1. 陳弘森 副教授 高雄醫學大學 牙醫學系 TEL: 07-3121101 轉 7008, 7020 E-mail: hosech@kmu.edu.tw 局部氟化 (Topical Fluoridation)

2. 學習目標 氟化物與牙齒面的作用機轉 局部氟化與牙科公衛 局部氟化的種類與使用方式 局部氟化的風險 學習資源： Murray JJ: Appropriate use of fluoride for human health. WHO, Geneva, 1996

5. Topical fluoridation Introduction Mechanism of topical fluoride Topical fluoride in dental public health Topical fluoride in dental clinic Risk of topical fluoride Conclusion

6. Introduction

8. 氮 Nitrogen N 拉丁文 nitrum = 硝石 1772 氧 Oxygn O 希臘文 oxy-genos = 造成酸的 1774 氟 Fluorine F 拉丁文 flurre = 流動 1886 氛 Neon Ne 希臘文 neos = 新的 1898

10. Mechanism of topical fluoride

11. Table 11-1 Hypotheses regarding fluoride’s anticaries mechanism of action Fluoride acts on the hydroxyapatite of the enamel per se: Decreasing its solubility Improving its crystallinity Remineralizing calcium-depleted mineral Action on the bacteria of dental plaque ： Inhibiting enzymes Suppressing cariogenic flora Action on the enamel surface ： Desorbing proteins and/or bacteria Lowering the free surface energy Alteration of tooth morphology

12. 化學結構 Ca 10 (PO 4 ) 6 (OH) 2 + 2F - → Ca 10 (PO 4 ) 6 F 2 + 2(OH) - enamel hydroxyapatite + fluoride fluorapatite + hydroxyl

13. Fig. 2. Schematic representation of the acid solubility ranking of dentally relevant minerals (18). Dental Mineral = carbonated apatite Ca 10-X NA X (PO 4 ) 6-y (CO 3 ) z (OH) 2-u (F) u Most soluble in acid Ca 10 (PO 4 ) 6 (OH) 2 = hydroxyapatite Less soluble Ca 10 (PO 4 ) 6 (OH) 2 = hydroxyapatite Less soluble Ca 10 (PO 4 ) 6 (F) 2 = fluorapatite Least soluble

15. Ｈ ＋ + F - ＨFＨF ＨFＨF pH7 Ｈ ＋ + F - Ｈ F pH 4.5 Ｈ ＋ + F - Ｈ F Fig. 6. Schematic representation of fluoride entering a bacterial cell in the form of HF at lower pH values, dissociating, and thereby providing H + and F - ions inside the cell.

16. Topical fluoride in dental public health

17. TABLE 9-3. COMPARATIVE EFFECTIVENESS OF TOPICAL FLUORIDE APPLICATIONS ON PREVIOUSLY ERUPTED AND NEWLY ERUPTED TEETH Caries Reduction (%) Clinical Investigation Topical AgentPreviously Erupted Teeth Newly Erupted Teeth Averill (1967) 52 NaF22.937.1 Horowitz (1969) 54 SnF 2 20.761.3 Muhler (1960) 55 SnF 2 44.284.0 Szwejda (1972) 56 SnF 2 20.444.4 Szwejda (1972) 56 APF22.563.0

18. TABLE 9-4. COMPARATIVE EFFECTIVENESS OF DIFFERENT TOPICAL FLUORIDE SYSTEMS FOR CARIES PREVENTION IN CHILDREN RESIDING IN NONFLUORIDATED COMMUNITIES Topical Fluoride System Deciduous TeethPermanent Teeth Number of Studies Average Reduction Number of Studies Average Reduction NaF623.1%3226.8% SnF 2 332.0%2235.7% APF132.8%1935.9%

19. TABLE 9-5. COMPARATIVE EFFECTIVENESS OF DIFFERENT TOPICAL FLUORIDE SYSTEMS FOR CARIES PREVENTION IN CHILDREN RESIDING IN OPTIMALLY FLUORIDATED COMMUNITIES Topical Fluoride System Deciduous TeethPermanent Teeth Number of Studies Average Reduction Number of Studies Average Reduction NaF112.0%24.5% SnF 2 137.0%520.6% APF0Unknown222.3%

20. TABLE 9-6. COMPARATIIVE EFFECTIVENESS OF DIFFERENT TOPICAL FLUORIDE SYSTEMS FOR CARIES PREVENTION IN ADULTS Clinical Investigation Fluoride System Number of Applications Length of Study Caries Reduction (%) Arnold 64 NAF(1%)11 year0 Frank 65 NAF(2%)16 months0 Driak 66 NAF(2%)13 years0 Kinkenberg & Bibby 67 NAF(1%)51 year44.5 Rickles & Becks 68 NAF(2%)42 years36.8 Kutler & Ireland 69 NAF(2%)41 year-13.2 Carter et al 70 NAF(2%)41 year12.0 Muhler 71 SnF 2 (10%)11 year15.0 Muhler 72 SnF 2 (10%)11 year16.0 Protheroe 73 SnF 2 (10%)12 years45.3 Harris et al 74 SnF 2 (10%)11 year15.0 Obersztyn et al 75 SnF 2 (10%)43 years42.1 Viegas 76 APF(1.2%F)11 year27.7 Curson 77 APF(1.2%F)51 year8.0

21. TABLE 9-1. RELATIONSHIP BETWEEN SURFACE ENAMEL FLUORIDE CONTENT AND CARIES PREVALENCE IN YOUNG ADULTS* Number of Subjects Caries Prevalence (DMFT) Enamel Fluoride Content (ppm) 4703459 315 - 112229 2912 - 261944 *Calculated from data by Keene et al. 1

22. TABLE 9-14. COMPOSITION AND USAGE OF APPROVED FLUORIDE RINSES Source of Fluoride Fluoride ContentRecommended Usage Percentppm NaF0.20900Weekly NaF0.02100Twice daily NaF0.05225Daily APF0.02200Daily SnF 2 0.10243Daily

23. TABLE 2 CLINICAL ANTI-CARIES STUDIES WITH FLUORIDE DENTIFRICES (after Volpe,1977) FluorideAbrasiveNo. of Studies Caries Reduction NaFMostly phosphates7Varying, mostly 20-30 SnF 2 Calcium pyrophosphate24“ SnF 2 Insoluble metaphosphate11“ Na 2 PO 3 FMostly calcium carbonate or insoluble metaphosphate 20“

24. Table 1. Topical fluoridation effect on patients with head and neck cancer after radiation therapy Patients No. Teeth No. CariesNon-caries Fluoride5367827 No fluoride95617752 P Value<0.005(Chia-Square test)

25. Topical fluoride in dental clinic

26. Table 11-7 Topical fluoride agents and systems Agents Sodium fluoride (NaF) Stannous fluoride (SnF 2 ) Sodium monofluorophosphate (Na 2 PO 3 F) Acidulated phosphate fluoride Amine fluoride Titanium fluoride (TiF 4 ) System F + varnish (rosin ; polyurethane) F + complexing agent (aluminum) F + pretreatment (dicalcium phosphate dihydrate) F + cationic surfactant (Lodyne; Zonyl FSC) F + soluble calcium (calcium chloride; calcium glycerophosphate) F + cationic polyelectrolyte (polyacrylic acid)

27. Recommended application technique 1. Paint – on technique 2. Tray technique 3. Topical electrolytic application

32. 2% neutral sodium fluoride (0.9% fluoride ion) 8% stannous fluoride (2% fluoride ion) 2.8% acidulated phosphate fluoride (1.23% fluoride ion)

38. Risk of topical fluoride

39. Danger The acute lethal dose is about 50mg/kg. The average 5 years child B.W. 20kg 3mg/kg early symptoms

40. Symptoms of fluoride toxicology 1. Chemical burn (ulceration / necrosis) 2. Inhibit enzyme (protoplasmic poison) 3. Binds calcium (nerve action) 4. Hyperkalemia (cardiotoxicity)

41. Treatment Immediate treatment Induced vomiting Protection of stomach Maintaince of blood calcium

42. Table3. DIFFERENT WAYS TO DELIVER FLUORIDE F ConcentrationFrequency of Application Water fluoridationOptimal 1 ppmContinuously Fluoride toothpaste500~1500 ppmTwice daily Fluoride tablets0.25~1 mg/tabletDaily Fluoride drops1000~2000 ppmDaily Rinsing solutions250~1000 ppmDaily Salt fluoridation250~350 ppmContinuously Milk fluoridation7.5 ppmAt school Concentrated solutions10,000 ppmBiannual Concentrated gels4000~12,300 ppmBiannual Lacquers1000~22,600 ppmBiannual

43. 1ppm[F - ] = 1 mgF/l = 1mgF/kg = 1x10 ─4 %F

44. Table 3-9 Toxic effects of fluoride in the human Concentration or dose of F MediumEffects 2 ppm or moreWaterMottled enamel 5 ppmWaterNo osteosclerosis 8 ppmWater10% osteosclerosis 20-80 mg/day or moreWater or airCrippling fluorosis 50 ppmFood or WaterThyroid changes 100 ppmFood or WaterGrowth retardation More than 125 ppmFood or WaterKidney changes 2.5-5.0 gAcute doseDeath Date from Smith and Hodge. 107

45. Conclusion

46. 氟化物製品之種類、濃度及用法 目前常用之氟化物製品有下列幾種，依濃度 1) 局部塗氟 ( 濃度 10,000 ~ 50,000 ppm) 2) 家用局部塗氟 (1,000 ~ 5,000 ppm) 3) 含氟牙膏 (800 ~ 1500 ppm) 4) 自用含氟漱口水 ( 濃度 250 ~ 1,000 ppm) 5) 專供發育中孩童長期服用之氟錠。

47. 結論 評量局部氟化在臨床上的重要性

48. Thank You For Your Listening!

50. ACID Remineralization Calcium phosphate +Fluoride Enamel crystal = Carbonated apatite Partly dissolved crystal Crystal nucleus Ca10(PO4) 6 (F)2 = fluorapatite-like coating on crystals Fig. 4. Schematic representation of demineralization and Remineralization processes which lead to remineralized crystals with surfaces rich in fluoride and of low solubility

56. Fluoride mouth rinses 1946 Bibby et al. Early trials 1962 Torell and Siberg 0.2% Fluorol 1965 Torell and Ericsson 0.05% Fluorol

58. Fluoride application in dentistry

59. Sodium fluoride 1942 Bibby was first to use 1948 Knutson 2% was used

60. Stannous fluoride 1950 Muhler & his workers 1959 Jordan et al. & Gish et al. 8% SnF 2 SnF 2 are acidic, with a pH 2.4 – 2.8 Application : once every 6 months.

61. Acidulated Phosphate Fluoride (APF) 1963 Brudevola et al. found APF APF systems consist sodium fluoride, hydrofluoric acid, and phosphoric acid (1.23% fluoride 0.98% phosphoric acid & pH 3 – 3.5)

65. 表二、國內近年來推廣氟化物使用之重要記事 ： 時間重要事件 八十一年 研究國人學童以含氟水 (225ppm 與 900ppm 兩類 ) 漱口防齲效 果，共計六年。該計畫於八十六年研究結果證實防取校果 約達 27% 與 36.3% 。 八十二年 推廣刷牙時省用含氟牙膏，鼓勵執行專業牙科塗氟。製作 相關單張小冊提醒民眾重視。 八十三年 ( 口腔保健年 ) 衛生署重新宣示遵循世界衛生組織最新的口腔保健政策， 推廣國人口腔衛生的潔牙，宣導健康飲食習慣，定期看牙 醫，及鼓勵適量用氟等方法以保護全民口腔健康。 八十五年 委託牙醫師公會辦理推廣國小學童含氟水漱口工作試辦計 畫。逐年擴辦，本 ( 八十八下半及八十九年 ) 年度補助一百 萬名學童參與本項預防保健計畫。

67. TABLE 4 COMPARISON OF CARIES INHIBITION FROM OPERATOR APPLIED APF SOLUTIONS AND GELS Study% DMFS Reduction SolutionGel Cons et al.(1970)018 Ingraham and Williams (1970)1241 Szwejda (1972)23*4* Horowitz and Doyle (1971)2824 Cobb et al. (1980)3435 Average All Studies19.424.4 *Fluoridated community.

68. Table 48. Mean Fluoride Concentrations in Deciduous Enamel in Children who brushed 1-9 Times with APF Prophylaxis Paste: compare with Control Teeth (Mellberg et al. 1974) GroupNo. of teeth ppm F at four depths(wn) 5153060 Untreated5270233916385 Paste- treated 71075236217486

69. Table 9-30. Fluoride Uptake in Enamel of Children Using NaF and SnF 2 Dentifrices 163 Dentifrice Used Fluoride Content (ppm) Sound EnamelIncipient Lesions Placebo364731 SnF 2 -Ca 2 P 2 O 2 373878 NaF-SiO 2 3791148

70. Table 9-35. In Vivo Fluoride Uptake with NaF and Na 2 PO 3 F/NaF Dentifrices Dentifrice StudiedFluoride SystemFluoride Content of Lesions (mg/cm 2 ) PlaceboNone2.28 Na 2 PO 3 F/NaFNa 2 PO 3 F(0.10% F) NaF(0.045% F) 3.47 NaFNaF(0.11% F)5.11

71. Table 52. Retention of Fluoride from NaF Mouthrinses by Children in Two Studies Age (yrs) No. of children Rinsing time (sec) F retention (mg) F retention (%) Ericsson and Forsman (1969): 7 ml of 245 ppm F rinse 4-510300.4224 5-720600.3522 Forsman (1974): 7ml of 110 ppm F rinse 45300.1722 45600.2329 610600.1620

72. Duraphat ® Fluoride varnish The outstanding preparation for topical caries prophylaxis and treatment of hypersensitive necks of teeth

73. FDA/ADA-Accepted Office Fluoride Application Systems F - FormpHCone.ppm F - Delivery Form TasteAdvantages/ Disadvantages ACIDULATED PHOSPHATE- FLUORIDE 3.0- 3.4 1.23% F - 12.300gel. solutiongood Deglazes porcelain, May etch glass-filled composites Enhance deep F - uptake. pH may aggravate dentin sensitivity. SODIUM FLUORIDE 7.02% NaF9.050gel. solutiongood Bland taste. STANNOUS FLUORIDE 2.38% SnF 2 20.000Powder to mix with water each use poor May stain teeth and anterior fillings. May aggravate dentin sensitivity.

74. 電離子游動應用法 (Topical electrolytic application) 利用電離子游動儀器 (Galvafluor) 及電導印模皿 (Impression support conductor) 促進氟離子 (F - ) 之滲透 入琺瑯質。 原理：手握正極，使身體及牙齒成正極，口咬負極 之電導印模皿。則 gel 之帶正電之鈉離子等移向負 極之印模皿，而帶負電之氟離子 (F - ) 移向正極之牙 齒，如此氟之滲透入琺瑯質更為加強。

78. 附表 – 口腔保健用品含氟量和急性氟中毒劑量的比較 ( 以 20kg 小孩為例 ) 程度 20 公斤兒童急 性中毒所需劑 量 使用 1000 ppm 牙膏每條 200g 的家庭號所需 數量 用 0.2%NaF 學 校漱口水所需 數量 致死劑量 (CLD,32-64 mg/kg) 640-1,280 mg 3.2-6.4 條 710-1420 cc 安全忍受劑量 (STD,8-16 mg/kg) 160-320 mg 0.8-1.6 條 180-360 cc 可能中毒劑量 (PTD,5 mg/kg) 100 mg 半條 111 cc