoride (NaF) APF and Stannous Fluoride (SnF2) Self-Applied: Toothpaste ­ Sodium Fluoride (NaF) Sodium Fluoride (NaF) Sodium Monofluorophosphate (SMFP) Stannous Fluoride (SnF2) Adjunct Therapies ­ Stannous Fluoride (SnF2) Sodium Fluoride (NaF) Sodium Fluoride (NaF) NaF and Chlorhexidine Gluconate Acidulated Phosphate Fluoride (APF)

Form

Gel or Foam Varnish Gel or Foam Rinse Paste Gel or Paste Gel or Paste Gel or Paste Gel or Rinse Gel Rinse Gel or Rinse Rinse

Concentration

1.23% or 12,300ppm 5% or 22,600ppm 2% or 9,040ppm 0.32%APF + 1.64% SnF2 By Prescription 1.1% or 5000ppm Adult 0.24% or 1000ppm / Child0.11% or 500ppm Adult 0.76% or 1000ppm / Child 0.38% or 500ppm 0.4% Gel 0.4% / Rinse 0.1% 1.1% or 5000ppm Weekly 0.2% or 900ppm / Daily 0.05% or 250ppm 0.003% NaF + 0.2% Chlorhexidine Gluconate Daily: 0.05% or 250ppm

Home rinsing dose = 2 tsp (10ml) Fluorosis and toxicity Fluorosis is a cosmetic problem that can appear as small chalky white areas (mild) to dark brown enamel with pitting (severe) caused by excessive systemic intake of fluorides during pre-eruptive tooth development. Toothpaste, fluoride rinses and gels often become unintended sources of systemic fluoride when they are swallowed. The use of evacuation during a topical treatment and close supervision of children using topical applications can preclude inadvertent swallowing. Acute toxicity reactions of GI upset with nausea and vomiting occur within 30 minutes of ingestion. Ingesting 32-64mg of fluoride per kilogram of bodyweight can be fatal. Conclusion Scepticism is prevalent when the topic of fluoride is mentioned both in public and in our dental practices. Yet, research on fluoride is continually presenting findings that demonstrate its ability to prevent demineralisation of tooth enamel and the remineralisation of early caries lesions with the added benefit of being antibacterial. It is the proper usage of topical fluorides, at home or in-office, that are the underlying factors to maximising both safety and benefits. Written by Terri Slough, RDH and produced by Incidental Concepts.

With the completion of this module, the participant should be able to: · Explain the role of topical fluorides in reducing and controlling dental caries/sensitivity · Understand fluoride concentrations and dosages · Identify sources of topical fluorides and their appropriate uses · Implement topical fluoride therapies based on caries risk assessment · Communicate the safety and benefits of topical fluorides Introduction Fluoride was introduced in toothpaste over 60 years ago and today it is recognised as the most effective agent for the prevention and control of dental caries, especially on smooth surfaces. The greatest acclaim is from systemic fluoride in the form of community water supplies, however research supports that most of the anti-caries effect is attributed to the regular use of topical fluoride products. An optimal level of fluoride concentration in saliva helps reduce sensitivity, prevent caries and repairs the early, non-visible stages of enamel, cementum and dentine caries. The greatest benefits rely on a multitherapeutic approach of professional and self-applied topical fluorides, and good oral hygiene regimens. Enamel formation Enamel maturation is virtually the same in all vertebrates, from wallabies to humans and is characterised by massive crystal growth. In its mature form tooth enamel is composed of an inorganic portion made up of 90% hydroxyapatite and 6-8% calcium carbonate, calcium fluoride and magnesium carbonate, with the remainder consisting of an organic matrix of protein and glycoprotein that functions as the basic scaffold for the crystals to build on (Figure 1). It is the tiny gaps between the calcium hydroxyapatite crystals and the matrix that provide a pathway for bacteria and acids. Fluoride mechanism Fluoride reduces the solubility of enamel by converting hydroxyapatite enamel crystals within the enamel matrix into fluorohydroxyapatite. This conversion strengthens the enamel to a state of hardness that exceeds its natural state. The primary dentition receives greater anticariogenic benefits from fluoride than the permanent dentition due to the porosity of newly erupted teeth. A continuous exchange of minerals between plaque and the enamel crystals occurs at the tooth surface and is dependent on the pH created by the organic acids. When the acid breaks the bonds between the apatite molecules, it liberates calcium and phosphates into the oral environment that combine with fluoride to enhance the remineralisation of decalcified enamel through the conversion of apatite molecules to fluorohydroxyapatite. Both high and low concentrations of fluoride have also been shown to affect the metabolism and quantity of plaque bacteria, specifically Streptococcus Mutans (stannous fluoride) through the formation of hydrogen fluoride (HF). It is the result of acid hydrogen from bacteria combining with fluoride. HF diffuses through cell walls and interferes with enzyme pathways by slowing down or destroying bacteria. In addition, gels and varnishes help strengthen sensitive areas around gum recession and natural wear through calcium deposition in the dentinal tubules on the tooth's surface. Professional fluoride applications Professional fluoride applications for adults and children provide a high concentration of fluoride in a loading dose (ave. 30mg per tray) to saturate demineralised areas. Tray application treatment is available in gel or foam (Figure 2) with neutral pH sodium fluoride (NaF) or acidulated phosphate fluoride (APF). Additionally, the NaF varnish has the advantage of timerelease to deliver fluoride directly to the areas needed with the release of fluoride over a period of time. Documented studies recommend using a neutral pH NaF formulation over APF treatments for patients with aesthetic restorations to protect them from micro etching and dulling. APF is a sodium fluoride solution that has been acidulated to pH 3.5 and buffered with a phosphate. It has a greater uptake because of its lower pH and acidulated formula that allows for more calcium fluoride (CaF) formation on the tooth surface. Although the suggested treatment time is 1-minute, only 80% benefit is reached in this duration so the full 4-minutes continues to be the standard for optimal results. A rinse system of stannous fluoride and APF is used as an alternative to tray applications, though not supported in scientific literature. Foam fluoride reduces fluoride exposure while maintaining the equivalent uptake of a gel but with only one-fifth the volume. The foam is fully retained in the tray and continuously dispersed as bubbles collapse on the teeth. Adjunct methods of introducing fluoride include: accelerated tooth resistance using fluoride with a lowenergy laser, fluoride-releasing restoratives and fluoride varnish as a provisional luting agent.

One ppm is the equivalent of 1 mg/L, (analogy = 1 inch in 16 miles) Self-applied fluoride Toothpastes, mouth rinses and home fluoride gels provide continuous low fluoride levels, which are needed to enhance the remineralization process of the tooth enamel. For most people fluoride toothpaste is their primary source of topical fluoride. There are three types of fluorides available in toothpastes (Figure 2): NaF, sodium monofluorophosphate (SMFP) and stannous fluoride (SnF 2). NaF is the most common, whereas SnF2 appears to be the most effective at inhibiting bacterial growth. Home fluoride gels are available in neutral pH NaF and 5.5pH SnF2. Daily and weekly fluoride rinses have been shown to be equally effective. Daily rinses are available over-the-counter and weekly rinses require a prescription or office dispensing. The benefits from fluoride rinsing for the primary dentition are less than those generally obtained for the permanent dentition, and due to uncontrolled swallowing reflexes children

under 6 years of age should not use them. Combination formulas, such as chlorhexidine gluconate and fluoride, offer control of plaque bacteria for hard and soft tissue benefits. Fluoride regimens Professional fluoride application is both a treatment and a preventive measure, therefore fluoride regimens should be tailored on a comprehensive view of each individual patient that includes: age, diet, salivary flow, caries rate, fluoride consumption and use, and a caries risk assessment. Risk factors include deficiencies in homecare, diet and health (physical, mental, oral) and/or active in fixed orthodontics, teeth bleaching, wine tasting, athletics or recreation drugs. Adults can benefit from both office and home fluoride regimens to increase remineralisation potential for undetectable subsurface or "white spot" lesions and the growing incidence of root caries. Children get the greatest benefit with an office fluoride application on newly erupted teeth within 12 months of eruption and appropriately supervised brushing twice a day using only a pea-sized dot of toothpaste. For best results, use fluoride at bedtime and delay eating or drinking for 30 minutes following any fluoride application.

Figure 1. Long/parallel hydroxyapatite crystals organised in bundles (green)

14 - AUXILIARY

MARCH/APRIL 2005

MARCH/APRIL 2005

AUXILIARY - 15

Auxiliary Education Programme

Name: ....................................... Tel: ...............................................

Instructions: 1. Remember to write your name in the space provided at the top of this page.

Module 11 - Topical Fluoride Written Assessment

2. To participate and be eligible for the $1500 cash prize and supplementary prizes, you MUST register. Registration is free and a form is located on page 17 or online at www.auxiliary.com.au 3. You can access the modules online to complete the assessments. The modules will be available online at the same time as each bimonthly Auxiliary magazine. 4. After studying the Education Module presented on the preceding two pages, complete the written assessment on a photocopy of the page or on a separate sheet of paper for the highest readability. It is important that you gain a thorough understanding of the module and the concepts it is presenting. The use of additional resources for better interpretation is also advised. Discuss the material with other oral health professionals at your practice. 5. Keep a copy of your completed written assessment to be used as a reference or to re-submit should it be requested. 6. Post or Fax your completed assessment to Auxiliary magazine, GPO Box 1481, Sydney NSW 2001 or Fax to (02) 9929-1999. 7. It is advised to complete and submit each module prior to the next published module. A bonus of 5 points per written assessment, for a total of 20 bonus points, will be given to each written assessment that is received prior to the distribution of the subsequent Education Module, excluding the final module in the series - Module 15. Bonus points will be added up to a total of 100 points with each assessment and cannot be carried over. 8. A total of five modules will be presented from March 2005 through December 2005. All five assessments MUST be received by 5.00PM, Friday 6 January 2006 to be eligible for the cash and supplementary prizes. This is not a game of chance and the winning entry will be assessed on its individual merits. The judges decision will be final. The results will be published in Auxiliary magazine Jan/Feb 2006. Optional Extra Points - 20 points Prepare a standard equation model to show the sequence of how a healthy tooth goes through demineralisation and then how the introduction of fluoride remineralises the tooth. This exercise is to facilitate your comprehension of the caries process and the effect of fluoride intervention. Example: A is the Healthy Tooth + B + C + D + E = Remineralisation. (Disclaimer: the example is for suggestive purposes only and does not depict the exact number of variables required in the equation).

Section 1: True/False - (20 points)

1. 2. 3. 4. 5.

Topical fluoride reaches the teeth directly? Dental caries are caused by a lack of fluoride? The highest concentration of topical NaF is 5000ppm? A 250ppm fluoride rinse would be recommended for daily use? Hydrogen fluoride is bacteriostatic?

T T T T T

/ / / / /

F F F F F

Section 2: ASSIGNMENT 1 - (40 points)

Fluoride History - As causes of dental caries and response to treatment vary between patients, a regimen of fluoride applications should be tailored to the needs of an individual patient rather than using the same routine for all patients. Design a simple questionnaire that will provide you with the pertinent information needed for tailoring a patient's fluoride regimen. (A4 maximum size)

Section 3: ASSIGNMENT 2 - (40 points)

Information Brochure - Fluoride is a contentious issue in our society. Patients are bombarded by a mix of truth and propaganda and turn to the dental profession for advice and education for an authoritative perspective. Prepare an information brochure that will help patients gain an understanding of both professional and self-applied topical fluoride. You may write this to the "pro fluoride" or the "against fluoride" point of view. It is to be reflective of your professional philosophy. Keep it brief and use vocabulary for easy comprehension. Consider what questions your patients, friends and family are asking you about this issue in order to present the most appropriate information. Guidelines: A4 is an ideal size (flat or folded), and limit the content to cover a maximum of 5 topic points. Oral-B will offer a supplementary prize for the best entry from Assignment #1 and one from Assignment #2.

PLEASE REMEMBER TO INCLUDE YOUR NAME AT THE TOP OF THE PAGE.

16 - AUXILIARY MARCH/APRIL 2005

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Auxiliary 03.05

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