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Year:2015|Volume:5|Issue:5|Page:341346
Recentadvancementsinfluoride:Asystematicreview

BansalA
IngleNA
KaurN
IngleE

AnkitaBansal1,NavinAnandIngle1,NavpreetKaur1,EktaIngle2
1DepartmentofPublicHealthDentistry,KDDentalCollegeandHospital,Mathura,India
2DepartmentofOralMedicineandRadiology,VasantdadaPatilDentalCollegeandHospital,Sangli,Maharashtra,India
DateofWebPublication

BansalA
IngleNA
KaurN
IngleE

Relatedarticles
Fluoridation
fluoride
varnishes

22Sep2015

CorrespondenceAddress:
AnkitaBansal
DepartmentofPublicHealthDentistry,KDDentalCollegeandHospital,Mathura,UttarPradesh
India

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SourceofSupport:Nil.,ConflictofInterest:Therearenoconflictsofinterest.

DOI:10.4103/22310762.165927

Abstract

Toreviewadvancementsoffluorideindentistry,asearchof21electronicdatabasesandWorldWideWebwasconducted.Relevantjournals
werehandsearchedandfurtherinformationwasrequestedfromauthors.Inclusioncriteriawereapredefinedhierarchyofevidenceand
objectives.Studyvaliditywasassessedwithchecklists.Tworeviewersindependentlyscreenedsources,extracteddata,andassessedvalidity.
Fluoridehasbecomeanimportanttoolinpreventivedentistry.Currentresearchisfocusedonthedevelopmentofstrategiestoimprovefluoride
efficacy.Fluoridetherapyintheformofvarnish,gel,mouthrinse,ortoothpastehasbeenusedextensivelyasacariespreventiveintervention
foroverthreedecades.Thepurposeofthisreviewistoinformthereaderaboutnewresearchrelatedtotheuseoffluorideforthepreventionof
dentalcaries.

Abstract
Introduction
Results
Discussion
References
ArticleTables
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Keywords:Fluoridation,fluoride,varnishes
Howtocitethisarticle:
BansalA,IngleNA,KaurN,IngleE.Recentadvancementsinfluoride:Asystematicreview.JIntSocPreventCommunitDent20155:3416
HowtocitethisURL:
BansalA,IngleNA,KaurN,IngleE.Recentadvancementsinfluoride:Asystematicreview.JIntSocPreventCommunitDent[serialonline]
2015[cited2016Sep27]5:3416.Availablefrom:http://www.jispcd.org/text.asp?2015/5/5/341/165927

Adsby Google

DentalHygieneSchools
DentalFluorideVarnish
Introduction

Mainbenefitoffluorideisinreducingtheriskofdentalcaries.Inrecentyears,rapidchangeshaveoccurredintheprevalenceofdentalcaries
acrosscountries.Todaycountriesshowadeclineintheprevalenceindentalcariesandmorechildrenarebecomingcariesfree.Declinein

dentalcariesmaybeattributedtothecariostaticefficacyoffluoride.[1]Researchintothemechanismsofanticariesefficacyoffluorideis
ongoing,whichmayleadtobetterpreventionstrategies.Newand/orimprovedfluorideproductsareenteringthemarketplaceatanincreased
ratetheseproductsincludetoothpastes,fluoridevarnishes,fluoridecontainingwhiteningagents,andotherfluoridecontainingcleaning
products.
Inearly2011,afteryearsofreviewandevaluation,theCentersforDiseaseControlandPrevention(CDC),EnvironmentalProtectionAgency
(EPA),andtheAmericanDentalAssociation(ADA)CDC,EPA,andtheADAproposedamodificationtotheirrecommendationsforthe
amountoffluorideindrinkingwatertobe0.7g/ml(ppm)atallplacesintheUnitedStates.Thus,until2011,theCDCandtheADAhad
recommendedthattheamountoffluorideindrinkingwatershouldrangefrom0.7ppminwarmerclimatesto1.2ppmincoolerclimates.
Studieshaveshownthatsomebrandscontainsufficientamountsoffluoridetherefore,whenmixedwithoptimallyfluoridatedwater,they
resultingreaterthanoptimalamountsoffluorideintheformula.TheCDCandADAhavevariedtheirrecommendationsregardingthisin
recentyears.In2006,theCDCandADAhadrecommendedthatlowfluoridewaterbeusedtoreconstituteinfantformulatoguardagainst
exposingtheinfanttoexcessamountsoffluoride.RecentevidencereviewedbytheCDCsuggeststhatmixingpowderedorliquidinfant
formulaconcentratewithfluoridatedwateronaregularbasismayincreasethechanceofachilddevelopingthefaint,whitemarkingsofvery
mildormildenamelfluorosis.
Therearesomerecentstudiesinwhichtheamountoffluoridemadeavailableintheoralcavityduringtoothbrushing(forapproximately2
min)wasmeasured.Itseemsthatindevelopingregionsoftheworld,therearetoothpastesmarketedthatcontainthetotalfluorideasindicated
onthelabel,buttheydonotreleasesufficientfluorideduringusetopreventcaries.Thisisduetothecompositionofthetoothpastewhichcan
renderasignificantamountofthefluorideunavailable.[2]
Aclinicalstudyin2006byWeintraubalsoconfirmedthatfluoridevarnishisefficaciousinreducingearlychildhoodcariesincidence.Clinical
studieshavedemonstratedthatvarnishescansupplyfluoridemoreefficientlythanothertopicalagents.[3]
ArecentcomprehensivesystematicreviewbyTwetmanetal.summarizedliteraturesonfluoridetoothpastefrom2002to2008and
concluded,Therewasstrongevidencethatdailyuseoffluoridetoothpastehasasignificantcariespreventiveeffectinchildren,comparedwith
placebo(preventedfraction24%).Theeffectwasboostedbysupervisedtoothbrushing,increasedbrushingfrequencytotwicedaily,anduseof
atoothpasteconcentrationof1500ppmfluoride.[4]
Theaimofthisstudyistodescribetheknowledgecurrentlyavailableonthistopicandtosuggesthowthisinformationcouldbeusedby
clinicianstoadvisetheirpatientsontheidealuseofthecurrentlyavailableproducts.
Results

Atotalof334potentiallyrelevantrecordswerefoundinthesevendatabases,75ofwhichwereduplicated.Atotalof157referenceswere
excludedbasedontheabstractsand65wereselectedforfulltextanalysis,25whichwereselectedforinclusioninthestudy.
Worldwide,extensivefluoridationprogramshavebeenintroducedinAustralia,Brazil,Chile,Colombia,Canada,HongKongSpecial
AdministrativeRegionofChina,Ireland,Israel,Malaysia,NewZealand,Singapore,theUK,andelsewhere.Morerecently,newprogramshave
beenintroducedinlargeconurbationsinthesouthandwestoftheUSA,includingLosAngeles(in1999),LasVegas(in2000),Sacramento(in
2000),andSanAntonio(in2002).
In2000,areportfromCalifornia'sChildren'sDentalHealthInitiativeAdvisoryCommitteestressedthebenefitsofwaterfluoridationand
recommendedthataccessshouldbeexpanded.[5]
Twoevidencebasedreviews(Yeungetal.,2005NationalHealthandMedicalResearchCouncil,2007)indicatethatthereislimitedsupport
thatfluoridatedmilkhasacariespreventiveeffect.[6]
CurrentlymilkfluoridationprogramsexistinseveralcountriesincludingBulgaria,Chile,China,Peru,theRussianFederation,Thailand,and
theUK.[7]
In19942004,saltfluoridationwasintroducedasacariespreventivemeasure.[8]FluoridatedsaltiswidelyusedinGermany,France,and
Switzerland,with3080%ofthemarketedsaltfordomesticusebeingfluoridated(MarthalerandPetersen,2005).Morethan30othercountries
worldwideusefluoridatedsaltandthistypeoffluoridedeliveryishighlyrecommendedbytheWorldHealthOrganization(WHO).Thereisno
randomizedclinicaltrial(RCT)conductedonthistopic,accordingtorecentreviews(SwedishCouncilonTechnologyAssessmentinHealth
Care,2002NationalHealthandMedicalResearchCouncil,2007Espelid,2008).Somecrosssectionalstudiesandcontrolledclinicaltrialsdo
indicatethecariespreventiveeffectofsalt,butfluoridatedsaltisprobablylesseffectiveamongsmallchildrenduetothelowsaltdietnow
recommendedforthisagegroup.[6]
Fluoridateddentifricesundoubtedlyhavebeenthecornerstoneofcariespreventionworldwideandaccountforthecariesdeclineobservedin
thepastfewdecadesinindustrializedcountries.Itisfoundtocause1530%decreaseincariesexperience(CDC,2001),whilearecent
systematicreviewconcludedthatthecariesreductionwas24%(Marinhoetal.,2003).[9]
In2005,astannousfluoridesodiumhexametaphosphate(SFSH)formulawasintroducedofferingprotectionagainstabroadrangeofhealthand
cosmeticconditionscommonlyexperiencedbypatients.Sodiumhexametaphosphatewasfirstintroducedinadentifricein2000.Itprovides
bettercoverageandretentiononthetoothsurface,thusincreasingitsabilitytoinhibitbothcalculusandstainformationontheenamelsurface.
[10]

Aclearevidenceofcariesinhibitingeffectoffluoridegelinpermanentdentitionwith28%reductionindecayed,missing,andfilledtooth
surfaces(DMFS)hasbeenfound(Marinhoetal.,2002).[9]
Somestudieshavecomparedfluoridevarnisheswithothertopicalfluoridedeliveryvehicles.TewariandassociatescomparedDuraphatwitha
2%NaFsolution,a1.23%acidulatedphosphatefluoride(APF),gel,andanegativecontrol.Theyreportedthatafter2.5years,thevarnish
resultedinahigherpercentageofcariesreduction(74%)thandidtheNaFsolution(28%)andtheAPFgel(37%).[11]
Fluoridereleasingdentalrestorativematerialsmayprovideanadditionalbenefitinpreventivedentistry.Comparisonoffluorideionreleasewas
madefromfourdifferentdentalrestorations(FujiVll,FujiIILC,Dyract,andZ350)indeionizedwaterfromday1untilday5.Theresult
showedsignificantlydifferentfluorideionreleasefromallofthem.ThefluoridereleasewashighestinFujiVlI,followedbyFujiIILC,
Dyract,andZ350.Theresultalsorevealedasignificantassociationoffluorideionreleasefromdentalrestorationsindeionizedwaterand
artificialsaliva,exceptforZ350(P&#610.787).Therewasgreateramountoffluoridereleasebyallthetestedmaterialsindeionizedwater
comparedwithartificialsaliva.[12]

Variousstudiesfoundthatsilverdiaminefluorideisusedasacariesarrestingagent.Hiraishietal.andMathewetal.(2012)foundthatsilver
diaminefluorideisusedasanendodonticirrigant.[13]
Anewsystemhasbeenintroducedindentistryforachievingaconstantrateofcontinuousfluoridereleaseforalongerperiodintheoralcavity
whichistheintraoralfluoridereleasingdevicetobeusedinhighriskgroups(Mirthetal.,1982Kulaetal.,1987ToumbaandCurzon,2005).
[14]

MobergSkldetal.studiedtheeffectofadditionalfluoriderinsesandvarnishesgivenandsupervisedinaschoolenvironmentandobserved
thateveningroupsofadolescentswithmoderatecariesexperience,cariesinitiationandprogressionweresignificantlyreduced.
AllpublishedRCTdatawhencombined,givetheconclusionthatfluoridetoothpastes,mouthrinses,gels,andvarnisheshavesimilar
effectivenessinpreventingcaries.
AsummaryofRCTsonfluorideconcentrationintoothpastesshowedapositivedoseresponse:Pasteswith10001500ppmFshowed23%
cariesreductioncomparedtofluoridefreeplacebothisvalueincreasedto36%forpasteswitharound2500ppmF.Forpasteshavingbelow
1000ppmF,nosignificantdifferencewasfoundwithplacebo,probablyduetothesmallnumberofstudies.[15]
Theobromineisusedasacariespreventingagentanditispresentincocoa.Sadeghpour(2007)statedthatthecocoaextractismoreeffective
thanfluorideinreducingdentalcaries.Similartofluoride,theobrominecanpreventdemineralizationandimproveresilienceoftoothbyacid.
[16]

Recently,newfluoridatedproductshavebeenintroducedinthemarket,whicharepresentedin[Table1]and[Table2].

Table1:Recently,newfluoridatedfoams,gels,varnishes,rinseshavebeenintroducedinthemarket,which
arepresentedintable
Clickheretoview

Table2:Recently,newfluoridatedprophylaxispasteandrestorativematerialshavebeenintroducedinthe
market,whicharepresentedintable
Clickheretoview

Discussion

Themostseriousdefectofthestudieswasthelackofappropriatedesignandanalysis.Manystudiesdidnotpresentananalysisatall.Thereare
alimitednumberofstudiesonadvancementsinfluoride,soitwasdifficulttocorrelatedifferentstudies.
Fluorideisstillthecornerstoneofmodernnoninvasivedentalcariesmanagement.Theprevalenceofdentalcarieshassteadilydeclinedoverthe
last20yearsduetodentalhygienepracticesandtheincreaseduseoffluoridecontainingproducts.Healthsurveysstillestimatethepercentage
ofadultswithDMFStobe98.3%(Brown).
In2008,extensivewaterfluoridationprogramswereintroducedinAustralia,Denmark,Ireland,England,NewYork,Brazil,andLithuania.
ZorecKarlovseketal.conductedastudyasaprojecttointroducesaltfluoridation.Inthestudy,theauthorsanalyzedurineofchildrenresiding
indifferentpartsofSlovenia.Theyconcludedthatfluorideexposurewaslow,asthemeandailyurinaryFexcretionwasfoundtobe0.19mg
F/24h.
Recently,milkfluoridationprogramwaslaunchedinThailandin2000andinMacedoniain2009.
In2002,Nakamotoprovedthattheobrominecanincreasethesizeofapatitecrystalsandincreaseresistanceoftoothtoaciddissolution.The
conclusionisfluorideandtheobromineincreaseresistanceofenameltoaciddissolutionaswellasinfluencethehardnessofenamelsurface.
Manyreportshavebeenpublishedthroughouttheworldabouttheprosandconsoffluoride.Aftermanyyears,thescientificconclusionhas
beenreachedthatfluoridetoothpasteandfluoridatedwater,salt,andmilkareofgreatbenefittodentalhealth,helptoreducedecay,andcause
noharmfulsideeffectstogeneralhealth.
Thus,fluorideinvariousforms,i.e.,varnishes,rinses,foams,gels,dentifrices,slowreleasingdevices,prophylaxispaste,remineralizingagents,
andinrestorativematerials,isnowavailabletodentalprofessionalsforuseinclinicalpracticeandtobeusedbypatientsathome.
Theirdifferentformulasandconcentrationsmakethemsuitablefortherapeuticmanagementofanumberofdentalproblemsincluding
prophylacticpreventionofdentalcaries,dentinalhypersensitivity,controlofallcariesfromincipienttorampant,andreductionintherateof
dentalerosion.Forthedentalprofessionaltobeabletochoosetheformulaandconcentrationofthetopicalagentthatismosteffectivein
managingaspecificdentalproblemforaparticularpatient,itisnecessarytobeawareofanumberofpropertiesoftheagentselected.Despite
itslongstandinghistoryanduse,cliniciansshouldhavebasicknowledgeoftheproductsandsafeuseoftheseproducts.Communicationtothe
patientisanimportantadjuncttomaximizethebenefitsandminimizetherisks.
Manystudieshavebeenpublishedthroughouttheworldaboutthedefluoridationmethods.[22]Fewinvestigatorshavestudiedreversefor
arsenicandfluorideremoval.However,recentworkbyFoxandHuxstephasshownreverseosmosistobeeffectiveinreducingthe
concentrationoffluoride.Theimprovementsindesignandmaterialsofthemembraneshavemadethewatertreatmentprocesseconomically
competitiveandhighlyreliable.Thuswithimprovedmanagementthisnewtechnologyfordrinkingwaterproductionmightbethebestoption.
Onthebasisofresultsandextensiveinvestigations,differentresearchershaddevelopedasimpleandeconomicaldomesticdefluoridation
processes.
Financialsupportandsponsorship
Nil.

Conflictsofinterest
Therearenoconflictsofinterest.

References

1. PradeepK,RaoPK.Remineralizingagents.IntJDentCaseReports201117384.

2. CareyCM.FocusonFluorides:UpdateontheuseofFluorideforthepreventionofDentalCaries.JEBDP2014127.

3. FluorideVarnish:AUsefulDentalPublicHealthTool.Availablefrom:
http://www.thedbgelearning.com/UserFiles/File/Articles/Paedodontics/P277_Fluoride_Varnish_A_Useful_Dental_Public_Health_Tool_.pdf.
[Lastaccessedon2015Mar10].

4. Fluoridetoothpaste.Availablefrom:
http://www.allianceforacavityfreefuture.org/Caries/Tools/en/us/downloads/Fluoride_Toothpaste_Full.pdf.[Lastaccessedon2015Mar11].

5. JonesS,BurtBA,PetersenPE,LennonMA.Theeffectiveuseoffluoridesinpublichealth.BullWorldHealthOrgan200583:6706.

6. Guidelinesontheuseoffluorideinchildren.EAPD20091012935.

7. MilkFluoridation.ACFF.Availablefrom:https://www.yumpu.com/en/document/view/32283248/milkfluoridationallianceforacavity
freefuture_pdf.[Lastaccessedon2015Mar10].

8. MarthalerTM,PollakGW.FluoridatedsaltinCentralEurope.SMZ20051156704.

9. ShaniAnnMani.Evidencebasedclinicalrecommendationsforfluorideuse:Areview.AOS20094:16.

10.SensabaughC,SagelME.StannousFluorideDentifricewithSodiumHexametaphosphate.JD200983708.

11.EugenioD.BeltrnAguilar,GoldsteinJW,StuartA.Lockwood.Fluoridevarnishes.JADA2000131:58996.

12.NikNoorulAzambtNikYusoff,AriffinZ,HassanA,AlamMK.FluorideReleasefromDentalRestorationsinDeIonizedWaterand
ArtificialSaliva.IMJ201320:6358.

13.SilverDiamineFluoride:AReviewandCurrentApplications.JOAOR20145121.

14.DupareR,KumarP,DupareA,JainR,ChitguppiR.IntraoralSlowReleaseFluorideDevices.IJPreClinDentRes20141:3741.

15.J.M.tenCate.Contemporaryperspectiveontheuseoffluorideproductsincariesprevention.BDJ2013214:1617.

16.AbdillahImronNasutionAI,Cutzawil.Thecomparisonofenamelhardnessbetweenfluorideandthebromineapplication.IntJContemp
DentMedRev201414.

17.ShannonPaceBrinker.Indicationsofinofficetopicalfluoridetreatments.CPS.Availablefrom:
http://www.voco.com/us/product/voco_profluorid_varnish/FluorideTreatment_CEcoursebyShannonPace.pdf.[Lastaccessedon2015
Mar09].

18.JaanaGold.FluorideVarnishProductsintheU.S.Market.GoldJofResDevelopment2013112.

19.RethmanJ.FocusonSealants.DDH.Availablefrom:www.dimensionsofdentalhygiene.com.2010April.[Lastaccessedon2015Mar09].

20.FocusonProphypastes.Availablefrom:http://www.dimensionsofdentalhygiene.com.2015Feb.[Lastaccessedon2014Mar09].

21.RethmanJ.FocusonSealants.DDH.Availablefrom:http://cpsmagazine.com.2015Feb[Lastaccessedon2010Mar09].

22.IngleNA,DubeyHV,KaurN,SharmaI.Defluoridationtechniques:Whichonetochoose.JHealthResRev20141:14.

Tables
[Table1],[Table2]

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