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Fluoride: Background and Foundation

Introduction

The decline of dental caries in the United States can logically be attributed to the widespread use of fluoride. Moreover, fluoride is safe when used appropriately, and may be of most benefit to those at highest risk of dental decay. The Centers for Disease Control and Prevention (CDC) recently issued new recommendations for fluoride use--a long-awaited document that highlights the need for fluoride throughout the life span (Table 1).1 Although some controversy surrounds fluoride application, the preponderance of evidence shows that fluoride usage can be a boon to oral health. This monograph--a special addition to The Journal of Practical Hygiene--addresses the use of fluoride. Included is basic information on mechanism of action, strategies for individuals of all ages, and case studies to demonstrate practical usage. As each clinician must determine the most relevant treatment plans for individual patients, the information contained in this publication is intended to aid in those decisions. The effective use of a treatment can hopefully reduce disease and advance one's quality of life--the ultimate goals of all oral hygiene therapies.

 

Table 1 – Synopsis of CDC Fluoride Recommendations

  • Continue and expand fluoridation of community drinking water in the proper amounts (0.7 – 1.2 ppm). All persons should know whether or not their primary source of drinking water has an optimal level of fluoride. Check with the municipal water supply, or use a fluoride test kit.
  • Daily and frequent exposure to fluoride will best reduce the risk of tooth decay for all age groups. Brush at least twice daily with a fluoridated toothpaste.
  • Use supplements and high-concentration fluoride products judiciously. Fluoride supplements for children may best be prescribed for those who are at high risk for decay and who live in communities that have a low fluoride concentration in their drinking water. High-concentration fluoride products, such as professionally applied gels, foams, and varnishes also may best benefit those who are at high risk of decay.
  • Parents should monitor the fluoride intake of children younger than 6 years old. Overuse of fluoride during this period can result in enamel fluorosis. Children under age 6 should only use a pea-sized (.25g) amount of fluoride toothpaste. Parents should consult their physician or oral health-care practitioner concerning the use of fluoride under age 2.
  • Label bottled water with the fluoride concentration. Increased labeling of bottled waters on a voluntary basis will allow consumers to make informed decisions on their fluoride intake.
  • Collaborative efforts by professional organizations, public agencies, and suppliers of oral health care products are needed to encourage behavior change to facilitate improved, coordinated use of fluoride products and regimens.
  • Additional research is needed to learn more about fluoride use and evaluate the current cost-effectiveness of fluoride modalities (eg, toothpastes, mouthrinses, supplements, gels, and varnishes).

 

Fluoride's Mechanism of Action

Fluoride is made available to the tooth surface by either systemic (eg, drinking water, supplements, food) or topical (eg, dentifrices, mouth rinses, professional treatments) application. When taken systemically, fluoride is rapidly absorbed into the bloodstream. It is then distributed to and stored in all tissues and organs, especially calcified areas. The amount of fluoride that is stored depends on the quantity of intake, the time of exposure, and the age and stage of development of the individual.2 Fluoride is deposited in enamel via systemic intake during the mineralization and maturation stages of tooth development, prior to eruption. If too much fluoride is ingested during tooth development, hypomineralization occurs, also known as fluorosis. Post-eruption, the teeth continue to receive fluoride from systemic as well as topical sources. Fluoride is deposited in enamel, cemental, and dentinal surfaces.

 

Fluoride acts to prevent carious lesions in several ways. It prevents demineralization, enhances remineralization, alters the action of plaque bacteria, aids in post-eruptive maturation of enamel, and reduces enamel solubility.3 A continuous exchange of fluoride to the tooth surface occurs. This exchange depends on the pH of the tooth surface and the amount of fluoride readily available. Daily and frequent exposure to small amounts of fluoride reduces the risk of caries for all age groups.1 Therefore, fluoridated drinking water and brushing at least twice a day with fluoridated toothpaste is appropriate for all individuals. Supplements and high concentration fluoride products (eg, professionally applied gels, foams and varnishes) are recommended for those who are at high risk for caries (Table 2).4 Rinsing immediately after a professional fluoride application has been shown to lessen its efficacy,5 therefore, the individual should not rinse, drink, eat brush, or floss for thirty minutes after application of a gel or foam fluoride, or two hours after varnish application.

 

Disease Process

An understanding of the disease process is important for the clinician to understand the importance of fluoride usage. Fluoride can prevent or intervene in several circumstances: caries, periodontal diseases, and dentinal hypersensitivity.

 

Caries

Dental caries is an infectious, multifactorial disease. In order for caries to occur, the tooth is susceptible to the disease, carbohydrate is available, and cariogenic bacteria are present.2 While numerous types of acid-forming bacteria are in the mouth, Streptococcus mutans is most often implicated in dental caries. Bacterial by-products (acids) attack the tooth surfaces (enamel or cementum) and erode them. If not treated, bacteria can penetrate deeper into the tooth and attack the dentin and pulp. Fluoride inhibits demineralization and enhances the remineralization process by creating a crystalline structure on the tooth surface that is more acid-resistant. Fluoride also affects cariogenic bacteria by inhibiting their metabolism of carbohydrates, thus slowing acid production.

 

Periodontal Diseases

Like dental caries, periodontal diseases are multifactorial: a susceptible host and bacteria are needed. In addition, other factors such as genetics, smoking, and systemic diseases can predispose one to a periodontal condition.6 While treatment of the periodontal diseases focuses on the elimination or control of all risk factors, much attention has traditionally been given to the control of suspected periodontal pathogens. Though, removal of plaque and bacteria by oral hygiene measures is key, antimicrobial treatment to target bacteria also plays a role in the control of periodontal conditions. Certain antimicrobials (eg, chlorhexidine gluconate, essential oils, and triclosan) have proven efficacy in the control of suspected pathogens,7 however, the role of fluoride remains unclear. Early studies have shown the adjunctive use of fluoride has potential in the treatment of periodontitis.8,9 Fluoride could interfere with the production of destructive enzymes by certain periodontopathogens.10 Most important, exposed root surfaces after periodontal treatment can be more susceptible to decay.11 In this regard, the use of fluoride could prevent carious lesions.

 

Dentinal Hypersensitivity

Exposure of dentin can cause varying degrees of discomfort. The dentin is comprised of calcified tissue and dentinal tubules. When the dentinal tubules are exposed and open, more sensitivity occurs. By covering or closing the tubules, blockage of the transmission of pain stimuli occurs. Sodium or stannous fluoride in solution, gel, or varnish forms seals the dentinal tubules, thus alleviating pain.

 

Caries Prevention Strategies

The use of fluoride to prevent dental caries is part of an overall oral health plan that includes additional approaches. Since fluoride can help make teeth less susceptible to decay, the other factors that contribute to carious lesions (eg, cariogenic bacteria and available carbohydrate) must be addressed for optimum results. Cariogenic bacteria are reduced through plaque control measures, while available carbohydrate is reduced through diet modification. Sealants can also protect teeth from demineralization and caries

 

Plaque Control

A disclosing agent can help identify areas of plaque that are not removed by a patient's oral hygiene regimen. While the scope of this monograph is not to discuss specific oral hygiene measures, the use of an appropriate toothbrush (manual or powered) as well as interdental aids is obviously important. In addition, a fluoride-containing dentifrice is beneficial for patients of all ages. High risk individuals may benefit from antimicrobial products to control bacteria. Delivery methods of an antimicrobial could include, rinsing, irrigating, or brushing. Most important, a plaque control regimen tailored to the individual produces the best long-term result.

 

Diet Modification

Adjunctive to plaque control, diet modification is part of a total oral health program. A dietary assessment can help the clinician and patient determine the best way to control a caries problem. Cariogenic foods or drinks such as those containing sucrose and fermentable carbohydrates should be noted, and their role in the caries process explained to the patient. The patient may not be aware of all sources of fermentable carbohydrates unless such an assessment is performed. The frequency of snacking is important and should be noted as well, since the cariogenic process is exacerbated with frequent snacking. Each exposure to cariogenic foods or drinks produces acid. This lowers the pH of tooth surfaces and leads to demineralization. The actual amount of cariogenic foods or drinks is not as important as how often the tooth surfaces are exposed to them. Frequent intake of such substances can decrease the oral pH for several hours a day.2

 

Sealants

Topically or systemically applied fluorides are protective of all tooth surfaces; however, the occlusal surfaces of teeth are more prone to caries merely because of their morphology. Data show that caries prevalence on occlusal surfaces is five times higher than on proximal surfaces. Although occlusal surfaces represent only 12.5% of the available surfaces, 88% of carious lesions occur at these sites.12 Sealants applied to the pits and fissures of teeth can provide added protection to these surfaces. In addition, some sealants contain fluoride and release the agent over time to enhance remineralization of incipient lesions. Since sealants prevent disease rather than treat its sequelae, they are an essential component of a modern, prevention-oriented practice.13

 

Recap and Subsequent Sections

This brief synopsis of fluoride's mechanism of action, the disease process, and caries prevention strategies is a primer for the information contained in the body of this monograph.  The sections to follow discuss fluoride use for prevention, fluoride therapy across the life span, and applications of fluoride concepts to case studies. As practitioners evolve from treating diseases to preventing them, fluoride is one measure that can interrupt destructive processes before they cause harm. Various fluoride approaches can be taken, including those performed in the public health sector, in the operatory by clinicians, and at home by patients. Fluoride needs vary across the life span. Based on the age, risk, and disease history of an individual, therapy is tailored to what the patient requires. Finally, for the clinician to apply the preventive and treatment concepts discussed in this review, practical application is necessary. Disease case types are presented and fluoride treatment protocols recommended based on the unique concerns of each case.

 

For more information about this topic, visit this link to read Part II – Fluoride Use for Prevention


 

References

  1. Centers for Disease Control and Prevention.  Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR 2001;50 (RR-14):1-42.
  1. Wilkins E. Clinical practice of the Dental Hygienist, 8th ed. Philadelphia,PA. Lippincott, Williams & Wilkins, 1999:456.
  1. Rolla G, Ekstrand J. Fluoride in Dentistry. 2nd ed. Copenhagen, Munksgaard, 1996:215-229.
  1. American Dental Association Council on Scientific Affairs. Journal of the American Dental Association, Vol 137. 2006. Professionally applied topical fluoride: Evidence-based clinical recommendations.
  1. Stooky G, Schemehorn B, Drook C. The effect of rinsing with water immediately after a professional fluoride gel application on fluoride uptake in demineralized enamel. Pediatr Dent 1986;8:153.
  1. American Academy of Periodontology. The pathogenesis of periodontal diseases. J Periodontol 1999;70:457-470.
  1. American Academy of Periodontology. World Workshop in Clinical Periodontics 1996;1(1):2340241.
  1. Mazza J, Newman M, Sims T. Clinical and antimicrobial effect of stannous fluoride on periodontitis. J Clin Periodontol 1981;8:203-212.
  1. Wieder S, Newman H, Strahan J. Stannous fluoride and subgingival chlorhexidine irrigation in the control of plaque and chronic periodontitis. J Clin Periodontol 1983;10:172-181.
  1. Yoits W. The action of sodium fluoride on suspected periodontopathogens. J Periodont Res 1988;23:340-344.
  1. Ravald N, Birkhed D, Hamp S. Root caries susceptibility in periodontally treated patients. J Clin Periodontol 1993;20:124-129.
  1. Kaste LM, Selwitz RH, Oldakowski RJ, et al. Coronal caries in the primary and permnent dentition of children and adolescents 1-17 years of age: United States, 1988-1991. J Dent Res 1996;75(Spec No):631-641.
  1. Limeback H. A re-examination of the pre-eruptive and post-eruptive mechanism of the anti-caries effects of fluoride: is there any anti-caries benefit from swallowing fluoride? Community Dentistry and Oral Epidemiology 1999;27:62-71.

 

 

Tables

Table 2: Caries Risk Assessment

 

Children

Adults

Low Risk

No new or incipient carious lesions in the past year

No new or incipient carious lesions in the past year

Moderate Risk

(any of the following)

One new, incipient or      recurrent carious lesion in   the past year

Deep or noncoalesced pits & fissures

High caries experience in siblings or parents

Malformed enamel or dentin

History of pit & fissure caries

Early childhood caries

Frequent consumption of refined carbohydrates

Decreased salivary flow

Low salivary buffering capacity

Compromised oral hygiene

Irregular professional care

Inadequate fluoride exposure

Proximal radiolucency

One to two new incipient or recurrent carious lesions in the past three years

History of numerous or severe caries

Deep or noncoalesced pits & fissures

Malformed enamel or dentin

Frequent consumption of refined carbohydrates

Decreased salivary flow

Low salivary buffering capacity

Compromised oral hygiene

Irregular professional care

Inadequate fluoride exposure

 

High Risk

Two or more new, incipient or recurrent carious lesions in the past year, or two or more of the following:

Deep or noncoalesced pits & fissures

Malformed enamel or dentin

Siblings or parents with high caries rate

History of pit and fissure caries

Early childhood caries

Frequent consumption of refined carbohydrates

Decreased salivary flow

Low salivary buffering capacity

Compromised oral hygiene

Irregular professional care

Inadequate fluoride exposure

Proximal radiolucency

High levels of cariogenic bacteria

Three or more carious lesions in the past three years, or two or more of the following:

History of numerous or severe caries

Deep or noncoalesced pits & fissures

Malformed enamel or dentin

Frequent consumption of refined carbohydrates

Decreased salivary flow

Low salivary buffering capacity

Compromised oral hygiene

Irregular professional care

Inadequate fluoride exposure

Root surfaces exposed by gingival recession

High levels of cariogenic bacteria

 

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