SYSTEMIC FLUORIDES

Presented by: Shalakha bhardwaj Final year

CONTENT
INTRODUCTION HISTORICAL BACKGROUND METABOLISM OF FLUORIDE FLUORIDE IN TEETH THEORIES OF MODES OF ACTIONS OF FLUORIDE FLUORIDE THERAPY  Topical fluorides  Systemic fluorides

COMMUNITY WATER FLUORIDATION The saturator system The dry feeder system The solution feeder system Venturi fluoridator system Saturation suspension cone

MILK FLUORIDATION FLUORIDE TABLETS, DROP, LOZENGES TOXICITY OF FLUORIDE  Acute Fluoride Toxicity  Chronic poisoning

CONCLUSION REFERENCES

 Dental caries is a major dental disease affecting a large population of the inhabitants of the world. The cariostatic efficiency of fluoride has been convincingly demonstrated and the recent decline in caries prevalence is primarily attributed to the increased use of fluoride agents.

What is fluoride?
The word fluorine is derived from a Latin word fluoro meaning to flow. Fluorine is a member of the halogen family with a relative atomic weight of 19 and an atomic number of 9. Freely available in nature, not in its elemental state. Dietary constituents: fish, tea Non-dietary: toothpaste, mouth rinses etc. Fluorspar is the principle fluoride containing mineral and the theoretical fluoride content is 49%. Fluoride helps to prevent tooth decay, strengthen tooth enamel, and reduce the harmful effects of plaque.

HISTORICAL BACKGROUND
1892-The use of fluorides for dental purposes began in the nineteenth century -Sir James Crichton Browne emphasized the importance of fluoride 1901-Dr. Frederick McKay highlighted the impact of fluoride in water. 1916-McKay and Dr. G.V. Black and mapped the geographical area of the stain 87.5% children in native area with the stain: 9 out of 10 children 1939-McKay and Trendly Dean concluded that the incidence of mottled enamel was halted by reducing the level of fluoride in water to1ppm.

 1902-fluoridens, Copenhagen, Denmark In the UK : mix with salt 1tsp fluoridensto 2 table sp salt no effort from user

METABOLISM OF FLUORIDE
DIET

DIGESIVE TRACT
DIGESTIV E JUICE

FAECES

PLACENTA & FETUS

MILK

CIRCULATING PLASMA FLUORIDE

SALIVA

URINE SOFT TISSUE SWEAT BONE

TEETH

FLUORIDE IN TEETH
Fluoride: identified as one of the elements present in dental hard tissues. Fluoride ion is calcium seeking Apatite: the principal mineral of skeletal tissues. Crystallized form of calcium phosphate : Ca10(PO4)6(X)2. If:X is OH hydroxyl apatite X is F Fluorapatite: more regular

Basic structure of apatite crystal

LAYER OF ABSORBED WATER,NORMALLY SURROUND THE CRYSAL

HPO2-4

F-

HYDROXY APATITE NUCLEUS Ca10 (PO4)6.(OH)2

PO3-4 Ca2+ HCO-3 Mg2+

F-

THEORIES OF MODES OF ACTIONS OF FLUORIDE

1. Fluoride increased resistance to acid attack: Fluoride were incorporated into tooth structure increased resistance to acid attack. Fluorapatite forms more compact and regular crystals than hydroxyapatite, present less surface area for the action of acids 2. Fluoride influence the solubility rate : Calcium and fluoride ions released from the apatite during initial dissolution forms Calcium Fluoride (CaF2) on the surface of the Fluorapatite hence reducing it solubility.

3. Fluoride catalyses stable apatite phase : Fluoride ions replace carbonate ions in the apatite structure. Apatite crystals with low carbonate contents are more stable and are less soluble compared to those with high carbonate ion content.

4. Fluoride favors remineralization of early carious lesions: Plaque fluid contain fluoride. Enhance re-mineralization of enamel by facilitating the re-precipitation of calcium and phosphate ions into the enamel Fluorapatite.

Enamel

Plaque Demineralization

Saliva

Remineralization Ph Bacterial Acids (H+) Ca2+ HPO4 2

-

pH

Salivary Reservoir
(Ca2+, HPO42-, F-)

Plaque Reservoir (Ca2+, HPO42-, F-)

5.Effect on acid production: Fluoride inhibits enolase and ATP-ase activity (Embden-Meyerhof pathway in bacterial metabolism) in oral streptococci hence reduces acid production 6. Fluoride affects the morphology of the teeth making them more self-cleansing : Fluoride administered during tooth formation may result in shallower and wider fissures ,more rounded cusps thus reducing the number and size of sites where food and plaque could accumulate.

FLUORIDE AFFECTING THE MORPHOLOGY OF THE TEETH

Fluoride Therapy
Topical Systemic fluorides

Topical
Topical fluorides are placed directly on the teeth. some preparations provide a high concentration of fluoride over a short period of time. Other preparation such as dentifiers provide a continuous low concentration of fluoride to the teeth Topical fluorides include toothpastes, mouth rinses and professionally applied fluoride therapies. They can be either professionally done (in the dental office) or self applied (at home)

DENTIFIERS

SELF APPLIED (FLUORIDE GELS)

MOUTH RINSE

Systemic fluorides
Systemic fluorides are those that are ingested into the body and become incorporated into forming tooth structures. Systemic fluorides when ingested during tooth development are deposited to some extent throughout the tooth surface. fluoride present in saliva, which continually bathes the teeth, provides a constant source that is also incorporated into plaque and facilitates remineralization

The different types of systemic fluorides are: Community water fluoridation Daily fluoride supplements (Rx drops or tablets) Bottled water School water fluoridation Salt (not in US) Certain foods

COMMUNITY WATER FLUORIDATION

Fluoridation is the controlled adjustment of a fluoride compound to a public water supply in order to bring the fluoride concentration up to a level which effectively prevents caries. The optimum water fluoride concentration will normally be within the range of 0.5ppm 1.0ppm. Marked reduction of caries when fluoride water levels were at 1-2 ppm. Mottling of enamel started to be noticeable at 1.5 ppm.

Optimal fluoride concentration & climatic conditions: In temperate regions 1ppm.

Temp in degree Celsius Recommended ppm

18.3

1.1 1.3

18.9 -26.6

0.8 1.0

26.7

0.5 -0.7

Levels of fluoride used: Irrigation water 10 mg/l Aquatic life - 1.5 mg/l Industrial water supply 1.0 mg/l Before fluoridation, the following factors should be taken into account: Daily fluoride concentration of the water supply Baseline dental caries prevalence Index of enamel fluorosis and post fluoridation data of the same population

Sample collection for fluoride estimation: 500 ml of water is taken in a clean dry polythene container 2cc of 6 N HCl is added to inhibit growth/enzymatic change Store at 4 degree Celsius for analysis

Fluoride concentration can be estimated by:

Fluoride electrode coupled with standard pH meter: Universally acceptable, quick, simple, economic. pH meter is used in conjunction with a fluoride electrode & electrode potentials of the sample is calculated. Two pH meters are used-Orion901 & Orion 407 Ion meter is one that has inbuilt facility of converting the electrode potentials into concentration of fluoride in ppm The unknown concentration of fluoride is calculated by Typical calibration curve Applying electrode potential difference by equation Direct ppm reading.

Scot- Sanchis method : Based on reaction between fluoride and red zirconium alizarine lake. Fluoride forms a colorless complex ion-ZrF6 & liberates free alizarine sulphuric acid(yellow) As the amount of fluoride increases, the color varies from yellow to red. Fluoride level is determined by comparing the color with that of standards. No longer used.

Choice of equipment & chemical for water fluoridation:

Should be adapted to local conditions & needs of water network Must be efficacious, safe &precise in all climatic conditions Of standard type-maintenance easily provided. Choice of distributor should be based on the quantity & type of fluoride bearing product used Equipment should have well defined precision limits i.e. not more than 5 percent error in the Whole system whatever variation in quantity of water

 It should have a safety mechanism that automatically stops the addition of fluoride if the flow through the treatment plant is suddenly reduced Adjustment must be easy and rapid Apparatus should operate between 20 & 80 percent of total capacity In each fluoridation system, an ant siphon mechanism should be installed in pipes distribute fluoride solution into water, to avoid a concentrated solution of fluoride entering the system.

Fluoride compounds used in water fluoridation:

A. Fluorspar : mineral containing varying amounts of CaF2 B. Sodium fluoride : white, odorless, free flowing material available either as a powder or a mixture of various crystals expensive source of fluorides C. Silicofluoride : obtained as by product of purification of phosphate rocks D. Sodium silicofluoride: Most popular Low cost, cheapest form of fluoride Solutions are corrosive E. Hydrofluosilic acid : More expensive F. Ammonium silicofluoride : Produced by neutralising fluosilic acid with either aqueous ammonia or ammonia in gaseous form

Types of equipment for water fluoridation

The saturator system Principle : 4 percent solution of sodium fluoride is produced and injected at the desired concentration at the water distribution source with the aid of a pump Factors limiting the utilization : a high hard water level ( total hardness of over 75 mg/l) Recommendation : for small town with a total requirement of less than 3.8 million liters/ day

THE SATURATOR SYSTEM

The dry feeder system Principle : Sodium fluoride or silicofluoride in the form of powder is introduced into a dissolving basin with the aid of an automatic mechanism Factor limiting utilization: the need for care of handling of fluoride, obstruction of pipes, compacting of fluoride while stacked in humid atmosphere. Recommendation : in medium sized town- 3.8 -19 million l/day

The dry feeder system

3. The solution feeder system Principle: Volumetric pump permitting the addition of a given quantity of hydrofluosilic acid in proportion to amounts of water treated. Factors limiting utilization: resistant to attack by hydrofluosilic acid Recommendation :in medium and large towns Capacity more than 7.6 million/ day

The solution feeder system

Venturi fluoridator system:

Non electrical system developed by J N Leo Activated by the flow of water in the main water line and there no possibility of accidental overdosing by surges of fluoride when the main water pump stops The tank containing fluoride is made of clear acrylic thermoplastic(plexiglass) Advantages Simple to install Cost is only three-fourths even though same amount of chemicals are used Non electrical system Operator can make visual inspection of the level of chemicals

Saturation suspension cone Consists of an upside down cone charged with a bag of sodium silicofluoride through which a constant flow of water percolates The solution is collected at the top by a horizontal perforated plastic pipe which forms the outlet A cone 0.91m high and 0.91m in diameter, mounted upside down An elevated constant head tank(7-10m head) for feeding water to prepare a constant volume of solution A 2cm diameter connecting pipe from the constant head tank to the lower end of the cone

 A surface collector consisting of a horizontal perforated 2.5 cm diameter pipe collects the solution and discharges into a wide mouth funnel which is connected to the pipe The cone must be built of a corrosion resistant material such as stainless steel or fiber glass The cone is charged with a 45 kg bag of sodium silicofluoride The quantity of salt in the cone be never less than 25 kg

Technical considerations of water fluoridation:

1.Maintenance and control: The fluoridation system must be carefully maintained to ensure maximum efficiency Uniform concentration of fluoride ions should be maintained 2.Control at the water treatment plans: Any difference in the fluoride content of water should be checked The analysis should be done several times a day 3.Control of the quality of analysis The responding authority should send three blind samples each month for analysis at the water treatment plant which should be returned to the responsible authority within 48 hrs

 If any difference known, technical assistance should be sought 4.Control of the quality of water in the network Personnel from the water plant should take samples from the network once a week and send them for analysis Fluctuations in concentrations should be noted 5.Control of the quality of fluorides used Each time the delivery of fluorides is received, the samples should be analyzed to verify whether they correspond to the criteria of quality approved by the responsible authorities.

Monitoring of fluoridated water

Hourly check of the weight of the chemical fed into the hopper. Calorimetric chemical testing through addition of zirconium alizarin reagent and the results to be compared with the standards Less frequent calorimetric testing is advisable(at weekly intervals) upon water at various parts of the distribution system Continuous electronic measuring and controlling of fluoride concentration in water

Practical aspects of water fluoridation

There is municipal water supply reaching a reasonable number of homes Suitable equipment is available in a treatment plant or pumping station A supply of a suitable fluoride chemical is assured There are workers in the water treatment plant able to maintain the system There is sufficient money available for the initial installation and running costs But with increase in dental caries, it is urged that water fluoridation be considered soon as safe drinking water

Limitations of community water fluoridation

50 percent of population in rural areas. Centralized water distribution system is lacking

Milk fluoridation
It is the addition of a measured quantity of fluoride too bottled or packaged milk to be drunk by children. It was introduced by Ziegler a pediatrician who started the first project with fluoridated milk in Swiss in 1953.

Rationale of milk fluoridation:

The nutritional value of milk has been well documented. Milk is often available to children through school and nutritional program and the use of such distribution system can provide a convenient and cost-efficient method. Virtually all form of milk products is suitable for fluoridation and the process is relatively simple. Milk fluoridation can be targeted to those communities in greatest need. Research has demonstrated the effectiveness of fluoridated milk in preventing dental disease The bioavailability of fluoride is not reduced by milk Fluoridated milk keeps a permanently low level of ionized fluoride within the oral cavity

 Fluoridated milk may be produced in number of different forms: Liquid(pasteurized and sterilized) Powder Sodium fluoride is by far most commonly used agent for large scale production of fluoridated milk. Other agents are calcium fluoride, disodium monofluorophosphate and disodium silicon fluoride To calculate the fluoride concentration it is necessary to considered the volume of fluoridated milk consumed daily by each child If 200-250 ml of milk consumed daily and the fluoride requirement is 1 mg per day the concentration of fluoride in milk is set at 5ppm. Sodium fluoride is generally added to milk in the form of concentrated aqueous solution using a fixed volume ration to obtain the required product usually 1l of solution in 1000l of milk. It is best that the solution if sodium fluoride is sterilized at the time of manufacture an d maintain sterile

FLUORIDE TABLETS, DROP, LOZENGES

Without fluoride in drinking water, a sensible alternative is to give fluoride tablets. 2.2 mg NaF contains 1.0 mg fluoride ion. Table shows F ion in relation to age & fluoridation level
Age Water Fluoridation Concentration (ppm) < 0.303 0.6> 0.6<

0.6< 6 mo 6 mo 3 yrs

0.25 mg 0.50 mg

0.25 mg

3-6 yrs

6-16 yrs1.0

1.0 mg

0.5 mg

Indications:
In areas where no central water supplies ,where the fluoride concentration of well water is low and where parental motivation is very high As an interim measure in these community with a central water system that have not yet implanted community water fluoridation In families where there is a high degree of mobility involving frequent change in the place of work and residence

TOXICITY OF FLUORIDE
Acute Fluoride Toxicity
Results from the accidental ingestion of excessive amounts of fluoride Certainly lethal dose (CLD): Adult = 5-10 g NaF taken at one time or = 32-64 mg F / Kg body weight Children = 2.5 g of NaF -Safety Tolerated Dose (1/4 CLD) Adult = 1.25-2.5 g NaF or= 8-16 mg F / Kg body weight Begin within 30 minutes of ingestion

Clinical features GIT: Fluoride in the stomach is acted by hydrochloric acid to form hydrofluoric acid that is irritable to stomach lining, causing:-Nausea, vomiting& diarrhea Abdominal pain: Increased salivation & thirst CVS: Hyperreflexia, convulsions & paresthesia CVS: Cardiac Failure Respiratory: Paralysis

Emergency Treatment Induce vomiting Administration of fluoride binding liquid if patients do not vomit: Milk, Lime Water gastric lavage Support respiratory and circulation Call emergency services and transport to hospital

Chronic poisoning Applies to long-term ingestion of fluoride in amounts that exceed the approved therapeutic levels. Continued ingestion of high doses of naturally occurring fluoride will be reflected in changes in the teeth. Fluorosis of enamel is caused by defective matrix formation (hypoplasia) probably due to direct effect of fluoride on ameloblast metabolism. Lesion is usually confined to outer third of the enamel giving opaque white flecks appearance in mild fluorosis

Clinical features of dental fluorosis: Lusterless, opaque white patch in the enamel which may become mottled, striated or putted Mottled area may become stained yellow or brown Hypoplastic area may also be present to such an extent in severe cases that normal tooth form is lost

NORMAL

MODERATE FLUOROSIS

SEVERE FLUOROSIS

Skeletal fluorosis: Occurs from the ingestion of very high amounts of fluoride for a long period of time. Its symptoms are varied in nature: Severe pain in the back bones, joint and hips, stiffness in the joint and spine Outward bending of legs and hands is seen in advance stages and these part lose their shape and contour Pregnant lactating mothers and children are most vulnerable group It may lead to blocking and calcification of blood vessels causing cardiac problems In it severe form, crippling fluorosis the spine become rigid and joint stiffen

References
Essentials of preventive and communities dentistry-Soben Peter Rahimah Abdul Kadir.(1991) Harrison.O., Gracis-Godoy F.(1999). Primary Preventive Dentistry Gluck G.M., Morgansteinw.M.(1998). Jongs Community Dental Health Caldwell R.C.,Stallardr.E.(1977). A Textbook of Preventive Dentistry J.J. Murray, A.J. Rugg-Gunn, G.N. Jenkins (1991). Fluorides I Caries Prevention