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1、COURSE#AND TITLE:PEDS 538,Pediatric DentistrySESSION#AND TOPIC:#9 Prevention of Dental Caries-FluorideDURATION:Equivalent to 1 hourFACULTY:Dr.Glenn MinahGENERAL GOALS:Become familiar with various soft tissue abnormalities and diseases found in childrenSPECIFIC OBJECTIVES:The student should be able t
2、o:1.State goals of fluoride therapy.2.Understand how optimal benefits of non-professional administration of fluoride can be accomplished.3.Describe rationale and clinical recommendations for professionally applied topical gels,fluoride varnish and home rinses and gels.,SESSION PLAN,SPECIFIC OBJECTIV
3、ES:The student should be able to:4.Describe optimal use of fluoride dentifrice.5.Know when intensive fluoride therapy is required and what type should be administered.METHODOLOGY:Web LectureASSIGNMENT:McDonald RE,Avery DR.Dentistry for the Child and Adolescent.Mosby,St.Louis,7th ed.2000.Chapter 10,p
4、.209EVALUATION:Written exam.Questions will be from the text portion of this presentation.,SESSION PLAN,TEXT,Goals of fluoride administrationNon-professional fluoride administration1.Systemic2.Topical gels3.Rinses4.DentifriceC.Professional administration1.Topical2.Varnish,SESSION OUTLINE,Goals of Flu
5、oride(F)Administration 1)Do not harm the patient.2)Prevent decay on intact dental surfaces.3)Arrest active decay.4)Remineralize decalcified tooth surfaces.,TEXT,GOALS OF FLUORIDE(F)ADMINISTRATION,Do no harm,Prevent decay on in tact dental surfaces,F,F,Arrest active decay,Remineralize decalcified tee
6、th,1.,2.,3.,4.,F,Fluorosis or toxicity,Do not harm the patientProbable toxic dose(PTD):The PTD is 5 mg F/kg body weight.For a 20 kg 5 to 6 year old this would be 100 mg and for a 10 kg 2 year old,50 mg.F content of dental products or treatments may exceed these values for young children.For example,
7、a gel tray containing 5 ml of APF contains 61.5mg F(F is absorbed more quickly when in acidic form.),100ml of 0.2 or 0.4%F mouthrinse contains 91 or 97mg F and a tube of fluoridated toothpaste contains as much as 230mg F.Sub-lethal toxic symptoms are manifested quickly after the dose and consists of
8、 vomiting,excessive salivation,tearing and mucous discharge,cold wet skin and convulsions with higher doses.Counter measures which should be administered immediately are emetics,1%calcium chloride,calcium gluconate or milk.(Calcium reacts with F in the GI tract and prevents its absorption.The most s
9、erious consequences of F toxicity stem from reactions of cationic electrolytes with systemic F.),1.,TEXT,POTENTIAL HARM,5 mg F/kg body weight,20 kg 6 year old,PTD=100 mg F,10 kg 2 year old PTD=50 mg F,230 mg F/tube toothpaste,ACT,91-97 mg F/container of F mouthrinse,Symptoms:VomitingExcess salivary
10、and mucous dischargeCold wet skinConvulsion at higher dose,Probable toxic dose:,Topical F,12,300 ppm F pH=3.5,61.5 mg F/5 ml,F,Ca,F,Ca,Counter Measures:Emetics1%calcium chlorideCalcium gluconatemilk,Divalent cations like Ca cause precipitation,of F and prevent absorbtion in the intestine.,F,Ca,F,Ca,
11、F,Ca,F,Ca,F,Ca,F,Ca,A serious systemic consequence is binding of F to Ca which needed for heart function.,POTENTIAL HARM,F,Ca,F,Ca,F,Ca,F,Ca,Fluorosis:Fluorosis occurs when teeth are developing.The most critical ages are from 0 to 6 years.After 8 years,risk of fluorosis is essentially past.During th
12、e critical ages F intake in excess of 0.1mg/kg body weight/day can lead to fluorosis.This is roughly 1mg/day for a 1 to 2 year old or 1.5 to 2 mg for a 5 year old.Remember that all forms of F intake comprise the daily consumption.This includes water intake(up to 1.5mg/day),foods(0.3 to 1.0mg)and esp
13、ecially significant in young children,swallowed toothpaste.Children under 2 years swallow 50%of toothpaste during tooth brushing and at 5years,25%,both of which may amount to 1mg F/day.,Do Not Harm the Patient,2.,TEXT,1098765432,FLUOROSIS,0.0 0.5 1.0 2.0 3.0 4.0,DMFT,PPM F IN DRINKING WATER,slight,s
14、evere,moderate,mild,F in excess of 0.1mg/kg body weight=fluorosis,POTENTIAL HARM,FLUOROSIS,F,F,Excess F affects mineralization of developing teeth,Up to age 6 is the critical age for fluorosis.After age 8,risk is past.,Enamel prism,FLUOROSIS,F in excess of 0.1mg/kg body weight=fluorosis,Maxium safe
15、dose for a 5 year old=2 mg F/day,Maxium safe dose for a 2 year old=1 mg F/day,1 2 3 4 mg F,supplements,toothpaste,fluids,food,DW Banting JADA 123:86,1991,Daily F intake of a 20 kg 4 year olds with different water F,0.5 ppm water F,1.2 ppm water F,FLUOROSIS,Children under 2 years swallow 50%of toothp
16、aste,5 year olds swallow 25%of toothpaste,Toothpaste=1 mg F/gram(1000 ppmF),1 to 3 grams,“pea”size amount(0.5g)is recommenred for fluorosis susceptible children.,moderate,severe,mild,pitting,Prevention of CariesDeposition of fluorapatite(FHA)in sound tooth structure:Caries protection results from FH
17、A being more acid resistant than pure hydroxyapatite(HA).Deposition takes place when F replaces hydroxyl groups in HA.This can occur pre-or post-eruption at neutral pH,or post-eruptively at neutral or acidic pH.At low pH,HA dissolves,then re-precipitates as new crystals which are larger and more aci
18、d-resistant due to higher FHA and lower magnesium and carbonate content.Deposition of FHA is accomplished both by systemic intake of F during tooth development,and topical F administration after eruption.Professional topical F treatments with concentrated acidulated phosphate fluoride(APF)gels(2.72%
19、APF gel contains 12,300 ppm F),is the most efficient way to accomplish this,especially when applied to newly erupted teeth(i.e.,age 2 for primary molars;age 6 to 8 for permanent first molars and anterior teeth;age 11 to 14 for permanent premolars and second molars).,1.,TEXT,MECHANISMS OF F PROTECTIO
20、N,F,F,F,F,F,F,F,F,F,F,F,F,Saliva(S),Plaque(P),Tooth(T),DEPOSITION,Increase FHA levels maximally in intact dental surfaces.,Theory:,Topical F is the best method for deposition.,F,F,F,F,F,F,F,F,Ca,PO4,PO4,Ca,Neutral pH,remineralization,DEPOSITION OF F,F,F,FHA,FHA,FHA,HA,pH 5.0,Ca,P,FHA is more acid re
21、sistant than HA,H+,H+,CO3,Mg,H+,H+,Mg and CO3 do not repreci-pitate,F,F,F,F,This has better F uptake due to more porosity,DEPOSITION OF F,Best F uptake is late pre-eruption and early post-eruption,F,F,F,F,F,F,F,F,F,F,F,F,Mature enamel,Surface build-up of F,F,F,F,Enamel fluid,Young enamel,Maximal F l
22、evels of in outer 5 microns,300020001000,PPM Fluoride,outer 2 microns=6000 ppm fluoride(max.uptake),Fluoride uptake is higher in a decalcified area,F,5 um,DEPOSITION OF F,Ca,Ca,Ca,Ca,Ca,F,F,F,As fluoride reacts strongly with calcium it does not penetrate far into the tooth.,3000 ppm F,1500 ppm F,F,D
23、EPOSITION OF F:,Maxium uptake can not be exceeded.(3000 to 4000 ppm F in outer 5 um),The F-rich surface can be abraded away.,TOPICAL F STUDIES,Averill JADA 74:990,1987DePaola JADA 87:155,1973Downer BritDJ 141:242,1978Horowitz JDent Child 27:157,1980Muhler JDent Child 27:1571980Szwejda JPub Health De
24、nt 32:110,1972,NaFAPFAPFSnF2SnF2APF,Caries reduction,100%,Newly erupted teeth,Previously erupted teeth,Bioavailability of F:A second theory of caries prevention asserts that F in the vicinity of carious activity(in enamel fluid)prevents dissolution of HA crystals.Although this mechanism requires onl
25、y low levels of F(less than 100ppm to as low as 1ppm),F must be present when the acid challenge takes place and therefore must be supplied continually.Examples of topical applications which ensure bioavailability are fluoridated drinking water and fluoridated dentifrices.A major source of bioavailab
26、le F is residual F in plaque and pellicle.F in plaque minerals such as CaF2 or calculus or in protein complexes is released during bacterial acid production.,Prevention of Caries,2.,TEXT,BIOAVAILABILITY,F,F,S,P,T,F,ACID,SUGAR,Provide continual low level of F to enamel fluid.The benefit occurs at the
27、 time of decalcification.,Theory:,MECHANISMS OF F PROTECTION,Water fluoridation is an example of a source.,BIOAVAILABILITY OF F,SUGAR,Low level of F,F,S,H+,H+,H+,H+,F,F,F,F,S,S,saliva,Plaque and enamel fluid,plaque,Intact HA crystals,H+,F,Decalcifying HA crystals,J Arends.JDR 69(SI):601,1990,Decalci
28、fication of enamel crystals:,F,Stable FHA,F,Loosely bound or adsorbed F,F,F,F,F,F,F,F,F,F,F,F,F,ACID,Protection from dissolution,F from plaque fluid,H+,H+,BIOAVAILABILITY OF F,F,F,Loosely-bound F will eventually become stable FHA.,J Arends.JDR 69(SI):601,1990,F,F,F,F,F,F,F,F,Protection only where is
29、,F,H+,H+,H+,H+,H+,BIOAVAILABILITY OF F,F,Ca,PO4,PO4,Ca,FHA with no,Incomplete protection,F,H+,H+,H+,H+,H+,F,J Arends.JDR 69(SI):601,1990,BIOAVAILABILITY OF F,F,F,F,H+,H+,MS,Effect on bacteria:,H+,H+,F,F,F,F,S,S,H+,F,H+,H+,The presence of fluoride at the time of glycolytic activity will alsoinhibit o
30、f plaque acidogenesis.,SOURCES OF BIOAVAILABLE F,1.saliva,0.080.02,ppm F in saliva after drinking,1 3 5 h,F,F,F,F,S,P,T,4.RESIDUAL F,ACT,2.Fluoridated water,3.Home care products,Calcium Fluoride,F,F,F,F,F,Topical F,CaF2 precipitates in plaque during topical F treatment,FHA,No FHA,No FHA,F,F,10 ppm F
31、 added to drinking water,LESIONS(mean),MS,8,30,5,DEPOSITION,BIOAVAILABILITY,Larson RH.Caries Res 10:321,1976,sugar,BIOAVAILABILITY VERSUS DEPOSITION OF F,Rodent studies:,plus,calcium loss,F ppm in solution,pH,5 4.5 4,BIOAVAILABILITY OF F,pH 5.0,HA,calcium,phosphate,JM Ten Cate.JDR 69(SI):614,1990,Re
32、search evidence:,F,F,Add F:,Summary of preventive F procedures and recommendations:The older view of caries prevention was that FHA deposition in non-carious dental surfaces should be maximized by systemic F administration during tooth development,and post-eruptively by topical F treatments.It was b
33、elieved that increased FHA provided increased protection against caries.Although implementation of high FHA deposition has proved beneficial,it does not afford as much protection as bioavailable F.Moreover,the high doses of F required,systemically or topically(which often becomes systemic intake)are
34、 partly responsible for the increasing incidence of fluorosis.Current clinical recommendations for preventive F measures are 1)to determine total F intake per day from all sources in order to assess over or under F exposure,2)determine caries risk,3)institute a regimen commensurate with individual c
35、aries risk status which emphasizes bioavailability of post-eruptive topical F(e.g.regular use of F dentifrice and other home products if indicated),4)administer professional topical F treatments,the timing of which should also be gauged to caries risk(This may not be needed in low risk individuals)a
36、nd 5)administer systemic topical F if indicated.(The latter is currently under review.Present Academy of Pediatric Dentistry recommendations are presented below.,Prevention of Caries,3.,TEXT,FLUORIDE SUPPLEMENTS,F in drinking water,F,Academy of Pediatric Dentistry current recommendations,TEXT,Determ
37、ine F intakeDetermine caries riskDevise personalized plan based on risk level.Stress bioavailability of F.Monitor F intake of young patients in an effort to prevent fluorosis.,SUMMARY OF PREVENTIVE F,Mechanisms:Caries arrest means that active lesions become inactive.This is accomplished clinically b
38、y adjusting several aspects of the oral environment such as by reducing intake of cariogenic dietary substrates,reducing plaque volume,stimulating salivary flow,increasing plaque levels of Ca+and PO4-,promoting favorable microbial shifts(i.e.reducing acidogenic and aciduric bacteria and encouraging
39、proliferation of alkalinogenic bacteria)and increasing bioavailable F.Bioavailable F arrests caries by 1)inhibiting decalcification by coating enamel crystals,intact or partially decalcified,with loosely bound F and thereby preventing further dissolution of crystals,2)catalyzing reprecipitation of d
40、issolved enamel crystals and 3)inhibiting acidogenesis and aciduricity of cariogenic bacteria.Arrested incipient lesions appear either as dark stained fissures which resist explorer penetration(Active probing of stained fissures with sharp explorers is not recommended as it may induce cavitation.),s
41、tained cervical incipient lesions or shiny enamel surfaces covering white spot lesions.Arrested carious dentin or root surfaces exhibit dark staining with hard and often shiny surfaces.,Arrest of Active Decay,1.,TEXT,Clinical recommendations:1)Determine total F exposure,2)determine caries risk and t
42、ailor clinical measures to risk status,3)institute dietary and plaque control procedures,4)control cariogenic bacteria,if indicated and 5)have patient maintain continual low level F exposure to decalcified sites.,Arrest of Active Decay,2.,TEXT,ARREST OF ACTIVE DECAY,incipiencies,Root caries,Indicati
43、ons:,Cases difficult to treat,i.e.,certain ECC cases,Interproximal caries in low or moderate risk patients.,ARREST OF ACTIVE DECAY,PO4,PO4,Ca,Ca,MS,LB,1.,2.,3.,Increase topical Ca and PO4 intake.,Encourage beneficial microbial shifts.,4.,Plaque control,Procedure:,Diet control,ARREST OF ACTIVE DECAY,
44、5.,Increase bioavailable F,F,Arrested caries turns dark,is firm and often glossy.,F,F,S,P,T,F,ACID,SUGAR,Indications and mechanisms:This clinical manipulation is intended to restore lost mineral from incipient lesions and reverse appearance of white spot lesions.(Review notes on remineralization fro
45、m Cariology course.)Generally,remineralization procedures are indicated for non-cavitated carious dental surfaces(enamel or cemental)in individuals who are not in the high or severe caries risk category.These are the same as caries arrest procedures with the exceptions that 1)only non-cavitated lesi
46、ons are indicated and 2)F,Ca+and PO4-exposure are monitored more carefully.Recommendations:Follow recommendations for caries arrest,above,along with application of recalcifying solutions(e.g.,Enamelon,which contains F)and/or F to affected sites.Recalcification of white spot lesions on anterior smoot
47、h surfaces require low concentrations of topical F(100 to 250ppm)since higher ones do not penetrate enamel as effectively and may cause preservation of the white spot by reacting only with the outer enamel layer.,Remineralization of Decalcified Surfaces,1.,2.,TEXT,REMINERALIZATION,Same procedures as
48、 for arresting caries.Exceptions or additions:Only non-cavitated lesions can be remineralized.Not recommended for severe of high caries risk patients.Ca,PO4 and F are administered more precisely.,White spot,before,after,Clinical Fluoride Products These include 1)professional topical F,2)F varnishes
49、3)home rinses and gels,4)dentifrices,5)supplements and 6)other agents such as sustained release devices.A detailed summary is presented in Tables at the end of the presentation.Professional Topical FProducts and description:The principal products are 2.72%acidulated phosphate fluoride(APF)gel and 2%
50、neutral sodium fluoride gel.Stannous fluoride(SnF2)is no longer used routinely for professional topical applications.APF,pH 3.5,contains 12,300 ppm F and is formulated from sodium fluoride and 0.1M phosphoric acid.This gel is intended to dissolve surface enamel which will re-precipitate with higher
