Prevention of Dental CariesFluoride UMB Dental School.ppt

course#andtitle:peds538,pediatricdentistrysession#andtopic:#9preventionofdentalcaries-fluorideduration:equivalentto1hourfaculty:dr.glennminahgeneralgoals:becomefamiliarwithvarioussofttissueabnormalitiesanddiseasesfoundinchildrenspecificobjectives:thestudentshouldbeableto:1.stategoalsoffluoridetherapy.2.understandhowoptimalbenefitsofnon-professionaladministrationoffluoridecanbeaccomplished.3.describerationaleandclinicalrecommendationsforprofessionallyappliedtopicalgels,fluoridevarnishandhomerinsesandgels.,sessionplan,specificobjectives:thestudentshouldbeableto:4.describeoptimaluseoffluoridedentifrice.5.knowwhenintensivefluoridetherapyisrequiredandwhattypeshouldbeadministered.methodology:weblectureassignment:mcdonaldre,averydr.dentistryforthechildandadolescent.mosby,st.louis,7thed.2000.chapter10,p.209evaluation:writtenexam.questionswillbefromthetextportionofthispresentation.,sessionplan,text,goalsoffluorideadministrationnon-professionalfluorideadministration1.systemic2.topicalgels3.rinses4.dentifricec.professionaladministration1.topical2.varnish,sessionoutline,goalsoffluoride(f)administration1)donotharmthepatient.2)preventdecayonintactdentalsurfaces.3)arrestactivedecay.4)remineralizedecalcifiedtoothsurfaces.,text,goalsoffluoride(f)administration,donoharm,preventdecayonintactdentalsurfaces,f,f,arrestactivedecay,remineralizedecalcifiedteeth,1.,2.,3.,4.,f,fluorosisortoxicity,donotharmthepatientprobabletoxicdose(ptd):theptdis5mgf/kgbodyweight.fora20kg5to6yearoldthiswouldbe100mgandfora10kg2yearold,50mg.fcontentofdentalproductsortreatmentsmayexceedthesevaluesforyoungchildren.forexample,ageltraycontaining5mlofapfcontains61.5mgf(fisabsorbedmorequicklywheninacidicform.),100mlof0.2or0.4%fmouthrinsecontains91or97mgfandatubeoffluoridatedtoothpastecontainsasmuchas230mgf.sub-lethaltoxicsymptomsaremanifestedquicklyafterthedoseandconsistsofvomiting,excessivesalivation,tearingandmucousdischarge,coldwetskinandconvulsionswithhigherdoses.countermeasureswhichshouldbeadministeredimmediatelyareemetics,1%calciumchloride,calciumgluconateormilk.(calciumreactswithfinthegitractandpreventsitsabsorption.themostseriousconsequencesofftoxicitystemfromreactionsofcationicelectrolyteswithsystemicf.),1.,text,potentialharm,5mgf/kgbodyweight,20kg6yearold,ptd=100mgf,10kg2yearoldptd=50mgf,230mgf/tubetoothpaste,act,91-97mgf/containeroffmouthrinse,symptoms:vomitingexcesssalivaryandmucousdischargecoldwetskinconvulsionathigherdose,probabletoxicdose:,topicalf,12,300ppmfph=3.5,61.5mgf/5ml,f,ca,f,ca,countermeasures:emetics1%calciumchloridecalciumgluconatemilk,divalentcationslikecacauseprecipitation,offandpreventabsorbtionintheintestine.,f,ca,f,ca,f,ca,f,ca,f,ca,f,ca,aserioussystemicconsequenceisbindingofftocawhichneededforheartfunction.,potentialharm,f,ca,f,ca,f,ca,f,ca,fluorosis:fluorosisoccurswhenteetharedeveloping.themostcriticalagesarefrom0to6years.after8years,riskoffluorosisisessentiallypast.duringthecriticalagesfintakeinexcessof0.1mg/kgbodyweight/daycanleadtofluorosis.thisisroughly1mg/dayfora1to2yearoldor1.5to2mgfora5yearold.rememberthatallformsoffintakecomprisethedailyconsumption.thisincludeswaterintake(upto1.5mg/day),foods(0.3to1.0mg)andespeciallysignificantinyoungchildren,swallowedtoothpaste.childrenunder2yearsswallow50%oftoothpasteduringtoothbrushingandat5years,25%,bothofwhichmayamountto1mgf/day.,donotharmthepatient,2.,text,1098765432,fluorosis,0.00.51.02.03.04.0,dmft,ppmfindrinkingwater,slight,severe,moderate,mild,finexcessof0.1mg/kgbodyweight=fluorosis,potentialharm,fluorosis,f,f,excessfaffectsmineralizationofdevelopingteeth,uptoage6isthecriticalageforfluorosis.afterage8,riskispast.,enamelprism,fluorosis,finexcessof0.1mg/kgbodyweight=fluorosis,maxiumsafedosefora5yearold=2mgf/day,maxiumsafedosefora2yearold=1mgf/day,1234mgf,supplements,toothpaste,fluids,food,dwbantingjada123:86,1991,dailyfintakeofa20kg4yearoldswithdifferentwaterf,0.5ppmwaterf,1.2ppmwaterf,fluorosis,childrenunder2yearsswallow50%oftoothpaste,5yearoldsswallow25%oftoothpaste,toothpaste=1mgf/gram(1000ppmf),1to3grams,“pea”sizeamount(0.5g)isrecommenredforfluorosissusceptiblechildren.,moderate,severe,mild,pitting,preventionofcariesdepositionoffluorapatite(fha)insoundtoothstructure:cariesprotectionresultsfromfhabeingmoreacidresistantthanpurehydroxyapatite(ha).depositiontakesplacewhenfreplaceshydroxylgroupsinha.thiscanoccurpre-orpost-eruptionatneutralph,orpost-eruptivelyatneutraloracidicph.atlowph,hadissolves,thenre-precipitatesasnewcrystalswhicharelargerandmoreacid-resistantduetohigherfhaandlowermagnesiumandcarbonatecontent.depositionoffhaisaccomplishedbothbysystemicintakeoffduringtoothdevelopment,andtopicalfadministrationaftereruption.professionaltopicalftreatmentswithconcentratedacidulatedphosphatefluoride(apf)gels(2.72%apfgelcontains12,300ppmf),isthemostefficientwaytoaccomplishthis,especiallywhenappliedtonewlyeruptedteeth(i.e.,age2forprimarymolars;age6to8forpermanentfirstmolarsandanteriorteeth;age11to14forpermanentpremolarsandsecondmolars).,1.,text,mechanismsoffprotection,f,f,f,f,f,f,f,f,f,f,f,f,saliva(s),plaque(p),tooth(t),deposition,increasefhalevelsmaximallyinintactdentalsurfaces.,theory:,topicalfisthebestmethodfordeposition.,f,f,f,f,f,f,f,f,ca,po4,po4,ca,neutralph,remineralization,depositionoff,f,f,fha,fha,fha,ha,ph5.0,ca,p,fhaismoreacidresistantthanha,h+,h+,co3,mg,h+,h+,mgandco3donotrepreci-pitate,f,f,f,f,thishasbetterfuptakeduetomoreporosity,depositionoff,bestfuptakeislatepre-eruptionandearlypost-eruption,f,f,f,f,f,f,f,f,f,f,f,f,matureenamel,surfacebuild-upoff,f,f,f,enamelfluid,youngenamel,maximalflevelsofinouter5microns,300020001000,ppmfluoride,outer2microns=6000ppmfluoride(max.uptake),fluorideuptakeishigherinadecalcifiedarea,f,5um,depositionoff,ca,ca,ca,ca,ca,f,f,f,asfluoridereactsstronglywithcalciumitdoesnotpenetratefarintothetooth.,3000ppmf,1500ppmf,f,depositionoff:,maxiumuptakecannotbeexceeded.(3000to4000ppmfinouter5um),thef-richsurfacecanbeabradedaway.,topicalfstudies,averilljada74:990,1987depaolajada87:155,1973downerbritdj141:242,1978horowitzjdentchild27:157,1980muhlerjdentchild27:1571980szwejdajpubhealthdent32:110,1972,nafapfapfsnf2snf2apf,cariesreduction,100%,newlyeruptedteeth,previouslyeruptedteeth,bioavailabilityoff:asecondtheoryofcariespreventionassertsthatfinthevicinityofcariousactivity(inenamelfluid)preventsdissolutionofhacrystals.althoughthismechanismrequiresonlylowlevelsoff(lessthan100ppmtoaslowas1ppm),fmustbepresentwhentheacidchallengetakesplaceandthereforemustbesuppliedcontinually.examplesoftopicalapplicationswhichensurebioavailabilityarefluoridateddrinkingwaterandfluoridateddentifrices.amajorsourceofbioavailablefisresidualfinplaqueandpellicle.finplaquemineralssuchascaf2orcalculusorinproteincomplexesisreleasedduringbacterialacidproduction.,preventionofcaries,2.,text,bioavailability,f,f,s,p,t,f,acid,sugar,providecontinuallowlevelofftoenamelfluid.thebenefitoccursatthetimeofdecalcification.,theory:,mechanismsoffprotection,waterfluoridationisanexampleofasource.,bioavailabilityoff,sugar,lowleveloff,f,s,h+,h+,h+,h+,f,f,f,f,s,s,saliva,plaqueandenamelfluid,plaque,intacthacrystals,h+,f,decalcifyinghacrystals,jarends.jdr69(si):601,1990,decalcificationofenamelcrystals:,f,stablefha,f,looselyboundoradsorbedf,f,f,f,f,f,f,f,f,f,f,f,f,acid,protectionfromdissolution,ffromplaquefluid,h+,h+,bioavailabilityoff,f,f,loosely-boundfwilleventuallybecomestablefha.,jarends.jdr69(si):601,1990,f,f,f,f,f,f,f,f,protectiononlywhereis,f,h+,h+,h+,h+,h+,bioavailabilityoff,f,ca,po4,po4,ca,fhawithno,incompleteprotection,f,h+,h+,h+,h+,h+,f,jarends.jdr69(si):601,1990,bioavailabilityoff,f,f,f,h+,h+,ms,effectonbacteria:,h+,h+,f,f,f,f,s,s,h+,f,h+,h+,thepresenceoffluorideatthetimeofglycolyticactivitywillalsoinhibitofplaqueacidogenesis.,sourcesofbioavailablef,1.saliva,0.080.02,ppmfinsalivaafterdrinking,135h,f,f,f,f,s,p,t,4.residualf,act,2.fluoridatedwater,3.homecareproducts,calciumfluoride,f,f,f,f,f,topicalf,caf2precipitatesinplaqueduringtopicalftreatment,fha,nofha,nofha,f,f,10ppmfaddedtodrinkingwater,lesions(mean),ms,8,30,5,deposition,bioavailability,larsonrh.cariesres10:321,1976,sugar,bioavailabilityversusdepositionoff,rodentstudies:,plus,calciumloss,fppminsolution,ph,54.54,bioavailabilityoff,ph5.0,ha,calcium,phosphate,jmtencate.jdr69(si):614,1990,researchevidence:,f,f,addf:,summaryofpreventivefproceduresandrecommendations:theolderviewofcariespreventionwasthatfhadepositioninnon-cariousdentalsurfacesshouldbemaximizedbysystemicfadministrationduringtoothdevelopment,andpost-eruptivelybytopicalftreatments.itwasbelievedthatincreasedfhaprovidedincreasedprotectionagainstcaries.althoughimplementationofhighfhadepositionhasprovedbeneficial,itdoesnotaffordasmuchprotectionasbioavailablef.moreover,thehighdosesoffrequired,systemicallyortopically(whichoftenbecomessystemicintake)arepartlyresponsiblefortheincreasingincidenceoffluorosis.currentclinicalrecommendationsforpreventivefmeasuresare1)todeterminetotalfintakeperdayfromallsourcesinordertoassessoverorunderfexposure,2)determinecariesrisk,3)institutearegimencommensuratewithindividualcariesriskstatuswhichemphasizesbioavailabilityofpost-eruptivetopicalf(e.g.regularuseoffdentifriceandotherhomeproductsifindicated),4)administerprofessionaltopicalftreatments,thetimingofwhichshouldalsobegaugedtocariesrisk(thismaynotbeneededinlowriskindividuals)and5)administersystemictopicalfifindicated.(thelatteriscurrentlyunderreview.presentacademyofpediatricdentistryrecommendationsarepresentedbelow.,preventionofcaries,3.,text,fluoridesupplements,findrinkingwater,f,academyofpediatricdentistrycurrentrecommendations,text,determinefintakedeterminecariesriskdevisepersonalizedplanbasedonrisklevel.stressbioavailabilityoff.monitorfintakeofyoungpatientsinanefforttopreventfluorosis.,summaryofpreventivef,mechanisms:cariesarrestmeansthatactivelesionsbecomeinactive.thisisaccomplishedclinicallybyadjustingseveralaspectsoftheoralenvironmentsuchasbyreducingintakeofcariogenicdietarysubstrates,reducingplaquevolume,stimulatingsalivaryflow,increasingplaquelevelsofca+andpo4-,promotingfavorablemicrobialshifts(i.e.reducingacidogenicandaciduricbacteriaandencouragingproliferationofalkalinogenicbacteria)andincreasingbioavailablef.bioavailablefarrestscariesby1)inhibitingdecalcificationbycoatingenamelcrystals,intactorpartiallydecalcified,withlooselyboundfandtherebypreventingfurtherdissolutionofcrystals,2)catalyzingreprecipitationofdissolvedenamelcrystalsand3)inhibitingacidogenesisandaciduricityofcariogenicbacteria.arrestedincipientlesionsappeareitherasdarkstainedfissureswhichresistexplorerpenetration(activeprobingofstainedfissureswithsharpexplorersisnotrecommendedasitmayinducecavitation.),stainedcervicalincipientlesionsorshinyenamelsurfacescoveringwhitespotlesions.arrestedcariousdentinorrootsurfacesexhibitdarkstainingwithhardandoftenshinysurfaces.,arrestofactivedecay,1.,text,clinicalrecommendations:1)determinetotalfexposure,2)determinecariesriskandtailorclinicalmeasurestoriskstatus,3)institutedietaryandplaquecontrolprocedures,4)controlcariogenicbacteria,ifindicatedand5)havepatientmaintaincontinuallowlevelfexposuretodecalcifiedsites.,arrestofactivedecay,2.,text,arrestofactivedecay,incipiencies,rootcaries,indications:,casesdifficulttotreat,i.e.,certainecccases,interproximalcariesinlowormoderateriskpatients.,arrestofactivedecay,po4,po4,ca,ca,ms,lb,1.,2.,3.,increasetopicalcaandpo4intake.,encouragebeneficialmicrobialshifts.,4.,plaquecontrol,procedure:,dietcontrol,arrestofactivedecay,5.,increasebioavailablef,f,arrestedcariesturnsdark,isfirmandoftenglossy.,f,f,s,p,t,f,acid,sugar,indicationsandmechanisms:thisclinicalmanipulationisintendedtorestorelostmineralfromincipientlesionsandreverseappearanceofwhitespotlesions.(reviewnotesonremineralizationfromcariologycourse.)generally,remineralizationproceduresareindicatedfornon-cavitatedcariousdentalsurfaces(enamelorcemental)inindividualswhoarenotinthehighorseverecariesriskcategory.thesearethesameascariesarrestprocedureswiththeexceptionsthat1)onlynon-cavitatedlesionsareindicatedand2)f,ca+andpo4-exposurearemonitoredmorecarefully.recommendations:followrecommendationsforcariesarrest,above,alongwithapplicationofrecalcifyingsolutions(e.g.,enamelon,whichcontainsf)and/orftoaffectedsites.recalcificationofwhitespotlesionsonanteriorsmoothsurfacesrequirelowconcentrationsoftopicalf(100to250ppm)sincehigheronesdonotpenetrateenamelaseffectivelyandmaycausepreservationofthewhitespotbyreactingonlywiththeouterenamellayer.,remineralizationofdecalcifiedsurfaces,1.,2.,text,remineralization,sameproceduresasforarrestingcaries.exceptionsoradditions:onlynon-cavitatedlesionscanberemineralized.notrecommendedforsevereofhighcariesriskpatients.ca,po4andfareadministeredmoreprecisely.,whitespot,before,after,clinicalfluorideproductstheseinclude1)professionaltopicalf,2)fvarnishes3)homerinsesandgels,4)dentifrices,5)supplementsand6)otheragentssuchassustainedreleasedevices.adetailedsummaryispresentedintablesattheendofthepresentation.professionaltopicalfproductsanddescription:theprincipalproductsare2.72%acidulatedphosphatefluoride(apf)geland2%neutralsodiumfluoridegel.stannousfluoride(snf2)isnolongerusedroutinelyforprofessionaltopicalapplications.apf,ph3.5,contains12,300ppmfandisformulatedfromsodiumfluorideand0.1mphosphoricacid.thisgelisintendedtodissolvesurfaceenamelwhichwillre-precipitatewithhigherfhacontent.neutralnafgels(9200ppmf)areindicatedwhencompositerestorationsarepresentsinceapfwilletchglassfillerparticlesofthecomposites.thisproductwillnotproducecomparablesurfacefhadeposition,butaccordingtoresearchevidence,achievesthesamecariesprotectionasapf.,1.,text,mechanismsofcariesprotection:theearliertheoriescenteredonincreasingdepositionoffha.nowitisbelievedthatbenefitsarederivedmainlyfromresidualfbuildupinplaqueandotheroralsurfacesorbiofilmsintheformofcaf2,othermineralsandprotein-boundf.thesereservoirsreleasefduringacidificationwhichactsasbioavailablef.(note:sealantsshouldnotbeplacedimmediatelyafterprofessionaltopicalftreatmentduetoinstabilityofthecaf2layerwhichprecipitatesonthetoothsurface.sealantsmaybeplacedafter24hours.)whenappliedevery6monthstochildreninfdeficientregions,alltypesofprofessionaltopicalfagentsachievedroughly30%cariesreductionversusshamtreatedcontrols.,professionaltopicalf,2.,text,professionaltopicalf,2.72%acidulatedphosphatef(apf),1.23%freef,12,300ppmf.2.0%neutralsodiumf,0.9%freef,9200ppmf.8%stannousf(nolongerusedroutinely).,f,0.1mh3op4,po4,ca,ca,f,dissolutionofsurfacelayer,reprecipitationoffluorapatite,1.,2.,3.,apf,ca,topicalfluorides:,h+,h+,precipitationofcalciumfluorideonenamelsurface,ca,po4,professionaltopicalf,caf2,donotsealteethimmediatelyafteratopicalftreatmentduetocaf2.,apfwilletchglassinfilledresins.useneutralfgel.,t,h+,plaqueacidswillreleasebioavailableffromcaf2.,f,f,ca,ca,resin,etchedglass,h+,h+,recommendations:1)determinetotalfexposure.2)determinecariesrisk.3)administerasindicatedby#1and2.(timingmaybemonthly,1,2,3or4timesayearorevencontra-indicated.)4)applyfor4minutes.5)addnomorethan2mltothegeltrayandmakeeveryefforttokeeppatientfromswallowingthegel.6)havepatientrefrainfromrinsing,eatingordrinkingfor30minutesafterapplication.,professionaltopicalf,3.,text,professionaltopicalf,recommendations:determinetotalfexposure.administer0,1,2,3,4timesayearasindicatedbycariesrisklevel.applyfor4minutes.useonly2mlofgelintrays,keeppatientsfromswallowingthegel.norinsing,drinkingoreatingfor30min.afterwards.,caries,twotopicalftreatmentsperyearreducedcariesby30%versusplacebogel.,topical,placebo,fluoridevarnishproductsanduse:applicationoffvarnishisessentiallyaprofessionaltopicalftreatment.durafloriscurrentlytheonlyconcentratedfvarnishsoldintheus(calledduraphatineurope)andcontains5%naf.flor-protectorcontains0.7%silanefandisusedasacavityvarnish.fortopicaltreatmentsduraflorshouldbeappliedto,andallowedtodryonallcottonroll-isolatedteeth.afterwardsthepatientshouldnoteatfor2hours.althoughthecariesbenefitsaresimilartotopicalfgels,lesstotalfisreleasedintotheoralcavityduringtreatment(i.e.,only3to6mg)thanfromgels.indications:applyto:1)teethduringoperatingroomprocedures,2)enamelincipiencies,3)exposedroots,4)marginsofrestorations,5)teethatriskwhichcannotbesealedsuchaseruptingmolarsorpremolarsor6)cariousanteriorteethinveryyoungchildren.,1.,2.,text,fluoridevarnish,duraflor5%naf,26,000ppmf,3-6mgfperdose.,fluor-protector0.7%silanef.usedasacavityvarnish,fluoridevarnish,cavityshield(omni)5%naf,0.40mlformixeddentition,0.25mlforprimarydentition,fluoridevarnish,whitespotsorotherincipiencies,allteethintheor,exposedrootsandrootcaries,marginsofrestorations,eruptingteeth,cariousanteriorteethinyoungchildren,indications:,2.,3.,4.,5.,1.,6.,homerinsesproductsanduse:theseareavailableasov