Phd topical fluoride preparation present

CONTENTS
• INTRODUCTION
• DEFINITION
• APPLICATION OF FLUORIDES
• INDICATION
• CONTRADICTION
• CONCLUSION

Introduction
By definition the term "topically appliedfluorides" is
used to describe those deliverysystems which provide
fluoride for localchemical reaction to exposed surfaces
of theerupted dentition. The delivery systemsinclude
measures designed for professionalapplication in the
dental office, such asfluoride-containing prophylactic
pastessolutions, gels and varnishes, as well assystems
designed for unsupervised home use,such as fluoride
dentifrices and rinses

Indications
1.Caries - active individuals (defined as those with past caries experience or those who develop
new carious lesions on smooth tooth surfaces).
2.Children shortly after periods' of. tooth eruption, especially those who are not caries free.
3.Those who take medication that decrease salivary flow or have received radiation to head and
neck.
4.After periodontal surgery when roots of teeth that have been exposed.
5.Patients with fixed or removable prosthesis and after placement or replacement of restorations.
6.Patients with an eating disorder or who are undergoing a change in life style which may affect
eating or oral hygiene habits conducive to good oral heath
7.Mentally and physically challenged individuals,
The choice of topical fluoride for each patient should depend on age, education, oral health habits
and physical dexterity

Types
Topical fluoride products can be divided into 2 broad categories.
1.Professionally applied products: Professionally applied fluoride products
are those medicaments typically dispensed by dental professionals in the
dental office and usually involve the use of high fluoride concentration
products ranging from 5000 and 19000 ppm which is equivalent to 5-19
mg F/ml.
2.Self applied products: Self-applied fluoride products are usually bought
and dispensed by the individual patient but at the recommendation of
dental personnel. These products include fluoride dentifrices, mouthrinses
and gels and typically are low fluoride concentration products ranging
from 200 to 1000 ppm or 0.2 - 1.0 mg fluoride/ ml

PROFESSIONALLY APPLIED TOPICAL
FLUORIDES
Bibby in 1942 was the first to demonstrate that the repeated application of
sodium or potassium fluoride to teeth of children significantly reduced their
caries prevalence This finding was the forerunner of numerous studies designed
to test the effectiveness of various topical agents and the best mode of
applying them to teeth Topical fluoride application by a dentist hygienist or
other dental auxiliary has become an established caries - preventive procedure
in the dental ofice. The three agents currently in use are neutral Sodium
Fluoride (NaF)Acidulated Phosphate Fluoride_ (APF) and Stannous Fluoride
(SnF2).
The fluoride may be used in an oqueous solution, a viscous gel, a prophylaxis
paste or asa dental varnish and can be applied using the paint on technique or
the tray technique

Rationale for using topical fluoride
agents
The rationale for using topical- fluoride agents is to speed the rate. and increase the
concentration of fluoride acquisition above the level, which occurs naturally. lf an
individual's only exposure to fluoride post-eruptively is in drinking water, it may take
years before surface enamel acquires an effective concentration. Topical fluoride hastens
process. Since immature and porous enamel acquires fluoride rapidly and since the
enamel surface of newly erupted teeth undergoes rapid maturation, it follows that the
best time to apply topical fluoride is soon after eruption. Also, the initial caries lesion,
characterized by a white spot, is porous and accumulates fluoride at a much higher
concentration than adjacent sound enamel. Pre-treating enamel with 0.05 Mphosphoric
acid, in order to increase enamel surface area, greatly enhances the uptake and retention
of fluoride. Lengthening the time interval between the applications of a solution also
increases fluoride uptake. This implies that periodic application of fluoride would enable
vulnerable enamel sites that are partially demineralized to accumulate fluoride

TOPICAL FLUORIDE COMPOUNDS USED IN
PREVENTIVE DENTISTRY
1.NEUTRAL SODIUM FLUORIDE (NaF)
Sodium fluoride (NaF) was the first fluoride compound to be used for
topical application A minimum of four applications with a 2%sodium
fluoride solution gives caries reduction ofabout30%.
Method of preparation of 2%neutral sodium fluoride
It is prepared by dissolving 20 grams of sodium fluoride powder in one liter
(1 000 ml)of distilled water in a plastic bottle. It is essential to store
fluoride in plastic bottles because if stored in glass containers, the fuoride
ion of solution can react with silica of glass forming silicon fluoride, thus
reducing the availability of free active fluorides for anticaries action

Method of application of neutral sodium fluoride according to Knutson’s
technique
If the sodium fluoride reagent is pure and uncontaminated, this solution has
a pH of 7Treatments are given in a series of four appointments.
• At the initial appointment, the teeth are first cleaned with aqueous pumice
slurry and then isolated with cotton rolls and dried with compressed air.
Teeth can either be isolated by quadrant or by half mouth.
• Using cotton-tipped applicator sticks, the2% sodium fluoride solution is
painted on the air-dried teeth so that all surfaces are visibly wet. Then with
the teeth still isolated, the solution is allowed to dry for3 to 4 minutes
• This procedure is repeated for each of the isolated segments until all of the
teeth are treated.
• A second, third and fourth fluoride application, each not preceded by a
prophylaxis, is scheduled at intervals of approximately one week.
• The four-visit procedure is recommended for ages 3, 7, 11 and 13 years,
coinciding with the eruption of different groups of primary and permanent
teeth. Thus, most of the teeth would be treated soon after their eruption,
maximizing the protection offered by topical application.

Mechanism of action of sodium fluoride
When sodium fluoride solution is applied on the tooth surface as a topical
agent, it reacts with the hydroxyapatite crystals in enamel t0form calcium
fluoride which is the main end product of the reaction. As a thick layer of
calcium fluoride gets-formed, it interferes with the further diffusion of
fluoride from the topical fluoride solution to react with hydroxyapatite and
blocks further entry of fluoride ions. This sudden stop of the entry of
fluoride is termed as "Chocking off effect "Fluoride then slowly leaches from
the calcium fluoride. Thus calcium fluoride acts as a reservoir for fluoride
release (t is for this reason that after each application of sodium fluoride on
to the tooth surface, it is left to dry for 4 minutes).
The calcium fluoride formed reacts with the hydroxyapatite crystals to form
fluoridated hydroxyapatite. The hydroxyapatite thus formed increases the
concentration of fluoride on enamel surface, which in turn makes the tooth
surface resistant against caries attack through the action of fluoride.

Advantages of neutral sodium fluoride solution
1.It is relatively stable when kept in a plastic container and there is no need
to prepare a fresh solution for each patient
2.The taste is well accepted by patients
3.The solution is non-irritating to the gingiva.
4.It does not cause discoloration of tooth structure.
5.Once applied to the teeth, the solution is allowed to dry for 3 minutes.
Thus the clinician in public health programs car pursue a multiple-choir
procedure
6.The series of treatments must be repeated only four times in the general
age range of3 to 13, rather than at annual or semiannual intervals,
therefore in a public health program, other groups of children can be
treated in the intervening years
7.Disadvantage of neutral sodiumfluoride solution
The major disadvantage of the use of sodium fluoride is that the patient
must make four visits to the dentist within a relatively short period of time

STANNOUS FLUORIDE (SnF2)
Stannous fluoride has been used at 8% and1 0% concentrations in
solutions equivalent to2 and 2.5% fluoride. Although the 10%solution is
usually used for adults and the 8%for children, there is no evidence of an
actual clinical difference between the two. However, the most commonly
used is 8% stannous,fluoride preparation
Method of preparation of stannous fluoride solution
Solutions of stannous fluoride are not stable. Soon after mixing they
become cloudy due to the formation of tin hydroxide. Since the stannous
is believed to contribute to the anticaries benefit of stannous fluoride,
aged solutions are considered to be clinically less effective. Muhler et al
recommended that afresh solution of stannous fluoride be prepared for
each patient. To prepare 8% stannous fluoride solution, the content of one
capsule which is 0.8 grams (O"No. gelation capsule) is dissolved" in 10ml
of distilled water in a plastic container and the solution is shaken briefly.

Technique of application (Muhlers technique)
Each tooth surface is cleaned with pumice. Or other dental cleaning agent for 5 to
10secondsUnwaxed dental floss is passed between the interproximal areas
(unwaxed floss has been recommended and continues to be used because it is
believed that waxed floss may coat the tooth surface and adversely affect fluoride
uptake Teeth are isolated and dried with air Stannous fluoride is applied using the
paint-on technique and the solution is kept for 4 minutes. repeat applications are
made every 6 months or more frequently if the patient is susceptible to caries
Mechanism of action of stannousfluoride
When stannous fluoride is applied in low concentration, in :hydroxyphosphate is
formed which gets dissolved in oral fluids and is responsible for the metallic taste
after topical application of stannous fluoride. At very high concentrations,
calciuformedfluorostannate gets formed along with tin tri-fluorophosphate. The
tin-tri-fluorophosphate is responsible for making the tooth structure more stable
and less susceptible to decay. Calcium fluoride is also the end product both at low
and high concentrations. The calcium fluoride so formed further reacts with
hydroxyapatite and 'a small fraction of fluorhydroxyapatite also gets formed

Advantages of stannous fluoride
Using an 8% stannous fluoride solution at6 to 12 months intervals conforms
to the practicing dentist's usual patient- recall system. Administrative
difficulties, particularly in public health programs, created by the need to
arrange four appointments (as for sodium fluoride applications) are avoided
Disadvantages of stannous fluoride
In aqueous solution the material is unstable. It undergoes fairly rapid
hydrolysis and oxidation and forms stannous hydroxide and stannic ion,
reducing the agent's etffctiveness,Since 8% solution is quite astringent and
disagreeable in taste, its application is unpleasant. The solution occasionally
causes irreversible tissue irritation manifested by gingival blanching. The
reaction usually occurs in individuals with poor gingival health.It occasionally
causes pigmentation of teeth which has a characteristic light brown color.
Staining usually appears in association with carious lesions hypocalcified
regions of the teeth and around the margins ot restorations

ACIDULATED PHOSPHATE FLUORIDE (APF)
Acidulated phosphate fluoride was introduced in the 1960's by Brudevold
and hisbco-workers at the Forsyth Dental Center,Boston, Massachusetts
Method of preparation of acidulated phosphate fluoride
An aqueous solution of acidulated phosphate fluoride is prepared by
dissolving 20 grams of sodium fluoride in 1 liter of 0.1 M phosphoric acid
and to this is added 50% hydrofluoric acid to adjust the pH at 3.0 and
fluoride ion concentration at 7.23%. It is also called as
Brudevold'ssolution.For the preparation of acidulated phosphate fluoride
gel, a gelling agent methylcellulose or hydroxyethyl cellulose is added to the
solution and the pH is adjusted between 4-5
Technique of application
The preferred method of application using aqueous preparation of
acidulated phosphate fluoride is the paint-on-technique and for gel
preparation the troy technique Acidulated phosphate fluoride is
recommended for application at 6 or 12month intervals

• The patient should sit upright in the chair.
• Oral prophylaxis is done
• The teeth to be treated are completely isolated and thoroughly dried with air
• Clinical application of APF gels should be done using trays that fit the patient's upper
and lower dental arches. A disposable foam-lined tray is preferred
• To reduce ingestion o fluoride, minimum amount of fluoride gel that will permit
complete coverage of the tooth surfaces should be dispensed. Usually, the amount is
less than 5 ml.
• After the trays have been properly positioned, saliva ejector is used to evacuate the
stimulated saliva and excess fluoride.
• It is reapplied every 15-30 seconds so as to keep the teeth moist with the fluoride
solution throughout he four-minute period.
• The patient should be told not to swallow the gel but to exert slight pressure using the
cheeks and tongue as well as light biting. forces in order to cause the gel to flow
interproximal. The fluoride gel should be in the mouth for 4 minutes and then the
remaining oral fluid should be expectorated.
• The patient is instructed not to eat, drink or rinse his mouth for at least 30 minutes

Mechanism of action of acidulated phosphate -fluoride
When APF is applied on the teeth, it initially leads to dehydration and shrinkage in the
volume of hydroxypatite crystals which further on hydrolysis forms an intermediate
product called dicalcium phosphate dihydrate (DCPD).
This DCPD is highly reactive with fluoride ion and starts forming immediately when APF is
applied. Fluoride penetrates into the crystals more deeply through the openings produced
by shrinkage and leads to formation of fluorapatite.The amount and depth of fluoride
deposited as fluorapatite is dependent on the amount and depth at which DCPD gets
formed.
For the conversion of whole of DCPD so formed into fluorapatite, deeper penetration and
continuous supply of fluoride is required. Because of this reason, APF is applied every30
seconds and the teeth has to be kept wet for 4 minutes Because high fluoride
concentration and lowpH favor fluoride deposition, acidification of the fluoride solution
with phosphoric acid was found to suppress the dissolution of enamel,as well as the
formation of calcium fluoride and provide a more effective treatment.
The intermediate product formed is the dicalciumphosphate dihydrate and calcium fluoride
is-the principal reaction product. Calcium fluoride that forms is partly lost by dissolution in
the saliva, but there is evidence that substantial amount is retained, probably by
transformation to fluorapatite.

Advantages of acidulated phosphate fluoride
Requires only 2 applications in a year and is thus suited for most dental
office routines.The gel preparation can be self applied and thus the cost
of application also gets reduced. It has the ability to deposit fluoride in
enamel to a deeper depth than neutral sodium fluoride or stannous
fluoride APF is stable and need not be freshly prepared for each patient.
Disadvantages of acidulated phosphate fluoride
Practical difficulties like the teeth should be kept wet for 4 minutes. So
repeated applications necessitates he se of suction thereby minimizing
its use in the field. This also increases the chair side time making this
method more expensive It is acidic, sour and bitter in taste cannot be
stored in glass containers Repeated r prolonged exposure of porcelain
or composite restorations APF can result in the loss of
materialssurfaceroughening and possible cosmetic changes.

AMINE FLUORIDE
In 1957, Muhlemann and co-workers of the University of Zurich, first studied the effects of amine
fluoride on enamel solubility in'vitro.They found that, under the conditions of their study, certain
organic fluorides were superior to inorganic fluorides in reducing enamel solubility.
They attributed the improved effect to a combination of chemical protection afforded by the
fluoride and physicochemical protection due to the organic portion of the molecule.
In addition to their ability to reduce enamel solubility, the amine fluoride shave other propertiès
that enhance their potential as cariostatic agents Some of them are surface active, that is,they have
an affinity for enamel and thus will hold the fluoride for a longer time against the tooth.
They also have antibacterial properties Their antibacterial effects appear to be greater than those
that can be accounted for by the presence of fluoride alone and have been attributed to the
organic portion of the molecule. Reduced plaque formation and anti glycolytic activity have both
been reported with these compounds, although not all studies have been positive.
For the prevention of dental caries in humans,amine fluorides have been tested in dentifrices,
mouthrinses and topical gels,where they have been either brushed on the teeth or applied with a
tray.
While the caries inhibiting potential of amine fluoride preparations appears to be good, despite
their surfactant and antibacterial properties, its not known if they are superior to the other
currently available fluoride agents

SELF APPLIED TOPICAL FLUORIDES
The control of dental caries rests largely in the personal life style of the
individual and that the sensible use of fluoride at home is an important
part of this behavior. Self-applied topical systems presently include
fluoride dentifrices, gels and rinses. All of these systems re intended
for daily use and contain generally comparable amounts of fluoride.
Depending on the manner of usage these preparations expose the
dentition to about 0.5-3.4 mg fluoride each time they are used.
DENTIFRICES
The first clinical trial of a fluoride dentifrice was initiated by Bibby in
1942. The active agent was sodium fluoride which had been added to a
conventional dentifrice containing dicalcium phosphate as the abrasive
In 1954, Muhler et al reported a clinical trial that tested stannous
fluoride in a paste with one calcium pyrophosphate abrasive system

Fluoride compounds in dentifrices
1. Sodium fluoride dentifrices 0.188 to 0.254%
2. Stannous fluoride dentifrices
3. Monofluorophosphate 0.564- 0.884%
4. Amine fluoride dentifrice

Adverse effects of dentifrices
A single brushing with a full ribbon of paste on a brush head provides about one
gram(equivalent _to 1ml) of toothpaste and will expose an individual to
approximately 1 mgF. It is only when substantial quantities of paste are eaten by
children, who may experience the phenomenon of pica, that the acute toxicity of
fluoride dentifrices must be considered.
The largest container of toothpaste manufactured, a nine ounce (270 gm)"family size"
tube consists of about 270 mg F(1mg Fx270gm). This amount of fluoride is below the
Certainly Lethal Dose (CLD) of320 mg F for a hypothetical two year old but exceeds
the Safely Tolerated Dose (STD) of 80mg F. Detergents and flavoring oils in dentifrices,
however irritate the stomach when ingested in large amounts and cause vomiting.
Also, abrasives may interfere with complete intestinal absorption of fluoride from
toothpastes. Thus, a child is unlikely to receive a highly toxic amount of fluoride from
eating a family sized tube of dentifrice The Food and Drug Administration advisory
review panel on over-the-counter (OTC)anticaries drugs has recommended that
fluoride content of dentifrice containers be limited to 260mg of fluoride.

FLUORIDE MOUTHRINSES
The use of a fluoride mouthrinse was first described by Bibby et al in
1946. Over several decades, fluoride mouth rinsing as become one of
the most widely Used fluoride preventive public health methods. In975
the Council on Dental Therapeutics ofhe American Dental Association
accepted neutral sodium fluoride and acidulate phosphate fluoride
mouth rinses as effective caries preventive agents. Later a stannous
fluoride mouthrinse was lso accepted by theAmerican Dental Association
Sodium fluoride mouthrinse
Sodium fluoride mouth rinses are usually formulated at concentrations
of either 0.2%(900 ppm F) for weekly use or0.05% (225ppm F) for daily
use. They have been tested both neutral and acidified forms in water
vehicle. These rinses are intended to be used by forcefully swishing 1Oml
of heliquid around. the mouth for 60 seconds before expectorating it

Preparation of sodium fluoridemouthrinse
Home use: It can be prepared by dissolving 200mgsodium fluoride tablet (1Omg
sodium fluoride and the rest lactose as a filler) in 5teaspoons of fresh clean
water(opproximately 25ml). This quantity insufficient for. Daily mouthrinse of a family
of about 4 members (2 adults and 2 children)providing_ approximately 0.04% sodium
fluoride. Use of lactose is essential as this does not react with fluoride. For weekly
use, 2gm of sodium fluoride powder is dissolved in1000ml of water.
In schools: The authorities can buy packets of sodium fluoride powder ( 2 grams
powder in each bucket) and dissolve this powder in 1 00ml of water to make 0.2%
solution
Mechanism of action of fluoride mouth rinses
Fluoride changes the enamel structure of teeth from predominantly hydroxyapatite
to fluorapatite.Fluoride may act by inhibition of bacterial metabolism and plaque acid
formation. This is however, unlikely to be the main mechanism of action of fluoride
mouthrinse's cariostatic effect, since very high concentration of fluoride is required.

Advantages of daily rinsing
lf the patient misses several sessions it is probably less
critical than if he was on a weekly schedule.
2. Advantage of the 0.05% sodium fluoride concentration
is that it can be used to provide both a topical and
systemic benefit when indicated for the individual patient.
Because of practical considerations, the low potency, high
frequency (0.05% sodium fluoride daily) rinsing regimen is
recommended for. Home use

FLUORIDE GELS
Fluoride gel products: or self application include neutral sodium fluoride and
acidulated phosphate fluoride with a fluoride concentration of 5,000 ppm and
stannous fluoride which has a concentration of1,000 ppm. The stannous fluoride
products are conventionally called gels, but actually are glycerin-based solutions.
The gels are either applied in trays or brushed on the teeth Professionally applied
topical fluoride treatment are given twice a year, whereas self applied fluoride
gels con be applied once a day more.
Patients brush their teeth for 1 minute with the gel or if trays are used several
drops are placed in each tray and held in contact with the teeth for 5 minutes.
Patients should be cautioned to expectorate excess gel and not to swallow
Also patients should rinse with tap water after brushing or tray application.
Because of the potential risk that young children with developing teeth might
swallow some of the gel, home fluoride gels are not recommended for children 6
yrs and younger.

Limitations of fluoride gels
They violate the principle of delivering low concentration of fluoride at
regular intervals. High concentration of fluoride deposit calcium
fluoride on the tooth surface rather than encouraging the formation of
hydroxyapatite .
They present a toxicity hazard. As relatively large amounts of fluoride
are given in an uncontrolled manner to people of varying intelligence-

Phd topical fluoride preparation present

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