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6.topical fluorides

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complete description of topical fluorides

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6.topical fluorides

  1. 1. 1 CHAITANYA.P II MDS Dept of Public Health Dentistry
  2. 2. Previous Questions • Dental fluorides Nov 2013. • Slow release fluoride devices. Apr 2015, Aug 2013 • Controversies about the use of fluoridated dentifrices. Oct 2011. • Fluoride toxicity. Jun 2013. 2
  3. 3. Contents • Introduction • Types of fluorides delivery • Types of topical fluorides a) Professional b) Self • Recent advances in topical application • Fluoride toxicity • Conclusion • References Topical Systemic 3
  4. 4. Introduction • Fluoride is the reduced form of the element fluorine. • Its atomic weight is 19 and atomic number is 9. • In nature it occur in the form of fluorspar(CaF2), fluorappatite (Ca10(PO4)6F2) and cryolite (Na3ALF6). • Fluorides are used in various forms for prevention of caries. • It occurs in natural water resources and influence the mineralization of teeth. Ref : MS Muthu pediatric dentistry principles and practice, 2nd edition,2011; pg:149, Elsevier4
  5. 5. Fluorides Delivery Methods TOPICAL FLUORIDES SELF APPLIEDPROFESSIONAL •Neutral Sodium fluoride •Stannous fluoride •APF Solu /Gels •Varnish •Dentifrices •Mouth Washes •Fluoride Gels FLUORIDES SYSTEMIC FLUORIDES I.Water Fluoridation i. Community Water Fluoridation ii. School Water Fluoridation II. Salt Fluoridation III. Milk Fluoridation IV. Fluoride tablets/ drops/ lozenges 5
  6. 6. Topical Fluorides 6 • Topical fluorides are those fluoride containing agents which are applied to the tooth surface in regular intervals in order to prevent the development of caries. • These exert an anticaries effect by increasing the concentration of fluoride in the outermost surface of the enamel.
  7. 7. Indications for topical Fluorides 1. Caries-active individuals i.e. those with past caries experience or those who develop new carious lesion on smooth tooth surfaces. 2. Children shortly after periods of tooth eruption, especially those who are not carries free. 3. Medication to reduce salivary flow or had undergone head and neck radiation. 4. After periodontal surgery when roots of teeth 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 lifestyle which may affect eating or Oral Hygiene Habits conductive to good oral health. 7. Mentally or physically challenged individuals. Ref : MS Muthu, Pediatric dentistry principles and practice, 2nd edition,2011; pg:155-159 Elsevier publication. 7
  8. 8. Professionally applied topical fluorides: It was introduced by Bibby in 1942. Bibby in 1942 was the first to demonstrate that the, repeated application of sodium or potassium fluorides to teeth of children significantly reduced their carries prevalence. This achievements became the fore runner of many studies to test the effectiveness of various topical fluorides and the effective methods of its application. Involve the use of high fluoride concentration products ranging from 5000- 19,000ppm, which is equivalent to 5-19 mgF/ml. Topical fluorides are divided into two categories 8
  9. 9. 9 Self applied products: Include fluoride dentifrices, mouth rinses & gels Are low fluoride concentration products ranging from 200-1000ppm or 0.2-1 mgF/ml.
  10. 10. Professionally Applied Fluorides 10 1.SODIUM FLUORIDE 2.STANNOUS FLUORIDE 3.ACIDULATED PHOSPHATE FLUORIDE 4. VARNISH Ref: MS Muthu, Pediatric dentistry principles and practice, 2nd edition,2011; pg:155-159, Elsevier publication. Ref: J.J.Murray, Fluorides in caries prevention, 3rd edition, 1999; pg:179-207,Butterworth-
  11. 11. Topically fluoride application by a Dentist , Dental Hygienist or any other Dental Auxiliary has become an established Caries-Preventive Procedure in the Dental History. The fluoride may be used in an aqueous solution, a viscous gel, a prophylactic paste or as a dental varnish and can be applied using the Paint on Technique or the Tray Technique. 11
  12. 12. Paint on Technique 12 Hodgson (2005) has suggested an alternative technique utilizing a 5 ml plastic syringe. This method allows a more efficient application of the varnish which can be particularly useful in cases where speed is important, such as with a difficult pediatric patient.
  13. 13. Tray Technique 13
  14. 14. Neutral Sodium Fluoride (NaF) Neutral Sodium Fluoride(NaF) was the first fluoride compound to be used for topical fluoride application. A minimum of four applications of with 2% Sodium Fluoride solution gives a caries reduction of about 30%. Methods of preparation of 2% NaF It is prepared by dissolving 20gm of Sodium Fluoride powder in one liter(1000ml) of distilled water in plastic bottle. It is essential to use plastic bottles because if stored in glass bottles it may react with silica and form Silicon Fluoride thus by reducing the availability of free active fluoride of anti- caries action. 14
  15. 15. Procedure for application of Sodium Fluoride [ Knutsons Technique ]: oral prophylaxis done teeth isolated either by quadrant or by half mouth 2% NaF solution is painted on the air dried teeth so that all surfaces are visibly wet allowed to dry for 3-4 minutes repeated for each of the isolated segments until all teeth are treated 2nd, 3rd and 4th NaF application, each not preceded by a prophylaxis, is scheduled at intervals of approximately one week. The fourth visit procedure is recommended for ages 3,7,11 and 13 years, coinciding with the eruption of different age groups of primary and permanent teeth. Thus, most of the teeth will be treated soon after their eruption, maximizing the protection afforded by topical application. 15
  16. 16. Mechanism of Action NaF Hydroxyapatite crystals Calcium Fluoride reacts forms “Chocking Off Effect” [as thick layer of formation of Calcium fluoride forms , it interferes diffusion of F from NaF solution to react with hydroxyapatite and blocks further entry of F ions] And acts as resorvior for F release [it is the reason allowed to dry for 3-4 minutes] Calcium Fluoride Hydroxyapatite crystals Fluoridated Hydroxyapatite increase of fluoride content on enamel surface resistance against caries attack 16
  17. 17. Advantages : • Relatively stable when kept on a plastic bottles • Taste well accepted by patients. • Non- irritant to Gingiva • Doesn't results in discoloration of teeth • Once applied allowed to dry for 3-4 minutes so can pursue a multiple-chair procedure in public health programme. • The series of treatment must be repeated only four times in general age range of 3-13 years rather than annual or semiannual intervals, therefore in public health program, other group of children can be treated in intervening years. Disadvantages: • The only disadvantage is that the patient has to make four consecutive visits within a short period of time. 17
  18. 18. Stannous Fluoride (SnF2) Stannous Fluoride has been used at 8% and 10% concentrations in solutions equivalent to 2 and 2.5% fluoride. Although 10% solutions used for adults and 8% for children there is no any clinical difference between the two. However 8% Stannous Fluoride is preferred. 18
  19. 19. 19 Methods of Preparation of Stannous Fluoride Solutions of Stannous Fluoride are not stable so soon after mixing they become cloudy due to formation of Tin Hydroxide reducing the agents effectiveness. Since, Stannous is believed to contribute to anticarries benefits, aged solutions are considered to be clinically less effective so Muhler et al recommended to use fresh solutions of Stannous Fluoride for each patients. To prepare 8%Stannous Fluoride solution the content of one capsule which is 0.8 gm(‘0’ no.gelation capsule) is dissolved in 10ml of distilled water in the plastic bottles and shaken briefly.
  20. 20. Procedure for application of Stannous Flouride [ Muhler’s Technique ] Teeth cleaned with aqueous pumice slurry Un-waxed dental floss is passed between the inter-proximal areas. Teeth are isolated and dried with air. SnF2 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 patients is susceptible to caries. 20 Ref: MS Muthu, Pediatric dentistry principles and practice, 2nd edition,2011; pg:155-159, Elsevier publication. Ref: J.J.Murray, Fluorides in caries prevention, 3rd edition, 1999; pg:179-207,Butterworth-
  21. 21. Mechanism of Action SnF2 Low concn tin Hydroxyphosphate oral fluids dissolve it forms gets ”metallic taste application” SnF2 high concentration Calcium tri-fluoro-stannate Tin tri-fluoro-phosphate “Tin tri-fluoro-phosphate makes tooth surface more stable & less suspectibility to decay” Calcium fluoride is also formed both at high and low conc which reacts with hydroxyapatite and results in formation of fluorohydroxyapatite. 21
  22. 22. • Advantages: – Using 8% Stannous Fluoride solution at 6-12 months intervals conforms to the practicing dentist’s usual patient – recall system. – Administrative difficulties, particularly in public health programs. • Disadvantages: – In aqueous solution the Stannous Fluoride is not stable. – Since 8% solution is quite astringent and disagreeable in taste, its application is unpleasant – The solution usually causes reversible tissue irritation manifested by gingival blanching usually on individuals with poor oral hygiene. – It usually causes pigmentation on teeth which has characteristic light brown color. Staining usually appears in association with carious lesions, hypo calcified regions and around margins of restorations. 22
  23. 23. Acidulated Phosphate Fluoride (APF) Acidulated Phosphate fluoride was introduced in1960’s by Brudevold and his co-workers at the Forsyth Dental Center, Boston, Massachusetts. Methods of preparation of Acidulated Phosphate Fluoride An aqueous solution of Acidulated Phosphate Fluoride is prepared by dissolving 20gms of Sodium Fluoride in 1 lit of 0.1 M phosphoric acid and then 50% hydrofluoric acid added to adjust the pH at 3.0 and fluoride ion concentration at 1.23%. It is also called as Brudevold’s Solution. 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. 23
  24. 24. Procedure for application of Acidulated Phosphate Fluoride The patient seated upright position in chair & Oral prophylaxis is done& teeth are treated completely. Clinical application of APF gel by tray technique [disposable foam line tray is preferred] To reduce ingestion a minimal amount of fluoride gel kept [coverage of tooth surfaces ,<5ml ] The patient is told not to swallow the gel but to exert slight pressure using the cheeks and the tongue as well as light biting forces in order to cause the gel to flow inter-proximally. The gel thins out under the biting force because of thixotropic nature. The fluoride gel should be in mouth for 4 minutes and remaining oral fluids should be expectorated. saliva ejector is used to wipe out saliva and excess fluoride The patient is instructed not to eat drink or rinse his mouth for at least 30 minutes. 24
  25. 25. 25
  26. 26. Mechanism of Action APF applied Initially leads to dehydration & shrinkage of hydroxyapatite crystals hydrolysis Dicalcium phosphate dihydrate (DCPD) highly reactive with fluoride ion Fluoride penetrates into crystals deeply through openings produced by shrinkage and leads to formation of Fluoroapatite The amount of Fluoroapatite deposited dependent on DCPD formation. For conversion of DCPD into fluoroapatite deeper penetration and continuous supply of Fluoride required. Hence APF solution was applied at 30 sec intervals and teeth kept wet for 4 minutes. High fluoride concentration and low pH, favors fluoride deposition, acidification of fluoride solution with phosphoric acid found to suppress dissolution of enamel, as well as formation of calcium fluoride The intermediate product DiCalcium phosphate & principal reaction product Calcium fluoride 26
  27. 27. Advantages: • Requires only 2 application in a year and is thus suited for most dental office routines. • The gel preparation can be self applied and the cost of application also gets reduced. • It has the ability to deposit fluoride in enamel to a deeper depth than a neutral Sodium Fluoride or Stannous Fluoride. • Acidulated Phosphate Fluoride is stable and need not be freshly prepared for each individual. Disadvantages: • Practical difficulties like the teeth should be kept wet for four minutes so repeated application necessitates the use of suction thereby minimizing its use in the field. This also increase the chair side time making this methods more expensive. • It is acidic, sour and bitter in taste. 27
  28. 28. Comparison Characterstics Sodium Flouride (NaF) Stannous Fluoride (SnF2) APF Percentage 2% 8% 1.23% Fluoride concn.(ppm) 9,200 19,500 12,300 pH Neutral (7) 2.4 - 2.8 3.0 Frequency of Application 4 at weelky intervals 3,7,11,13 yrs Biannually Biannually Adverse effect - Tooth pigmentation Gingival irritation - Caries reduction 30% 32% 28% 28 Ref: MS Muthu, Pediatric dentistry principles and practice, 2nd edition,2011; pg:155-159, Elsevier publication. Ref: J.J.Murray, Fluorides in caries prevention, 3rd edition, 1999; pg:179-207,Butterworth-
  29. 29. 1.FLUORIDE VEHICLES: Aqueous solutions & gels The gel adheres to teeth & eliminates the continuous wetting of enamel surfaces required when solutions are used. Thixotropic solutions are not gels, but have a high viscosity under storage conditions & become fluid under conditions of high stress 29
  30. 30. FLUORIDATED PROPHYLACTIC PASTES: If prophylaxis pastes containing fluoride are used, the lost fluoride is replenished & there is a significant gain in the concentration of fluoride. 30
  31. 31. FOAM: Developed to minimize the risk of fluoride over dosage as well as to maintain the efficacy of topical fluoride treatment. Advantages : Its lighter than a conventional gel & therefore only a small amount of agent is needed for topical application The surfactant has cleansing action by lowering surface tension, this facilitates the penetration of material into interproximal surfaces. It doesn’t require suctioning so it offers advantages for home use 31
  32. 32. FLUORIDE VARNISH: Increasing the time of contact between enamel surface & topical fluoride agents favours the deposition of fluorapatite & fluorhydroxyapatite. DURAPHAT: It s a viscous yellow material, containing 22,600 ppm fluoride as sodium fluoride in a neutral colophonium base. FLUORPROTECTOR: Its a clear polyurethane based product containing 7000 ppm fluoride from difluorosilane. Its dispensed in 1ml ampules each ampule containing 6.21mg of fluoride. CAREX: It has low fluoride concentration than duraphat & has equal efficacy to that of duraphat as caries preventive agent. 32
  34. 34. Recommendation For Topical Fluoride Application According to Lecompte (1987), the recommendation for Topical Application of high potency fluorides are:- 1. Not more than 2gm of gel per tray or approximately 40% of tray capacity should be dispended. Even more conservative amount should be considered for small children. 2. To prevent the swallowing of saliva during 4 min topical application , use of Saliva Ejector is recommended. 3. Following the 4 min of application procedure, the patient should be instructed to expectorate thoroughly for from 30 sec-1 min, regardless the use of suction cause the Expectoration is the only single most effective way of reducing orally retained fluoride. 4. When utilizing custom individually fitted trays for patients requiring daily or weekly application of a high fluoride concentration product utilize only 5-10 drops of products per tray. 34
  35. 35. Care for Fluoride Carriers (Trays) • Rinse and dry the trays thoroughly after each use. Clean them by brushing them with a toothbrush and toothpaste. • Occasionally, the trays can be disinfected in a solution of sodium hypochlorite (Clorox) and water. Use one tablespoon of Clorox in about one-half cup of water. Soak them for about 15 minutes. • If the trays become covered with hard water deposits, soak them in white vinegar overnight and brush them the next morning. • Do not boil the trays or leave them in a hot car as they may warp or melt. 35 Ref: MS Muthu, Pediatric dentistry principles and practice, 2nd edition,2011; pg:155-159, Elsevier publication. Ref: J.J.Murray, Fluorides in caries prevention, 3rd edition, 1999; pg:179-207,Butterworth-
  36. 36. 36
  37. 37. 37
  38. 38. Self Applied Topical Fluorides Self applied fluorides products are usually bought and dispended by the individual patient but at the recommendation of a dental professional. These fluoride products are of low concentration ranging from 200-1000 ppm or 0.2-1.0 mgF/ml. The self applied fluoride usually are:- 1. Fluoride Dentifrices 2. Fluoride gels 3. Fluoride rinse 38
  39. 39. 39 History The first clinical trial of a fluoride dentifrices was initiated by Bibby in 1942. The active agent was Sodium Fluoride which had been added to a conventional dentifrices containing Dicalcium phosphate as the abrasive. In 1945 Muhler et al reported a clinical trial that tested stannous fluoride in a paste with a new calcium pyrophosphate abrasive system. In 1955, the stannous fluoride dentrifice became the the first dentrifice recognized by FDA [Food and Drug Administration] as an effective tooth decay preventive product which was later accepted by ADA [American Dental Association].
  40. 40. It’s a mixture of abrasive or polishing agents, detergent, Binders, flavoring agent, and substances necessary to facilitate their preparation Therapeutic paste/dentifrices contains addition one or more Compounds intended for reduction of oral dental diseases. Exact formulation depends on Manufacturer but basic components remains same 40
  41. 41. Fluoride Dentifrices Fluoride Dentifrices plays a significant role in caries prevention since it requires active participation by the patient to have any effect. It has been demonstrated that the subject who brush twice a day or more with 1000 ppm or, 1500 ppm or, 2500 ppm fluoride dentifrices, have significantly reduced caries prevalence. 41
  42. 42. Fluoride Compounds in Dentifrice 1. Sodium Fluoride Dentifrice 2. Stannous Fluoride Dentifrice 3. Monofluorophosphate 4. Amine Fluoride Dentifrice 42
  43. 43. COSMETIC THERAPEUTIC THERAPEUTIC FUNCTIONS: 1) Physico -mechanical functions * Removes fermentable materials * Disrupts delicate balance of environmental conditions necessary for acid formation * Prevents formation of thicker and more cariogenic plaque 2) Chemical function: Based on anticaries mechanism of fluorides 43
  44. 44. 1) NaF or Na – monofluoroPhosphate Cariostatic effect 2) Sorbitol, Glycerin Humectants 3) Silica, DCP Abrasive 4) Na- Lauryl sulfate Surfactant 5) Water Vehicle 6) Hydrated Na Phosphate or Na- citrate Buffer 7) saccharin Sweetener 8) Spearmint oil, menthol, coriander Flavor eucalyptol, lemon 9) Titanium di oxide Opacifier 10) Xantham gum, Ca- carrageenan cardomer Binder 11) Aqueous solution Na-benzoate Stabilizer pH adjusted to approximately neutral 44
  45. 45. SODIUM FLUORIDE: Caries reduction was insignificant because of incompatibity of components of abrasive system Na-bicarbonate, Na meta phosphate, Na phosphate are used 1973 FDA approved NaF + Calcium pyrophosphate – 650ppmF 45
  46. 46. STANNOUS FLUORIDE: Mulher associates at Indiana university 1955 ---1ST To recognized by FDA Undergoes quick dissociation by hydrolysis and oxidation so needs to be stabilized , 1% stannous pyrophosphate is used Not compatible with CaHPo4 so replaced with Ca – pyrophosphate or insoluble Meta phosphate 46
  47. 47. DISADVANTAGES: •Staining of teeth, particularly in mouth with poor oral hygiene •Pigmentation of hypo plastic areas and margins of restoration •Metallic taste, due to low pH & high conc. of Sn2F •Astringent taste and difficult to mask with flavoring agents •Poorly accepted by children So now not available in market 47
  48. 48. MONO FLUOROPHOSPHATE: 1981, most widely used, with good results Doesn’t occur in nature so prepared synthetically in laboratory, OKALAHOMA CONTAINS: 1 Atom of phosphate 2 atom of 02 1 Atom of fluoride Exist as divalent ion 48
  49. 49. ADVANTAGES: No staining of teeth. Abrasive system includes * CHALK ( calcium carbonate) & * DICAL ( Di calcium phosphate) MECH OF ACTION : not absolutely established , thought that Monofluorophosphate anion has anticaries property of its own and exchange phosphate groups in apatite crystals Other Mech.. is by slow hydrolysis, releases F ions PO3F2 + H2O▬> H2PO4 + F- 49
  50. 50. Also thought that their might be release catalyst present in the saliva or dentifrices Other mech.. Is due to Fluoride ion released by degradation of the complex PO3F2 - ion in the oral environment by bacterial enzymes, Contains 800ppmF 50
  51. 51. AMINE FLUORIDE: 1st tested in Zurich, Switzerland Components: Amine fluoride 297 (OLAFLUR) contains 1000ppmF Amine fluoride 242(HETAFLUR) contains 250ppmF Both are stable and have long life 51
  52. 52. FEATURES: Insoluble meta phosphate * Is the abrasive & polishing agent * Less foaming action * Developed to improve the affinity of fluoride to enamel by the Organic Cationic molecule thus making more resistant to dental caries * Marketed in Europe and not in north America * Have shown Higher reductions in dental caries Other superior properties includes: Reduced enamel solubility Increased F uptake by enamel Antiglycolytic property 52
  53. 53. DISADVANTAGES/LIMITATIONS: Concern has been raised for * Taste characteristics and * Long range toxic effects RETENTION OF FLUORIDE DENTIFRICES: Continuous use at low conc. is beneficial as Fluoride conc. in oral fluid is elevated to bring its effect 53 Ref: J.J.Murray, Fluorides in caries prevention, 3rd edition, 1999; pg:179-207,Butterworth- Heinemann publication. Ref: Shobha tandon, Text book of Pediatric dentistry, 3rd edition,2009:pg.160-204, paras medical publishers
  54. 54. Fluoride Mouth Rinses • The use of fluoride mouth rinses was first described by Bibby et al in 1946. • In1979 the Council of Dental Therapeutics of American Dental Association acepted Neutral Sodium fluoride and Acidulated Phosphate Fluoride mouth rinses as effective caries preventive agents. Sodium Fluoride Mouth rinses • They are usually formulated at concentrations of either0.2%(900ppm F) for weekly use or 0.05%(225 ppm F) for daily use. • These rinses are intended to be used forcefully swishing 10ml of the liquid around mouth for 60 sec before expectoring it. 54
  55. 55. Advantages of Daily Rinsing • If the patient misses several sessions it is probably less critical than if he was on a weekly schedule. • Advantage of 0.05% Sodium Fluoride concentration is that it can be used to produce topical as well as systemic benefit when indicated for individual patient. 55 Ref: Marinho VCC, Higgins JP, Logan S, Sheiham A. Fluoride mouthrinses for preventing dental caries in children and adolescents.Cochrane Database Syst Rev.
  56. 56. Fluoride Gels Fluoride gels products includes neutral sodium fluoride and acidulated phosphate fluoride with a fluoride concentration of 5000 ppm and stannous fluoride with1000 ppm. The stannous fluorides products usually called gels, but actually are glycerin based solutions. • The gels are applied either by brushing or in trays. • Professionally, applied fluoride given twice a year while self applied fluoride can be once a day or more. • Patients brush their teeth for 1 min with a gel or if trays used several drops are placed in each tray and applied for 5 min. Patient should be informed to expectorate the gel and not to swallow. And should rinse mouth after the application so as to minimize the risk of swallowing gels by children and usually not recommended for children 6 years or younger. 56
  57. 57. Limitation of Fluoride Gels • They violate the principle of delivering low concentration of fluoride at regular intervals. High concentrations of fluorides deposit calcium fluoride on teeth rather than forming hydroxyapatite. • They present a toxicity hazard as relatively large amounts of fluorides are given in uncontrolled manner to people of varying intelligence. • They are tedious to use on daily basis over a long period of time. However they may be a value when prescribed professionally for use at home especially for high risk subjects. 57 Ref: Marinho VCC, Higgins JP, Logan S, Sheiham A. Systematic review of controlled trials on the effectiveness of fluoride gels for the prevention of dental caries in children. J Dent Educ.
  58. 58. • Intra oral fluoride releasing devices are those which release a predetermined quantity of fluoride inside the mouth over a long period when attached to the tooth surfaces. • It consist of a rate controlling membrane inside which a central depot of fluoride containing plastic copolymer matrix is embedded. • The release of fluoride ions into oral cavity regulated by the matrix core of the copolymer membrane. • These devices release 0.02-0.2ppm 0f fluoride for a period about 3-4months. 58 Recent advances in topical fluorides Slow release fluoride devices
  59. 59. • The copolymer membrane –USA • The glass bead-UK • Mixture of sodium fluoride and hydroxyapatite. 59 Types
  60. 60. 60 COWSAR et al 1976
  61. 61. 61 Original glass device attached to the buccal surface of the first upper right permanent molar Kidney-shaped device bonded to the upper first permanent molar tooth
  62. 62. 62 The latest version of the fluoride glass slow release device and plastic retention bracket Latest glass device and bracket attached to upper first permanent molar tooth
  63. 63. Hydroxyapatite-Eudragit rs100 Diffusion Controlled F System • This is the newest type of slow-release F device, which consists of a mixture of hydroxyapatite, NaF and Eudragit RS100; it contains 18 mg of NaF and is intended to release 0.15 mg F/day. • It was demonstrated that the use of this device is able to significantly increase salivary and urinary F concentrations for at least 1 month 63 Ref:Juliano Pelim Pessan et al, SLOW-RELEASE FLUORIDE DEVICES: A LITERATURE REVIEW; Journal of Applied Oral Science;2008;16(4):238-44
  64. 64. 64 Conclusion The role of fluoride in preventive dentistry is very important as it has a long history of effective decline in caries occurrence when used wisely either systemically or topically
  65. 65. 65 Reference 1. MS Muthu, Pediatric dentistry principles and practice, 2nd edition,2011; pg:155- 159, Elsevier publication. 2. J.J.Murray, Fluorides in caries prevention, 3rd edition, 1999; pg:179- 207,Butterworth-Heinemann publication. 3. Shobha tandon, Text book of Pediatric dentistry, 3rd edition,2009:pg.160-204, paras medical publishers 4. Juliano Pelim Pessan et al, SLOW-RELEASE FLUORIDE DEVICES: A LITERATURE REVIEW; Journal of Applied Oral Science;2008;16(4):238-44. 5. Marinho VCC, Higgins JP, Logan S, Sheiham A. Fluoride mouthrinses for
  66. 66. 66 6. Marinho VCC, Higgins JP, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries in children and adolescents.Cochrane Dababase Syst Rev. 2003;(1):CD00278. 7. Marinho VCC, Higgins JP, Logan S, Sheiham A. Systematic review of controlled trials on the effectiveness of fluoride gels for the prevention of dental caries in children. J Dent Educ. 2003;67(4) 8. B. Øgaard et al, A prospective, randomized clinical study on the effects of an amine fluoride/stannous fluoride toothpaste/mouthrinse on plaque, gingivitis and initial caries lesion development in orthodontic patients;the European journal of orthodontics,2005,8-12. 9. Cehreli ZC et al, Effect of 1.23 percent APF gel on fluoridereleasing restorative
  67. 67. THANK YOU 67