Systemic fluorides

Dr G. kayalvizhi

Contents
Introduction water fluoridation School water fluoridation Salt fluoridation Milk fluoridation Fluoride tablets and drops Prenatal supplementation Defluoridation Conclusion references

Water fluoridation

Definition upward adjustment of the concentration of fluoride ion in public water supply in such a way that the concentration of f ion in the water may be consistently maintained at 1 ppm.

Optimal level of fluoride

Optimum fluoride concentration WHO 1971 0.7-1.2ppm Cold climate -1.2 ppm Hot climate 0.7 ppm Moderate climate 1ppm WHO 1994- 0.5-1ppm

Galagon and vermillion 1957 based on body wt & climatic conditions = ppm F (conc.) = 0.34/E Where E = -0.038+0.0062 x temperature of the area in 0F

Choice of equipment and chemicals used

Fluoride compounds Fluorspar- caf hydrofluosilicic acid Sodium fluoride from hydrofluosilicic acid (expensive) Silicofluorides purification of phosphate rocks Sodium silicofluoride (low cost but corrosive) ammonium silicofluoride

Equipment Characteristics of system

Equipment should be adapted to local conditions Safe and efficacious, precise Standard type Well defined precision limits Antisiphon mechanism

Types of equipment for water F

Saturator granular Na F Dry Distributor silicofluoride or Na F Liquid distributor hydrofluosilicic acid

Types of equipment
equipment principle Factors limiting utilisation recommenda tion

Saturator system
Dry feeder

4% saturated solution of NaF (pump)

NaF or silicofluoride (Automated)

High hard water level

Care in handling

Small towns <3.8millions lt/day

Medium sized town 3.8millions lt/day Medium , large sized towns 7.6million/day

Solution feeder

hydrofluosilicic acid (volumetric pump)

Equipmentpolyvinyl chloride

Saturator system

Volumetric feeder

Solution feeder

Two other systems

Venturi fluoridator system J.N.Leo Non-electrical system Activated by the flow of water in the main water line Adv- Simple to install, low cost Saturation suspension cone- brazil Upside down cone charged with a bag of silicofluoride- collected at the top

Venturi fluoridator

Saturated- suspension cone

Method of estimation of fluoride concentration in drinking water fluoride electrode coupled with ph meter (orion, radiometer) Scot- sanchis method Zirconium alizarin reagent

Water fluoridation studies

Study Dean et al weaver year 1939 1944 place Galesburg,mon mouth South& north shields Ppm F 1.7 1.4 0.4 result dmft 41% dmft

Tan& storvick
Murray Murray & Atkinson Backer dirkis Whittle & downer

1964
1969 1971 1974

Corvalis albarny 1
Hartepool,york London Holland & new zealand Birmingham salford F/NO N-f 1.5-2 0.2

56% dmft
64% dmft 93% dmft Prox& gingival caries 54% dmft

1979

Benefits of water fluoridation

Smooth surfaces receive maximal protection Has both pre and post eruptive effects Systemic and topical effect Fluoride in saliva remineralisation Changes morphology of Occusal surfaces Least expensive large group Bottled beverages- diffusion/ halo effect

Safety of water fluoridation (1940-1978)

Leone et al 1959Bart let Texas- 8ppm F (15yr) mottled enamel ` Cameron- 0.4ppm

Weidman 1963
up to 4ppm- no radiographic evidence

Hodge 1963 11ppm- no kidney/ thyroid damage

Ericson 1978 no evidence of cancer

WHO 1978 no harmful effect, less dental decay

Limitations of water fluoridation

Financial and technical resources Fear of adverse effects Implementation of fluoride schemes

Feasibility in India
Most effective, practical and economical public health measure Shortcoming central pipe water supply system (30%)

India does not need water fluoridation an illusion

Rama Subramanian et al 1979 7 states A.P, tamilnadu, gujarat, maharashtra, U.P, himachal pradesh & punjab A.P & gujarat -6-16PPM only 5% - high F area 3% - optimal F area 90% - water deficient F 66% - <0.5ppm

Lakdawala & punekar 1979 Bombay 0.08ppm

Alternatives to water fluoridation

School water fluoridation Fluoridated salt Milk Fluoride tablets Fluoride drops Fluoride oral rinses

School water fluoridation

1954 Virginia island, 2.3ppm, 1962 - 21.9% caries reduction Pennsylvania 5ppm 5yrs 28.6%, 10yrs 39% less dmft USA - North Carolina- Vermont, Kentucky, Nebraska, Florida, Montana Heifetz et al 1983 12yr study (6.3ppm) 47% reduction

Results of these several studies - Effective public health measure

Venturi fluoridator system

Advantages
Effective public health measure

Disadvantages
Limited pre eruptive contact (5-6yr) Intermittent exposure of F to children (5-6hrs 4.5ppm over dosage

Salt fluoridation
Introduced in Switzerland 1955 Salt fluoridated 90 mgF/kg (canton of Zurich) 250mgF/kg (canton of vaud 1970) Belgium, France, Germany, Spain, Hungary Clinical trials Wespi et al 1955 20-25% Muhlemann 1967- 300mgF/kg - 1.5mgF/5gm of salt Toth 1976 250mgF/kg salt - 41% (2-6yr) - 8yr - 58%(7-11yr) - 36% (12-14yr)

Production of fluoride containing salt

Spraying conc. solutions of NaF on salt on a conveyer belt (Switzerland and Hungary) NaF & CaF mixed Po4 - salt (U.S.A)

Requirements for application of fluoridated salt

Low fluoride drinking water Lack of political will and resources to fluoridate water

Factors favoring the implementation of salt fluoridation in Switzerland

Decentralized water supply Uniform low water F Centralized salt production Public ownership Low cost

Advantages of salt fluoridation Safe Supplement Consumer free choice No supervised water distribution systems Lifelong daily compliance Small amounts Low cost Disadvantages Low consumption Safety - Hypertension ? No problem of acute toxicity

Limitations
Limited to domestic salt Variation in salt intake Difficulty in controlling the distribution of various conc Requires refined salt produced with modern technology Technical expertise Multiple sources of water

Feasibility in India
Effectively controlled supply Individual monitoring not required (5-8gms of salt/day) Freely available Cariostatic effectiveness and excretion Does not alter its color

Milk fluoridation
Ziegler 1955 (Swiss city of winterthur) 0.03 ppm F (Erickson 1971) Compounds NaF- conc. aqueous solution disodiummonofluorophosphate reacts ca disodiumsilicofluoride pasteurized milk Manufacture fl added to milk in appropriate quantity Fluoridated milk- pasteurized / sterilised (liquid) - powder WHO 1994 - 0-1mgF/day (age+water F)

Studies Inamura 1956 (Japan) 36.3% - (2.5mg NaF ) Rusoff et al 1962 (U.S.A) 35% (3.5ppm F) Benoczy 1984 longitudinal study (3-9yr old) 3yr 200ml milk +0.4mg F (3-5yyr old) 0.75mgF (6-9yr old) Primary teeth Ziegler 1964 14 31% (1ppm) Benoczy 1983 74% Effectiveness of milk F bioavailability is not reduced promotes remineralisation (low level of ionised F)

Rationale Target children directly Less expensive Consumers choice

Advantages Staple food Consumption confined to groups who need it most Concerns Absorption long Children who do not drink milk / consumption declines with age

Stamm 1972 4 criticisms of milk fluoridation as public health measure 1) low socioeconomic 2) less benefit 3) cost 4) slow absorption

Feasibility of milk fluoridation in India

Controversy binding and complexing of F + ca, p Ericson1958 4hr Cannot afford milk No centralised milk supply system Variation of intake and quantity

fluoride supplements
1940 , pre eruptive effect Common dietary supplementsFluoride drops vitamins Fluoride tablets - vitamins Lozenges Oral rinse supplements

Commercially available
NaF tablets fluoroday tymafluor, luride (U.K) Vitamins Drops 0.125,0.25,0.50mg

Oral rinse 1mg/5ml

dosage
2.2mg (1mgF) 1.1mg (0.5mgF) 0.55mg (0.25mgF) APF tablets/ KF/CaF

Fluor-A-Day Chewable Tablets

Luride Chewable Tablets

Luride drops

Sodium fluoride tablets and drops

Lozenges

oral rinse

Factors to be considered before determining proper F dosage

Concentration of fluoride in drinking water Total amount of bioavailable fluoride Age of the child Dosage forms commercially available milk & milk products

Fluoride dosage based on F content of drinking water (ADA)

F content of drinking water <0.3ppm 2wks-2yr 2-3yr 3-14yr

o.25 mg

0.50

1mg

0.3-0.7ppm

0.25

0.50

>0.7ppm

Recommendations to fluoride supplements

(British society of pediatric dentistry)
1) Not a public health measure- recommended for individual children 2) <0.3ppm/ high risk patients- recommended dosage 6mon-3yr 3-6yrs >6yrs 0.25mgF/day 0.50mgF/day 1mgF/day

Indications for use

No central water supply low F conc parental motivation high Interim measure Water/ salt F cannot be implemented Frequent changes in work

Precautions
Stomach upset Risk of mild fluorosis

Effect of fluoride tablets on deciduous teeth

Hoskova 1968 93% (prenatally) 82% - 54% (birth) 56% (kailis et al) Since birth 6-8yr -40% (Prichard 1969) - 3 yr 78% (hennon 1971) After 3yr 0-38%

Caries reduction 50-80% (bef 2yr 3-4yr)

Effect of fluoride tablets on permanent teeth

Sodium fluoride tablets 0% caries reduction Bibby 1955 33-38% (Berner 1967, Pollack 1960) APF tablets 23- 30% (depaola 1968,aasenden 1972) Aasenden& peebles 1974 -0.5mgF daily (<3yr) 1mg (8-11yr) 80% 20-40% caries reduction

Prenatal fluoride supplements

1966 FDA banned marketing of products bearing claim that caries would be prevented in their offspring of women who used the products in their pregnancy Rationale for the use of prenatal fluorides in caries prevention Transfer of F from maternal circulation to fetal circulation Clinical trials with prenatal fluorides

Placental transfer of F ?
1) Fluorosis in primary teeth - thylstrup (3-21ppm) 2) Prenatal fluoride metabolism

3) Elevated maternal blood conc. ? 4) Prenatal exposure to fluoridated water

- blayney & hill, tank & storvick 1964- benefit primary teeth - Horowitz & heifitz 1967, Katz & muhler- minor - Carlos 1962 - prevalence differed - Arnold- greater reduction- pre/post 5) fluoride supplements - felt man & kozell 1961- pre+postnatal - Pritchard -Glenn study 1977-79- prenatal
Legros et al 1983 protect teeth Changing the morphology of teeth Densely placed enamel rods No evidence

Defluoridation
Deflouridation - scientific means to improve the quality of water with high fluoride conc by adjusting the optimum level in drinking water Methods Adsorption and ion exchange methods
Adsorb F + exchange negative ions activated alumina, fluidized activated alumina, activated bauxite, zeolite, tricalcium phosphate,super phosphate, activated bone char, magnesite

Precipitation method - High ph co-precipitation of several elements + fl ions - Alum, alum + lime, lime softening, CaCl

Methods based on membrane separation Reverse osmosis expensive 30% of raw water is lost

Reverse osmosis unit

Ion exchange resins

Anion exchange resins - polystyrene, quaternary ammonium
- 10-15 cycles replacement - High cost, unacceptable taste.

Cation exchange resins - saw dust carbon, defluoron 1, carbion

Defluoron 1
Sulphonated saw dust impregnated with 2% alum. High attritional losses (bhakuni 1964, 1970)

Carbion
Good durability , bulk density 680g/lt

Pilot plant gangapur - Rajasthan (4.8ppm) 8:1 Carbion & defluoron 1, alum

Magnesia (Thergaonkar 1971-73)

removed excess fluoride- ph>10 High cost, large conc., complexity of preparation

Defluoron 2 (1968)
Sulphonated coal +alum cycles, 2-4yrs life regeneration and maintenance of plant skilled operation

Indian technology for deflouridation

NEERI ,Nagpur - 1960 Nawlakhe 1974 Nalgonda technique 1975 (Andhra Pradesh)

Nalgonda technique (Nawlakhe 1974)

Addition of 2 readily available chemicals Sodium aluminate /lime- hastens settlement of ppt bleaching powder disinfection filter alum added to F water

Domestic / community water supplies

Domestic treatment
container 20- 50lt

Lime water + bleaching powder

Alum solution (10min) Clear water (1hr)

Community level- fill and draw type

200-2000 poulation

Community level- fill and draw type

The picture shows Defluoridation Plant attached to Hand Pump.

CHEMICAL TANK OUTLET INLET CHEMICAL DOSING SYSTEM HAND PUMP PERFORATED SHEET GRAVEL

VALVE 1 VALVE 2 GRAVEL LAND BACK WASHLINE MASONARY M.S. STAND DRAIN

Indications for adopting Nalgonda technique

Absence of acceptable, alternate low fluoride source within transportable distance Total dissolve solids below1500mg/l

Raw water fluoride ranging from 1.5 20mg F /l

Salient features of Nalgonda technique

No regeneration media No handling of caustic acids and alkalis Domestic and community levels Manual operated Chemicals municipal water supplies Cost effective Flexible design <1mg/l Little wastage of water and least disposal problem Needs minimum of mechanical and electrical equipment

Combined Nalgonda and calcined magnesite technique

In Tanzania (1985- 1990) Nalgonda technique was passed thru a filter bed consisting of calcined magnesite granules Ph rise >10 Impractical for rural regions

Prasanti technology 1998

Activated alumina Bio-science dept, A.P 25 community defluoridation plants 200400people 500 domestic defluoridation plants Cost effective

Activated alumina

Other materials tried in India

Fish bone charcoal university of Roorkee Drumstick plant (ca, mg) reduce water turbidity Askali extract mycetial biomass, Hyderabad Clay minerals Tricalcium phosphate

References
Fluorides in dentistry Fejerskov Fluorides Amrit tewari Salt fluoridation - Adv dent res 1995 Dcna 1999 Essentials of preventive and community dentistry soben peter J of Indian dental association 1986 JDR 1992 clinical uses of Fluorides- stephen wei j dent child 1981