5 topical flouride

8/12/2019 5 Topical Flouride..

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http://www.aap.org/oralhealth/pact

Protecting All Childrens Teeth

Fluoride


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Introduction

Fluoride is the negatively charged ionic form of the element fluorine that has

a high affinity for calcium. It plays an important role in the prevention of

dental caries.

Although the primary mechanism of action of fluoride in preventing dental

caries is topical, systemic mechanisms are also important. Fluoride acts in

the following ways to prevent dental caries:

1. It enhances remineralization of the tooth enamel. This is the mostimportant effect of fluoride in caries prevention.

2. It inhibits demineralization of the tooth enamel.

3. It makes cariogenic bacteria less able to produce acid from carbohydrates.


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Learner Objectives

Upon completion of this presentation, participants will be able to:

State the 3 mechanisms of action of fluoride in dental caries prevention. Summarize the available sources of fluoride and their relative benefits.

List strategies to minimize the development of fluorosis.

Discuss the fluoride supplementation guidelines.

Recognize the various forms of fluorosis and recall their prevalence.


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Fluoride Facts

Fluoride has been available in the United States since the mid-1940s.

In 2008, 64.3% of the population served by public water systemsreceived optimally fluoridated water.

Public water fluoridation practice varies by city and state.

Water fluoridation was recognized by the Centers for Disease Control

and Prevention (CDC) as one of the 10 greatest public health

achievements of the 20th century.


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Fluoride Facts, continued

There is strong evidence* that community water fluoridation is

effective in preventing dental caries.The recommended concentration of fluoride in drinking water

was decreased in 2011 from 0.7-1.2 mg/L to 0.7 mg/L.

Clinicians should balance the benefits of fluoride against the riskof fluorosis when deciding whether to fluoridate water.

Water filters may decrease the fluoride content of communitywater. Activated charcoal filters and cellulose filters have anegligible effect; reverse osmosis filters and water distillationremove almost all fluoride from water.


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Systemic Sources of Fluoride

Fluoride can be ingested through:

Drinking water

Other beverages

Foods

Toothpaste

Fluoride supplements


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Bottled Water

No one source exists to tell consumers the

fluoride content in bottled waters.

The US Food and Drug Administration (FDA)

does not require that fluoride content be

listed on the labels of bottled waters.

It is appropriate to assume that children

whose only source of water is bottled are

not receiving adequate amounts of fluoride

from that source.


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Commercial Beverages and Foods

Many foods and beverages are made with community fluoridated water,

so they contain fluoride.

Foods such as seafood and certain teas can also have a naturally high

fluoride content.

This must all be taken into account when determining daily fluoride intake.


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Infant Nutrition

Human breast milk contains almost

no fluoride, even when the nursing

mother drinks fluoridated water.

Powdered infant formula contains

little or no fluoride, unless mixed

with fluoridated water. The amount

of fluoride ingested will depend on

the volume of fluoridated water

mixed with the formula.


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Toothpaste

Toothpastes effects are mainly topical, but some toothpaste isswallowed by children and is available systemically.

Strategies to Minimize Toothpaste Ingestion

Discourage children from swallowingtoothpaste.

Encourage spitting of toothpaste.

Supervise brushing until spitting can

be ensured.

Limit the amount of toothpaste on thetoothbrush.


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Fluoride Supplements

Supplements should be considered

especially for patients at high risk fordental caries whose community water

source is suboptimal.

Supplements are available in liquid,

tablet, or lozenge form.


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Fluoride Supplements, continued

CDC Quality of Evidence to Support the Use of Fluoride Supplements

Children 6 years and younger: Grade II-3. Strength of recommendation ofC with targeted effort at populations at high risk for dental caries.

Children 6-16 years: Grade 1. Strength of recommendation of A withtargeted effort at populations at high risk for dental caries.

Pregnant women: Quality of evidence against providing fluoridesupplementation to pregnant women to benefit their children is Grade 1.Strength of recommendation of E (good evidence to reject the use of themodality).


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Fluoride Supplements, continued

The 2010 ADA guideline* recommends

fluoride supplements be prescribed

only to children at high risk forcaries development. Strength of

recommendation: B

The United States Preventive Services

Task Force recommends fluoridesupplementation be prescribed at

recommended doses to children older

than 6 months whose primary water

source is deficient in fluoride. Strength of recommendation: B


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Topical Sources of Fluoride

Following are the most commonforms of topical fluoride:

Toothpaste

Fluoride mouthrinses

Fluoride gels

Fluoride varnish


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Toothpaste

Toothpaste is the most recognizable source of

topical fluoride.

The addition of fluoride to toothpaste began

in the 1950s.

Brushing with fluoridated toothpaste is associated

with a 24% reduction in decayed, missing, and filled tooth surfaces.

The CDC concluded that the quality of evidence for fluoridated toothpaste

in reduction of caries is grade 1. Strength of recommendation is A for use

in all persons.


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Fluoride Mouthrinses

Mouthrinses containing fluoride are recommended in a swish and spit

manner.

Mouthrinses are available over the counter. Frequency of use ranges

from daily to weekly.

The CDC concluded that quality of evidence for fluoride mouthrinses

is Grade 1. Strength of recommendation is A with targeted effort at

populations at high risk for dental caries.


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Fluoride Gels

Fluoride gels are professionally applied or prescribed for home

use under professional supervision. They are typically recommendedfor use twice per year.

The CDC concluded that the quality of evidence for using fluoride gel

to prevent and control dental caries in children is Grade 1. Strength

of recommendation is A, with targeted effort at populations at high

risk for caries.


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Fluoride Varnish

Varnishes are a professionally applied,

sticky resin of highly concentrated

fluoride (up to 22,600 ppm).

In the United States, fluoride varnish

has been approved by the FDA for use

as a cavity liner and root desensitizer,

but not specifically as an anti-caries

agent.

For caries prevention, fluoride varnish

is an off label product.


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Fluoride Varnish

Application frequency for fluoride varnish

ranges from 2 to 6 times per year.

The use of fluoride varnish leads to a

33% reduction in decayed, missing,

and filled tooth surfaces in the primary

teeth and a 46% reduction in the

permanent teeth.

The CDC concluded that the quality of evidence for using fluoride varnish

to prevent and control dental caries in children is Grade 1. Strength of

recommendation is A, with targeted effort at populations at high risk for

dental caries.


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Community Water Fluoridation

The goal of community water

fluoridation is to maximize dental

caries prevention while minimizing thefrequency of enamel fluorosis.

In January 2011, the US Department

of Health and Human Services announced

that the optimal fluoride concentrationis 0.7 ppm.

Because there is geographic variability in community water fluoridation,

it is important to know fluoride content of the water children consume.


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Water Fluoridation

The US Environmental Protection Agency

requires that all community water supplysystems provide customers an annual

report on the quality of water, including

fluoride concentration. Providers can

contact the local water authority for

this information.

Fluoride content of a towns water can also be determined byaccessing CDCs My Water's Fluoride Web site.
http://apps.nccd.cdc.gov/MWF/Index.asp


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Well Water

Wide variations in the natural fluoride

concentration of well water sources exist.

Private wells should be tested for fluoride

concentration before prescribing supplements.

Testing can be done through local and state

public health departments or through

private laboratories.


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Fluoride Supplementation

When access to community water fluoridation is limited, fluoride can be

supplemented in liquid, tablet, or lozenge form.

Fluoride supplements require a prescription. A 2010 ADA guideline*

recommends fluoride supplements be prescribed only to children determined

to be at high risk for the development of caries.


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Supplementation Dosing Schedule

The American Academy of Pediatrics, American Dental Association (ADA),and American Academy of Pediatric Dentistry (AAPD) have developed thefollowing dosing schedule for fluoride supplementation:

1. All sources of fluoride must be considered, including primary drinkingwater, other sources of water, prescriptions from the dentist, fluoridemouthrinse in school, and fluoride varnish.

2. Supplementation should be provided if fluoride access is limited.

3. Children younger than 6 months and older than 16 years should notbe supplemented.

4. Children who have adequate access to (and are drinking) appropriatelyfluoridated community water should not be supplemented.


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Fluorosis

Fluorosisis caused by an increased

intake of fluoride.

Mild forms of fluorosis appear as

chalk-like, lacy markings on the

tooths enamel.

In the moderate form of dental

fluorosis, a white opacity can be

seen on more than 50% of the tooth.

Severe fluorosis results in brown, pitted, brittle enamel.


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Fluorosis

Dental fluorosis occurs during tooth development.

Permanent teeth are more susceptible to

fluorosis than primary teeth.

The most critical ages of susceptibility are

0 to 6 years, especially between the ages

of 15 and 30 months.

After 7 or 8 years of age, dental fluorosis cannot

occur because the permanent teeth are fully

developed, although not erupted.


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Prevalence of Fluorosis

The prevalence of dental fluorosis has increased in the United States

from 22.8% in 1986-1987 to 32% in 1999-2002.

This can be attributed to the increased availability and ingestion of

multiple sources of fluoride by young children, including:

Foods

Beverages

Toothpaste

Other oral care products

Dietary fluoride supplements


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Prevalence of Fluorosis, continued

Some form of dental fluorosis is found in the following age groups*:

40% of US children ages 6-11 years49% of 12- to 15-year-olds

42% of 16- to 19-year-olds

Most of this fluorosis is mild and barely noticeable by non-dental health

professionals.


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Prevalence of Fluorosis, continued

Although the effects of dental fluorosisare mainly aesthetic, the increased

prevalence mandates that health

professionals be aware of all possible

sources of fluoride before

considering supplementation.


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Fluorosis and Toothpaste

Ingestion of toothpaste increases the

risk of enamel fluorosis.

If fluoridated toothpaste is used,

strategies to limit the amount

swallowed include limiting the amount

placed on the brush and observing thechild as they brush.


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According to the AAPD, the best way to

minimize a child's risk for fluorosis is tolimit the amount of toothpaste on thetoothbrush.

The AAPD suggests a smear oftoothpaste for children younger than

2 years of age and a "pea-sized"amount for children ages 2 to 5.


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For children younger than 2, the CDC suggests the pediatrician considerfluoride levels in the community drinking water, other sources of fluoride,and factors likely to affect susceptibility to dental caries when weighing therisk and benefits of fluoride toothpaste. The CDC does not give specificadvice on how much toothpaste to use in children younger than 2.

For children younger than 6, the CDC recommends that parents:

1. Limit toothbrushing to 2 times a day.

2. Apply less than a pea-sized amount to the toothbrush.3. Supervise tooth brushing and encourage children to spit out excess

toothpaste.

4. Keep toothpaste out of the reach of young children to avoid accidentalingestion.


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A 2007 Maternal and Child Health Bureau expert panel recommended:

All children at high risk for dental caries use fluoride toothpaste

Children younger than age 2 use a smear of toothpasteChildren aged 2-6 years use a slightly larger, pea-sized amount

The AAP endorses this recommendation.

When deciding whether to use fluoridated toothpaste in children youngerthan 2, the panel recommends considering:

The child's risk of dental caries

The risk of dental fluorosis

The benefit of the topical application in the form of fluoridated toothpaste


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Question #1

What is the most critical age of susceptibility to fluorosis of the

permanent teeth?

A. Between 0 and 15 months of age.B. Between 15 and 30 months of age.

C. Between 30 and 45 months of age.

D. The risk of fluorosis in the permanent teeth is equal across all ages.

E. None of the above.


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Answer

What is the most critical age of susceptibility to fluorosis of the

permanent teeth?

A. Between 0 and 15 months of age.B. Between 15 and 30 months of age.

C. Between 30 and 45 months of age.

D. The risk of fluorosis in the permanent teeth is equal across all ages.



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Question #2

True or False? The most important mechanism of action of fluoride

is a systemic effect.

A. True.B. False.


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Answer

True or False? The most important mechanism of action of fluoride

is a systemic effect.

A. True.B. False.


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Question #3

Which of the following is the most important function of fluoride in

caries prevention?

A. Fluoride enhances remineralization of tooth enamel.B. Fluoride inhibits demineralization of tooth enamel.

C. Fluoride negatively affects the acid producing capabilities of cariogenic

bacteria.

D. Fluoride displaces sugars from the surface of the teeth.

E. All of the above are equally important.


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Answer

Which of the following is the most important function of fluoride in

caries prevention?

A. Fluoride enhances remineralization of tooth enamel.B. Fluoride inhibits demineralization of tooth enamel.

C. Fluoride negatively affects the acid producing capabilities of cariogenic

bacteria.

D. Fluoride displaces sugars from the surface of the teeth.

E. All of the above are equally important.


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Question #4

True or False? Fluoride supplements should be prescribed for high-risk

children whose community water source is suboptimal.

A. TrueB. False


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Answer

True or False? Fluoride supplements should be prescribed for high-riskchildren whose community water source is suboptimal.

A. TrueB. False


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Question #5

Which of the following is a symptom of mild fluorosis?

A. A white opacity on more than 50% of the tooth.

B. Dark spots on the teeth.C. Brown, pitted, brittle enamel.

D. Chalk-like, lacy markings on the enamel.



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Answer

Which of the following is a symptom of mild fluorosis?

A. A white opacity on more than 50% of the tooth.

B. Dark spots on the teeth.C. Brown, pitted, brittle enamel.

D. Chalk-like, lacy markings on the enamel.



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References

1. American Academy of Pediatric Dentistry. Guideline on Infant Oral Health Care.Council on Clinical Affairs. Reference Manual 2011. 33(6): 124-128.2. American Academy of Pediatric Dentistry. Policy on Early Childhood Caries (ECC):Classifications, Consequences, and Preventive Strategies. Pediatr Dent 2011, 33(6):47-49.3. American Dental Association Council on Scientific Affairs. Professionally appliedtopical fluoride. Evidence-based clinical recommendations. JADA. August 1, 2006.137(8): 1151-1159.

4. Berg J, Gerweck C, Hujoel PP, et al. Evidence-Based Clinical RecommendationsRegarding Fluoride Intake from Reconstituted Infant Formula and Enamel Fluorosis. AReport of the American Dental Association Council on Scientific Affairs. JAMA. January2011 vol. 142(1): 79-87.

5. Centers for Disease Control and Prevention. Recommendations for using fluoride toprevent and control dental caries in the United States. MMWR. 2001; 50(RR-14): 1-42.Available online at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm.Accessed November 20, 2006.


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References, continued

6. Centers for Disease Control and Prevention. Surveillance for Dental caries, Dentalsealants, Tooth Retention, Edentulism, and Enamel Fluorosis-United States, 1988-1994and 1999-2002. MMWR Surveillance Summaries. 2005. 54(03);1-44. Available onlineat: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5403a1.htm. Accessed

November 20, 2006.7. Centers for Disease Control and Prevention. Using Fluoride to Prevent and ControlTooth Decay in the United States Fact Sheet, updated Jan 2011.www.cdc.gov/fluoridation/fact_sheets/fl_caries.htm8. Department of Health and Human Services. HHS Recommendation for FluorideConcentration in Drinking Water for Prevention of Dental Caries. Federal Register. Vol.76(9): January 13, 2011.9. Krol DM. Dental caries, oral health, and pediatricians. Curr Probl Pediatr Adolesc

Health Care. 2003; 33(8):253-270.10. Lewis CW, Milgrom P. Fluoride.Pediatr Rev. 2003; 24(10):327-336.11. Lewis DW, Ismail AI. Periodic health examination: 1995 update: 2. Prevention ofdental caries. The Canadian Task Force on the Periodic Health Examination. Can MedAssoc J. 1995; 152(6): 836-46.
http://www.cdc.gov/fluoridation/fact_sheets/fl_caries.htmhttp://www.cdc.gov/fluoridation/fact_sheets/fl_caries.htmhttp://www.cdc.gov/fluoridation/fact_sheets/fl_caries.htmhttp://www.cdc.gov/fluoridation/fact_sheets/fl_caries.htm


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12. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride varnishes for preventingdental caries in children and adolescents. The Cochrane Database of SystematicReviews 2002, Issue 1. Art. No.: CD002279. DOI: 10.1002/14651858.CD002279. Thisversion first published online: 21 January 2002 in Issue 1, 2002.

13. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Topical fluoride (toothpastes,mouthrinses, gels, or varnishes) for preventing dental caries in children andadolescents. The Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.:CD002782. DOI: 10.1002/14651858.CD002782. This version first published online: 20January 2003 in Issue 1, 2003.14. Oral health in America: A Report of the Surgeon General. Rockville MD: USDepartment of Health and Human Services, National Institute of Dental andCraniofacial Research, National Institutes of Health; 2000. Available online at:

http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral. Accessed November 20,2006.15. Rozier RG, Adair S, Graham F, et al. Evidence-Based Clinical Recommendations onthe Prescription of Dietary Fluoride Supplements for Caries Prevention. A Report of theAmerican Dental Association Council on Scientific Affairs. JADA. December 2010 vol.141(12): 1480-1489.


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16. US Environmental Protection Agency. 40 CFR Part 141.62. Maximum contaminantlevels for inorganic contaminants. Code of Federal Regulations 2002:428-9.17. US Environmental Protection Agency. 40 CFR Part 143.3 National secondary

drinking water regulations. Code of Federal Regulations 2002; 614.18. United States Preventive Services Task Force. Guide to clinical preventive services,2010-2011. Available online at: http://www.ahrq.gov/clinic/pocketgd.htm. AccessedJanuary 28, 2011.

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