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Application of Fluoride & Ca P

DENT 5302 TOPICS IN DENTAL BIOCHEMISTRY 16 April 2007. Application of Fluoride & Ca P. in caries control measures. Objectives:. Rationale for clinical use of fluoride and calcium phosphate Risk factors for development of dental fluorosis . Outline.

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Application of Fluoride & Ca P

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  1. DENT 5302 TOPICS IN DENTAL BIOCHEMISTRY 16 April 2007 Application of Fluoride & Ca P in caries control measures Objectives: • Rationale for clinical use of fluoride and calcium phosphate • Risk factors for development of dental fluorosis

  2. Outline • Delivery means of fluoride as caries preventive agents • Effectiveness of fluoride products • CPP-ACP • Rationale for clinical use • Risk factors for fluorosis • Sample questions

  3. Delivery means of fluoride • Systemic fluoride • Water fluoridation • Salt, milk, sugar fluoridation • Fluoride supplements community approach Individual-based • Topical fluoride • Professional (Operator-applied) fluoride products • Over-the-counter fluoride products Individual-based • Fluoride-containing restorative materials

  4. Effectiveness of fluoride products • Water fluoridation Effectiveness: (high caries prevalence) • 40-49% in primary teeth • 50-59% in permanent teeth • Low caries prevalence & use of other F-products: ~ 20% • Fluoridated toothpastes • Caries preventive effect ~ 25 % • Cariostatic effect in life-long use in population may be much greater • Fluoride mouthrinses • Weekly rinse: 0.1-0.2% (~1000-2000 ppm F) • Inconclusive when other fluoride products are used • Daily rinse: 0.025-0.05% (~250-500 ppm F) • 10-65% caries reduction in subjects with root caries risk Modified from: Ripa LW. J Dent Res 1990;69(Spec Iss):786-796.

  5. Effectiveness of fluoride products • Fluoride gels • 4-37 % caries inhibition (overall = 22%), independent of F toothpaste or fluoridated water • Fluoride varnishes • Highest F concentration (5%) among F-containing product • Meta-analysis: 38% caries reduction (patients used F-toothpaste) Modified from: Ripa LW. J Dent Res 1990;69(Spec Iss):786-796. • F-containing restorative materials • Glass ionomers provide protection against recurrent caries in high risk patients (e.g., xerostomia) who did not routinely used topical fluoride (less compliance) McComb D et al. Oper Dent 2002;27:430-437. Haveman CW et al. J Am Dent Assoc 2003;134:177-184.

  6. Milk protein derivative CPP-ACP • Casein protein contributes to anticariogenic properties of milk • Casein phosphopeptides (CPP) derived from casein protein stabilize amorphous calcium phosphate (ACP) in solution • CPP binds well to dental plaque • CPP localizes calcium and phosphate ions • Inhibit demin and promote remin Reynolds EC. J Spec Care Dent 1998;18:8-16.

  7. CPP-ACP enhances remineralization process • Sugar-free gum + CPP-ACP 100% enamel remin vs control Reynolds EC et al. J Clin Dent 1999;10:86-8. CPP-ACP Tradename: Recaldent

  8. Rationale for clinical use caries risk, product efficacy, patient compliance, cost-effectiveness ratio, background F exposure, access to dental care, safety issues What factors to consider? • Frequent exposure to low level F is more effective Which method? • Patient’s compliance may be more effective than the product per se Example Cost-Benefit ratio • F toothpaste + good dental care Low caries prevalence • Water fluoridation + F toothpaste Is professional fluoride application necessary? Caries incidence in low caries group = 0.25 DMFS / year Fluoride gel (2X year) reduced caries 22 % Save 0.055 DMFS per year How much? Safety issues • Chronic toxicity or long-term effect Dental fluorosis

  9. Percentage of fluorosis cases attributable to specific fluoride sources Optimally fluoridated community Nonfluoridated population Attributable risk (%) Attributable risk (%) Fluoride Source Fluoride Source F supplement: During year 1-2 Tooth brushing: > pea-sized & > once per day > pea-sized & once per day pea-sized & > once per day Formula (powder concentrate) 13 46 22 2 9 F supplement: (pre-1994) Year 1 Year 2-8 Tooth brushing: Began during Y 1 & 2 > once per day Began during Y 1 & 2 once per day Began after Y 2 > once per day Used > pea-sized Formula feeding 29 65 34 8 6 45 0

  10. Risk factors for dental fluorosis • Tooth brushing behavior with F toothpaste 32% of children under age 2 brushed with F toothpaste 91% among 4-year-olds brushed with F toothpaste Preschoolers swallowed 55-79% (max 90 %) of toothpaste 34% of fluorosis in non-fluoridated areas: children < 2 years old brushed > 1 per day 45% from > pea-sized amount of F toothpaste 68% of fluorosis cases in areas with optimal water fluoridation: > pea-sized amount of F toothpaste Odds ratio for fluorosis with the use of F-toothpaste = 1.6-1.8

  11. Toothpastes with flavor for children Is that a good idea??? Special toothpaste with 500 ppm F for young children Children < 6 years old, unless fully developed swallowing reflex: Pea-size amount of F toothpaste Toddler: No F toothpaste until 2 years of age ADA, Nov 2006

  12. Risk factors for dental fluorosis • Fluoride supplements Inappropriate use causes fluorosis Prescribed by dentists/physicians Not in areas with water fluoridation Test F in the water supplies. Other sources of fluoride: juice or bottled water Animal studies: threshold plasma F level for dental fluorosis One ‘spike’ of 0.2 ppm/day for 1 week One or two ‘spikes’ of 0.1 ppm/day for 1 week dental fluorosis no dental fluorosis If a child (5 kg,10 lb, ? < 1 year old) is given 0.5 mg F = 0.1 mg/kg Ingesting 0.1 mg/kg can raise plasma F level to exceed 0.2 ppm

  13. Recommended Dietary Fluoride Supplement Schedule Fluoride concentration in community drinking water Age < 0.3 ppm None 0.25 mg/day 0.50 mg/day 1.0 mg/day 0.3-0.6 ppm None None 0.25 mg/day 0.50 mg/day > 0.6 ppm None None None None 0 –6 months 6 months – 3 years 3 – 6 years 6 – 12 years How much fluoride is in my water? http//apps.nccd.cdc/gov/MWF/Index.asp My Water’s Fluoride, Oral Health Resources National Center for Chronic Disease Prevention and Health Promotion, CDC Where to send water to test fluoride content? Fluoride Testing Service, School of Dentistry, University of Minnesota Order water kit box from Doug Magne 612-624-9123 Dr. Robert Ophaug 612-625-5198

  14. Multiple sources of drinking water • 5 year old child • Home water is 0.25 ppm F • School water is 1 ppm F • Ingest 50 % from each source Example 0.25 ppm x 0.5 = 0.125 ppm F 1 ppm x 0.5 = 0.5 ppm F Effective concentration = 0.625 ppm F Therefore, if you base the recommendation according to home water fluoride level, the child will get 0.5 mg F supplement. However, according to the effective concentration, the child does not need any F supplement.

  15. Risk factors for dental fluorosis • Fluoridated water Drinking optimally F water by itself is not a risk factor Most bottled waters < 0.3 ppmF Home filtration (distillation/reverse osmosis) removes > 90% F Carbon/charcoal filters do not remove F Juices: 0.02 – 2.8 ppmF; 42% > 0.6 ppmF (halo) Soft drinks: 0.02 – 1.28 ppmF ; 77% > 0.6 ppmF (halo) USDA National Fluoride Database of Selected Beverages and Foods http://www.nal.usda.gov/fnic/foodcomp/Data/Fluoride/fluoride.pdf Aquafina 0.05 ppm Crystal 0.24 ppm Dannon 0.11 ppm Dasani 0.07 ppm Perrier 0.31 ppm Dannon Fluoride To Go 0.78 ppm

  16. Risk factors for dental fluorosis • Infant formula reconstituted with fluoridated water Significant source of F (1 ppm for powder concentrates, 0.5 ppm for liquid concentrates), especially when > 1 L is ingested. Responsible for 9% of dental fluorosis Recommendation for infants (birth to 12 months): Liquid concentrate or powdered infant formula should be mixed with water that is fluoride free or contains low levels of fluoride. Labeled: purified, demineralized, deionized, distilled or reverse osmosis filtered water Breast milk and cow milk: very low in fluoride (0.01-0.04 ppm) 1979: US manufacturers voluntarily reduced F to 0.15-0.30 ppm Note: Infant chicken product can have 8 ppm F; 20 times higher than infant fruit

  17. Recommended references 1. Brambilla E. Fluoride - Is it capable of fighting old and new dental diseases? Caries Res 2001;35(suppl 1):6-9. 2. Ripa LW. An evaluation of the use of professional (operator-applied) topical fluoride. J Dent Res 1990;69(Spec Iss):786-796. 3. Zimmer S. Caries-preventive effects of fluoride products when used in conjunction with fluoride dentifrice. Caries Res 2001;35(suppl 1):18-21. 4. Warren JJ, Levy SM. Systemic Fluoride. Sources, amounts, and effects of ingestion. Dent Clin N Am 1999;43:695-711. 5. Bowen WH. Fluorosis. Is it really a problem? J Am Dent Assoc 2002;133: 1405-1407. 6. Pendrys DG. Risk of enamel fluorosis in nonfluoridated and optimally fluoridated populations: considerations for the dental professional. JADA 2000;131:746-755.

  18. Sample questions: Fill in blank / short answer Give one example of strategy to prevent dental caries if you believe in the ecologic plaque hypothesis. (2 points) ______________________________________________________ • Base on your knowledge on enamel composition and the de/remineralization process, why do newly erupted teeth have relatively greater caries susceptibility and become less caries susceptible over time? (4 points) • ____________________________________________________________________________________________________ • 2. ________________________________________________________ • _______________________________________________________

  19. This picture is a ground section of early enamel carious lesion. Name the following zones and choose a description from the given list that is the best matching with each zone. Zone 1 ____________________ Description ______ Zone 2 ____________________ Description ______ Zone 3 ____________________ Description ______ List of description A. This zone has very small porosities and the largest crystal size as a result of remineralization process. B. This zone is invaded by cariogenic bacteria. C. Bacteria will not invade if this zone is still intact. D. This zone has the same percentage of pore volume as sound enamel. E. This zone has the highest activity of demineralization. F. This zone has the smallest crystal size and the most stable because fluoride ions substitute hydroxyl ions.

  20. Multiple choice Which of the following F-containing product has the highest absorption rate? a. Toothpaste with sodium monofluorophosphate b. NaF mouthrinse c. Acidulated phosphate fluoride gel d. Duraphat fluoride varnish e. Fluoridated salt

  21. Based on your knowledge of the effects of fluoride on the de/remineralization of enamel, what would you expect to happen to the incidence (rate of development) of dental caries in adults if optimal fluoridation of a low-fluoride community water supply was discontinued? a. The incidence of dental caries would increase due to the rapid loss of fluoride from the enamel surface. b. The incidence of dental caries would not change since the fluoride in surface enamel is retained over long period of time. c. The incidence of dental caries would increase because of the decrease in fluoride concentration in dental plaque and plaque fluid. d. The incidence of gingivitis would increase because plaque formation increases dramatically if the concentration of fluoride in water is less than 0.2 ppm. e. The incidence of dental caries would not change since the fluoride in surface enamel can be released under acidic condition and add more fluoride ions to the plaque fluid.

  22. A 5-year old child resides in a home supplied with well water containing 0.45 ppmF, and goes to kindergarten with 1.0 ppmF in drinking water. It is estimated that 40% of the child's drinking water is consumed at school and 60% at home. According to the ADA’s fluoride supplementation schedule above, this child should have _____________. a. no fluoride supplement. b. a daily supplement of 0.25 mg of F- c. a daily supplement of 0.25 mg of NaF d. a daily supplement of 0.50 mg of F- e. a daily supplement of 1.0 mg of NaF

  23. The mother of a 5 year-old child (25 kg body weight) calls your office and informs you that the child became ill and vomited because the child had eaten a sample dentifrice (4 oz tube, 1000 ppm fluoride). The maximum amount of fluoride that could have been ingested by the child is _______________. (1 oz is approximately 30 g) a. 30 mg b. 120 mg c. 120 mg d. 4,000 ppm e. 4,000 mg

  24. The correct response to the mother in the previous question is _________. a. to tell her that nausea and vomiting are normal reactions to the ingestion of fluoride at this level, and that emergency treatment and hospitalization are not necessary. b. to tell her that this situation has the potential to be life-threatening and the child should be transported to a hospital immediately. c. to tell her that the amount of ingested fluoride may have exceeded the Probable Toxic Dose (PTD). Since the child has vomited, however, no emergency treatment is needed. d. Since the Minimum Lethal Dose of fluoride has not been exceeded no emergency treatment or hospitalization is necessary.

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