SESSION PLAN

COURSE # AND TITLE: SESSION # AND TOPIC: DURATION: FACULTY: GENERAL GOALS:

PEDS 538, Pediatric Dentistry # 9 Prevention of Dental Caries-Fluoride Equivalent to 1 hour

Dr. Glenn Minah

Become familiar with various soft tissue abnormalities and diseases found in children The student should be able to:

SPECIFIC OBJECTIVES:

1. State goals of fluoride therapy.

2. Understand how optimal benefits of nonprofessional 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 OBJECTIVES:

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: ASSIGNMENT:

Web Lecture McDonald RE, Avery DR. Dentistry for the Child and Adolescent. Mosby, St. Louis, 7th ed. 2000. Chapter 10, p. 209 Written exam. Questions will be from the text portion of this presentation. TEXT

EVALUATION:

SESSION OUTLINE

A. B.

Goals of fluoride administration Non-professional fluoride administration 1. 2. 3. 4. Systemic Topical gels Rinses Dentifrice

C. Professional administration 1. Topical 2. Varnish

TEXT

Goals of Fluoride (F) Administration 1) Do not harm the patient. 2) Prevent decay on intact dental surfaces. 3) Arrest active decay. 4) Remineralize decalcified tooth surfaces.

GOALS OF FLUORIDE (F) ADMINISTRATION

1. Do no harm

3.

Arrest active decay

F
Fluorosis or toxicity

2.

Prevent decay on in tact dental surfaces

4.

Remineralize decalcified teeth

F F

TEXT

Do not harm the patient

1.

Probable 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, 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 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 serious consequences of F toxicity stem from reactions of cationic electrolytes with systemic F.)

POTENTIAL HARM Probable toxic dose: 5 mg F / kg body weight

61.5 mg F/
5 ml

ACT

91-97 mg

F/ container of F mouthrinse

Topical F, 12,300 ppm F pH= 3.5

20 kg 6 year old, PTD= 100 mg F

Symptoms: 1. 2. Vomiting Excess salivary and mucous discharge Cold wet skin Convulsion at higher dose

230 mg F/
10 kg 2 year old PTD = 50 mg F

tube toothpaste

3. 4.

POTENTIAL HARM

A serious systemic consequence is binding of F to Ca which needed for heart function.

Counter Measures: 1. 2. 3. Emetics 1% calcium chloride Calcium gluconate milk F Ca Divalent cations like Ca cause precipitation, of F and prevent absorbtion in the intestine. Ca F

F 4.

F Ca F Ca Ca F F F Ca Ca

Ca

F Ca Ca F F F Ca Ca

TEXT

Do Not Harm the Patient

2.

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 the 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 especially 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.

POTENTIAL HARM

DMFT 10 9 8 7 6 5 4 3 2

FLUOROSIS

severe moderate mild slight 0.0 0.5 1.0 2.0 3.0 4.0 PPM F IN DRINKING WATER F in excess of 0.1mg/ kg body weight = fluorosis

FLUOROSIS

F F
Excess F affects mineralization of developing teeth Enamel prism

Up to age 6 is the critical age for fluorosis. After age 8, risk is past.

FLUOROSIS Daily F intake of a 20 kg 4 year olds with different water F

1 2 3 4 mg F 0.5 ppm water F 1.2 ppm water F

Maxium safe dose for a 2 year old = 1 mg F / day

Maxium safe dose for a 5 year old = 2 mg F / day F in excess of 0.1mg/ kg body weight = fluorosis

supplements fluids

toothpaste food

DW Banting JADA 123:86,1991

FLUOROSIS

5 year olds swallow 25% of toothpaste

Children under 2 years swallow 50% of toothpaste

1 to 3 grams

Toothpaste = 1 mg F / gram (1000 ppmF)

pea size amount (0.5g) is recommenred for fluorosis susceptible children.

mild

moderate

pitting

severe

TEXT

Prevention of Caries
1.

Deposition of fluorapatite (FHA) in sound tooth structure: Caries protection results from FHA 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 acid-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% 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).

MECHANISMS OF F PROTECTION

DEPOSITION

Saliva (S) Plaque (P) Tooth (T)

F
F

F F

F F F FF F
Topical F is the best method for deposition.

Theory: Increase FHA levels maximally in intact dental surfaces.

DEPOSITION OF F

F F F Neutral pH F F

FHA is more acid resistant than HA

FHA

H+
PO4

PO4 F Ca F

H+
FHA CO3 HA

F Ca

pH 5.0 F
FHA

Mg

H+ H+

remineralization

Mg and CO3 do not reprecipitate

P Ca

DEPOSITION OF F Surface build-up of F Best F uptake is late preeruption and early posteruption

F F F
F F
Mature enamel
Enamel fluid

F F

F
Drinking water F No F Permanent teeth 3000 2000 Primary teeth 900 600

F
Young enamel

This has better F uptake due to more porosity

Maximal F levels of in outer 5 microns

DEPOSITION OF F
Fluoride uptake is higher in a decalcified area
5 um
3000 ppm F

PPM Fluoride 3000 2000 1000

1500 ppm F

outer 2 microns = 6000 ppm fluoride (max. uptake)

F
Ca Ca Ca Ca Ca

As fluoride reacts strongly with calcium it does not penetrate far into the tooth.

DEPOSITION 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 74:990,1987 DePaola JADA 87:155,1973 Downer BritDJ 141:242,1978

Caries reduction
100%

NaF APF APF

Horowitz JDent Child 27:157,1980 SnF2 Muhler JDent Child 27:1571980 Szwejda JPub Health Dent 32:110,1972 Newly erupted teeth SnF2 APF

Previously erupted teeth

TEXT

Prevention of Caries
2.

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 only 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 bioavailable 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.

MECHANISMS OF F PROTECTION

BIOAVAILABILITY

Water fluoridation is an example of a source.

S P
T

F
F

SUGAR ACID

Theory:
Provide continual low level of F to enamel fluid. The benefit occurs at the time of decalcification.

BIOAVAILABILITY OF F Decalcification of enamel crystals:

SUGAR

Low level of F

F
S

saliva

H+
plaque S

H+
Decalcifying HA crystals

F
F F

F
Plaque and enamel fluid

H+
Intact HA crystals

H+
F

H+
J Arends. JDR 69(SI):601,1990

BIOAVAILABILITY OF F

F from plaque
fluid

J Arends. JDR 69(SI):601,1990

F
F F F F F
F

F
F F F F

ACID

H+ H+
Protection from dissolution
F F

Loosely-bound F will eventually become stable FHA.

Stable FHA
Loosely bound or adsorbed F

BIOAVAILABILITY OF F

H+ H+
F F
F

FHA with no

H+
F F

H+

H+
PO4

PO4

H+

H+

Ca

H+
Ca

H+ H+
Incomplete protection

Protection only where is

J Arends. JDR 69(SI):601,1990

BIOAVAILABILITY OF F

Effect on bacteria:

F H+
MS

H+
S

S F

H+
F

F F H+ F

H+

H+

The presence of fluoride at the time of glycolytic activity will also inhibit of plaque acidogenesis.

H+

SOURCES OF BIOAVAILABLE F

1. saliva
ACT

2. Fluoridated water

3. Home care products

Topical F
4. RESIDUAL F

ppm F in saliva after drinking 0.08 0.02

F
F

F
F

F F
F
F

S P T

Calcium Fluoride

1 3

5 h

CaF2 precipitates in plaque during topical F treatment

BIOAVAILABILITY VERSUS DEPOSITION OF F Rodent studies:

LESIONS (mean)

No FHA

30
MS plus

FHA

DEPOSITION

F
No FHA

F sugar

BIOAVAILABILITY

10 ppm F added to drinking water

Larson RH. Caries Res 10:321, 1976

BIOAVAILABILITY OF F Research evidence:

Add F:

calcium loss
5 4 3 2 1 0 0.05 0.1 1 5

HA

pH 5.0

pH
phosphate

calcium

F ppm in solution
JM Ten Cate. JDR 69(SI):614,1990

TEXT

Prevention of Caries
3.

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 believed 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 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 caries risk status which emphasizes bioavailability of posteruptive 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) and 5) administer systemic topical F if indicated. (The latter is currently under review. Present Academy of Pediatric Dentistry recommendations are presented below.

TEXT

FLUORIDE SUPPLEMENTS F F in drinking water AGE <0.3ppm 0.30.6ppm >0.6ppm

6m-3y

0.25

3-6y
6-16y

0.5
1.0

0.25
0.5

0
0

Academy of Pediatric Dentistry current recommendations

SUMMARY OF PREVENTIVE F 1. 2. 3. Determine F intake Determine caries risk Devise personalized plan based on risk level. Stress bioavailability of F. Monitor F intake of young patients in an effort to prevent fluorosis.

4. 5.

Arrest of Active Decay

1.

TEXT

Mechanisms: Caries arrest means that active lesions become inactive. This is accomplished clinically by 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 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 dissolved 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.), stained 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.

TEXT

Arrest of Active Decay

2.

Clinical recommendations: 1) Determine total F exposure, 2) determine caries risk and tailor 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

Root caries

Indications:

incipiencies

Cases difficult to treat, i.e., certain ECC cases

Interproximal caries in low or moderate risk patients.

ARREST OF ACTIVE DECAY

Ca 3.

PO4

Ca

PO4

Procedure: Diet control

1.

Increase topical Ca and PO4 intake.

4. MS

LB

2.

Plaque control

Encourage beneficial microbial shifts.

ARREST OF ACTIVE DECAY

5. Increase bioavailable F

S P T

F
F

SUGAR ACID

Arrested caries turns dark, is firm and often glossy.

TEXT

Remineralization of Decalcified Surfaces

1.

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 from 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 lesions are indicated and 2) F, Ca++ and PO4--- exposure are monitored more carefully.

2.

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 smooth 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

Same procedures as arresting caries.

for

White spot

Exceptions or additions: 1. Only non-cavitated lesions can be remineralized. 2. Not recommended for severe of high caries risk patients. 3. Ca, PO4 and F are administered more precisely. before after

Clinical Fluoride Products These include 1) professional topical F, 2) F varnishes 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.

TEXT

1.

Professional Topical F Products and description: The principal products are 2.72% acidulated phosphate fluoride(APF) gel and 2% 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 FHA content. Neutral NaF gels (9200 ppm F) are indicated when composite restorations are present since APF will etch glass filler particles of the composites. This product will not produce comparable surface FHA deposition, but according to research evidence, achieves the same caries protection as APF.

TEXT

Professional Topical F
2.

Mechanisms of caries protection: The earlier theories centered on increasing deposition of FHA. Now it is believed that benefits are derived mainly from residual F buildup in plaque and other oral surfaces or biofilms in the form of CaF2, other minerals and protein-bound F. These reservoirs release F during acidification which acts as bioavailable F. (Note: sealants should not be placed immediately after professional topical F treatment due to instability of the CaF2 layer which precipitates on the tooth surface. Sealants may be placed after 24 hours.) When applied every 6 months to children in F deficient regions, all types of professional topical F agents achieved roughly 30% caries reduction versus sham treated controls.

PROFESSIONAL TOPICAL F Topical Fluorides:

2.72% acidulated phosphate F (APF), 1.23% free F, 12,300 ppm F. 2.0% neutral sodium F, 0.9% free F, 9200 ppm F. 8% stannous F (no longer used routinely).

APF
2.

Reprecipitation of fluorapatite
Ca

F
PO4

F
1. 0.1 M H3OP4 Ca 3. Ca PO4 Ca Precipitation of calcium fluoride on enamel surface

H+

H+

Dissolution of surface layer

PROFESSIONAL TOPICAL F CaF2

Do not seal teeth immediately after a topical F treatment due to CaF2.

H+

H+

H+

Etched glass

F
Ca

Ca F

T
APF will etch glass in filled resins. Use neutral F gel.

Plaque acids will release bioavailable F from CaF2.

resin

TEXT

Professional Topical F
3.

Recommendations: 1) Determine total F exposure. 2) Determine caries risk. 3) Administer as indicated by # 1 and 2. (Timing may be monthly, 1, 2, 3 or 4 times a year or even contra-indicated.) 4) Apply for 4 minutes. 5) Add no more than 2ml to the gel tray and make every effort to keep patient from swallowing the gel. 6) Have patient refrain from rinsing, eating or drinking for 30 minutes after application.

PROFESSIONAL TOPICAL F Recommendations: 1. 2. Determine total F exposure. Administer 0,1,2,3,4 times a year as indicated by caries risk level. Apply for 4 minutes. caries

placebo
topical

3.

4.

Use only 2 ml of gel in trays, keep patients from swallowing the gel.
No rinsing, drinking or eating for 30 min. afterwards.

5.

Two topical F treatments per year reduced caries by 30% versus placebo gel.

TEXT

Fluoride Varnish
1.

Products and use: Application of F varnish is essentially a professional topical F treatment. Duraflor is currently the only concentrated F varnish sold in the US (called Duraphat in Europe) and contains 5% NaF. Flor-Protector contains 0.7% silane F and is used as a cavity varnish. For topical treatments Duraflor should be applied to, and allowed to dry on all cotton roll-isolated teeth. Afterwards the patient should not eat for 2 hours. Although the caries benefits are similar to topical F gels, less total F is released into the oral cavity during treatment (i.e., only 3 to 6mg ) than from gels.

2.

Indications: Apply to: 1) teeth during operating room procedures, 2) enamel incipiencies, 3) exposed roots, 4) margins of restorations, 5) teeth at risk which cannot be sealed such as erupting molars or premolars or 6) carious anterior teeth in very young children.

FLUORIDE VARNISH

Duraflor 5% NaF, 26,000 ppm F, 3-6 mg F per dose.

Fluor-Protector 0.7% silane F. Used as a cavity varnish

FLUORIDE VARNISH

0.25 ml for primary dentition

Cavity Shield (OMNI) 5% NaF

0.40 ml for mixed dentition

FLUORIDE VARNISH Indications:

3. Exposed roots and root caries 5.

Erupting teeth

1.

All teeth in the OR

2. White spots or other incipiencies

4. Margins of restorations

6.

Carious anterior teeth in young children

TEXT

Home Rinses
1.

Products and use: These are available as over-the-counter (OTC) daily rinses (0.05% NaF, 230ppm F; 0.02% NaF, 200ppm), or as prescription weekly rinses (0.2% NaF, 910ppm F or 0.4% SnF2, 970ppm F). Patients should rinse 1x/day for 1 minute with 10ml.

2.

Indications: 1) High caries risk patients. 2) Exposed root surfaces. 3) School prevention programs.

HOME F RINSES
Daily Rinse: Weekly Rinse

ACT PREVIDENT 0.05% NaF, 0.023% free F, 230 ppm F, 2.3 mg F / dose Indications: 1. 2. PHOS -FLOR 3. High caries risk Exposed roots

0.2% NaF, 0.091% free F, 910 ppm F, 9.1 mg F / dose.

Prevention programs

0.02% APF, 0.02% free F, 200 ppm F, 2 mg F / dose.

TEXT

Home Gels Products and use: Home gels are available as prescription 1.1% NaF (5000ppm F) and 0.4% SnF2 (1000ppm). These are self-administered by the exposure of F to teeth than do rinses.

Indications: 1) High or severe (rampant) caries risk patients. 2) Exposed root surfaces when evidence of caries is present. 3) School prevention programs.

HOME GELS
GEL-CAM 0.4% SnF2, 0,097% free F, 970 ppm F, 23mg F/ dose.

Indications: 1. 2. 3. Severe caries Root caries Prevention programs

PREVIDENT 1.1% NaF, 0.5% free F, 5000 ppm, 1025 mg F/ dose. Radiation caries

TEXT

Dentifrices
Product descriptions: Dentifrices are sold as pastes or gels. The latter theoretically penetrates retention sites better, and are more acceptable to young children than pastes. The main ingredients of dentifrices, from a preventive standpoint, are F salts and abrasives. One of 4 types of F salts are used, i.e., 1) 0.2% NaF, 2) 0.76% sodium monofluorophosphate (MFP), 3) 0.4% SnF2 or 4) amine F. Amine F is not sold in the US. Most dentifrices contain 1mg F/gram which amounts to 1mg or 1000ppm F in each toothbrushing dose. A few newer products contain up to 1500ppm F. According to trial data, all F dentifrices reduce caries by 25 to 32% versus control paste without F, when used twice daily. MFP and NaF are the standard types of F used in the US. SnF2 exhibits a shorter shelf life and may cause staining of teeth. MFP is formulated with covalently bound fluoride which improves stability, and can be used with abrasives containing Ca++ which will react with and inactivate non-covalently bound F. F is released from MFP in vivo by enzymatic reactions and supposedly achieves better enamel uptake of the F ion than NaF pastes. Common abrasives are a) sodium metaphosphate, b) silica, c) sodium bicarbonate, d) acrylic polymer, e) dicalcium phosphate or f) calcium carbonate. The latter two can only be used with MFP. The FDA requires that at least 60% of free F ion be available in doses, over the life of the dentifrice. NaF and MFP dentifrices lose about 20% F availability within 2 years.

DENTIFRICE (TOOTHPASTE,TP)

Pastes

Key ingredients in TP: 1. 2. F salt Abrasive

Gels: 1. Better interdental penetration More acceptable to children

2.

DENTIFRICE
F salt in TP: 1. 2. 0.2% NaF 0.76% sodium monofluorophosphate (MFP) 0.4% stannous F F Sn F SnF2 exhibits less shelf life and may cause dental staining Amine F is not sold in the US. It adsorbs to enamel and has anti-bacterial properties MFP does not react with calcium abrasives (F is covalently bound) and has better uptake by enamel crystals.

Na PO4 F

3.

4. Amine F F salt (all reach 1000-1500 ppm F)

Na F

1 gram of TP = 1 mg F F

The ADA requires that 60% of free F ion be available over the shelf life of the TP. NaF and MFP lose about 20% free F in 2 years.

DENTIFRICE
Abrasives: 1. Sodium metaphosphate PO4 Na PO4 5. Dicalcium phosphate F PO4 Ca PO4 Ca It is desirable to have PO4 and Ca and HCO3 3. Na bicarbonate Na CO3 H Ca as abrasives Ca 4. Acrylic polymer CO3

H+
F

2. Sodium Silica

Ca
Na

6.

Calcium carbonate
Ca CO3

These can be used with MFP

TEXT

Dentifrices Use considerations: Noteworthy concerns are fluorosis from swallowed toothpaste in children, and the F content of commercial products. The latter involves toothpaste trial data showing that preventive effects correlate positively with F content. As a result, commercial products are prepared with increasing amounts of F, and this may become a fluorosis concern with young children. Accepted provisions for reducing child intake of F are use of toothbrushes with small heads to limit paste application, and instructing parents to use no more than a pea size amount of paste (approximately 0.5g) on the toothbrush (High concentration F dentifrice should not be used before age 7.). Another concern is rinsing after tooth-brushing. Studies show that 50% of the benefit is lost when this is routinely practiced. No rinsing after brushing, or rinsing with an OTC F mouthrinse are recommended. Finally, tooth-brushing should be conducted just before bed-time in order to take advantage of night-time reduction of oral clearance mechanisms. F bioavailability will thus be increased.

F USE CONSIDERATIONS S P T

F
High flow

salivary

F
Brush before bedtime

awake S P T

F F

F F
Low salivary flow

F F F

Evidence shows that increased F use and F concentration increases bioavailability in stagnation sites. (Note: be aware of fluorosis susceptible patients.)

asleep
Rinsing after brushing reduces F effectiveness by 50%. Recommendations: Do not rinse after brushing or rinse with a F rinse.

Commonly Used F Products Type of F

Professional gel

F salt
2.72% APF 2.0% NaF

Free F
1.23% 0.9%

Brand name
Nupro

Company
Dentsply

F ppm
12,300 9200

F mg/dose
24.6-61.5 18.4-46

F varnish

5.0% NaF 0.05% NaF 0.02% APF

2.6%

Duraflor

Pharma Science J&J Colgate

26,000

3-6

Daily rinse

0.023% 0.02%

Act Phos-Flor

230 200

2.3 2.0

Weekly rinse

0.2% NaF 0.4% SnF2 1.1 NaF

0.091%

Prevident

Colgate

910

9.1

Home gel

0.097% 0.5%

Gel-Kam Prevident

Colgate Colgate

970 5000

1.94-4.85 10-25

Commonly Used F Products

Type of F
Supplements

F salt

Free F
1.0%
0.5%

Brand name
Luride

Company

F ppm
1000
500

F mg/dose

F tablets

2.2% NaF
1.1% NaF

Colgate

1
0.5

0.55% NaF
F drops 1.1% NaF

0.25%

250

0.25

0.5%

500

0.25mg per 1/2ml

Dentifrice

0.22% NaF
0.76% MFP

0.1%
0.1%

1000
1000

1
1