1. Fluoride application
Dr. Abdelmonem Altarhony

2. At the end of this lecture you should understand :
Mechanism of action of NaF
Case selection and indications
Types and material needed
Steps of fluoride application
Post application instructions

3. Mechanism of action of Sodium Fluoride
When sodium fluoride is applied on the tooth surface it reacts with hydroxil apatite crystals rapidly to form calcium fluoride.
As a thick layer of calcium fluoride gets formed it interferes with the further diffusion of fluoride from aqueous solution to react with hydroxil apatite.

4. The calcium fluoride reacts with hydroxil apatite
to form fluoridated hydroxil apatite.
This increases
the concentration of
the tooth structure
surface
more
fluoride, making
stable, and surface more resistant to caries attack. It also helps in reminaeralization of the initial decalcified areas.

6. Demineralization - Remineralization

7. CARIES PROCESS NO CAVITY C A R I E S Pulpal lesion RESTORATION Dentin
Enamel lesion
White spot
NO CAVITY
De- Remineralization
DIAGNOSIS
TIME 9

8. Case Selection and indications
When fluoride is applied to
teeth, it
gets
deposited in the outer enamel,
making
more
resistant to dissolution by acids.
The frequency
and
availability of
low
concentration of
fluoride
is more important in
caries prevention but infrequent professional applications are indicated for some patients or groups.

9. Professionally applied fluoride agents
recommended for public health programs for:
are
1. For areas
with
relatively
homogenous high-risk
prevalence, fluoride-deficient drinking water and lack of fluoride toothpaste, but personnel resources available for a school-based preventive program;
2. In special
risk
groups
such
as the mentally
handicapped or elderly people with reduced salivary flow, exposed root surfaces and heavily restored dentitions; and in people with senile dementia. 11

10. From a cost-effectiveness aspect professionally applied fluoride agents are also justified as a public health measure for specific groups of children
(applications of 2% NaF), coinciding with the eruption of different groups of primary and permanent teeth. (3, 7, 11 and 13 years of age) 12

11. Indications Patients who are at high risk for caries on
smooth surfaces
Patients who are at high risk for caries on root surfaces
White spots
Active decay
Special patient groups, such as:
Orthodontic patients or patients with multiple restored teeth/ bridges/ crowns
Patients undergoing head and neck irradiation
-Patients with decreased salivary flow ( Xerostomia)
Children whose permanent molars should, but
can not be sealed.
Additional protection if necessary for children in areas whithout fluoridated water

12. Radiation caries Radiotherapy is frequently associated with xerostomia
due to decreased salivary secretion
This and other cause of decreased salivation may lead to a rampant form of caries, indicating the significance of saliva in preventing caries. 14

13. Incipient caries not an
The early caries lesion best seen on the smooth surfaces of the teeth, is visible as a ‘White Spot’
Histologically, the lesion has an apparently intact
surface layer overlying subsurface demineralization.
Significantly many
such
lesions can
under go
remineralization &
thus
the lesion is
not an
indication for restorative treatment Remineralised with fluoride application 15

14. White Spot Lesion: It is a subsurface lesion Internal loss of minerals
External (outer) surface
White Spot Lesion:
It is a subsurface
lesion

15. Early childhood caries
Early childhood caries would include, two variants:
Nursing caries and rampant caries.
The difference primarily exist in involvement of the teeth (mandibular incisors) in the carious process in rampant caries as opposed to nursing caries.
Dr.Caroline Mohamed 17

16. Teenage caries (adolescent caries)
This type of caries is a variant of rampant caries where the teeth generally considered immune to decay are involved.
The caries is also described to be of a rapidly burrowing type, with a small enamel opening.
The presence of a large pulp chamber adds to the woes, causing early pulp involvement.
hamed 18

17. Adult caries
With the recession of the gingiva and sometimes decreased salivary function due to atrophy, at the age of years, the third peak of caries is observed.
Root caries and cervical caries are more commonly found in this group.
Sometime they are also associated with a partial
denture clasp. 19

18. Types and materials needed
Professionally Applied Fluorides
Types and materials needed

19. Topical fluoride therapy
Sodium Fluoride
Stannous Fluoride
Acidulated Phosphate Fluoride
Fluoride Varnish
Self applied fluoride agents
Fluoride Dentifrice
Fluoride Mouth Wash
Fluoride Impregnated Dental Floss
Fluoride Chewing Gum
Alternative fluoride agents
Intraoral Controlled Release Device for Fluoride
Fluoride Containing Alginates
Fluoride Restorative Materials

20. Fluoride delivers

21. Gels The effect of fluoride gels is related to the concentration, time
of application, accessibility, and other factors.
Most commercial fluoride gels for daily use by self-care contain about 0.5% fluoride in the form of neutral NaF, acidulated phosphate fluoride, SnF2 or amine fluoride plus NaF. The last two also have documented anti plaque effects.
D Caroline Mohamed 35

22. Fluoride delivers

23. Fluoride delivers

24. Fluoride delivers

25. Delivery systems for professional topical application of fluorides
The following systems are available for professional
application:
fluoride solutions for painting gels,
prophylaxis pastes, and
slow-release agents, such as varnishes and glass- ionomer cements.
The fluoride concentration in agents for professional use ranges from 1% to 8%. 29

26. Amine fluoride and silane fluoride are also in
The fluoride compounds most commonly used professionally are neutral NaF, acidulated phoshate fluoride,and SnF2 .
Amine fluoride and silane fluoride are also in
some commercial products. 30

27. Sodium fluoride Method of Preparation : Technique of application :
To prepare 2% NaF –20 gms of NaF is dissolved in 1 liter distilled water in a plastic container
Technique of application :
Prophylaxis
Isolation
2% NaF applied
Allowed to dry 3 – 4 min
Patient is advised to avoid rinsing, drinking and eating for
next half an hour

28. Advantages : Disadvantages : Chemically stable Acceptable taste
Non-irritant to gingiva
Does not discolor teeth
Inexpensive
Disadvantages :
4 visits within a short time
30% Caries reduction

29. Stannous fluoride Method of Preparation :
To prepare 8% SnF – 0.8 gms is dissolved in 10 ml of distilled water in a plastic container and shaken.
Technique of application :
(Muhler Tech)
Prophylaxis
Teeth are isolated with cotton rolls
SnF is applied with cotton tipped applicators
Patients are allowed to expectorate
after cotton rolls are removed
A six monthly interval treatment schedule is advised.

30. No. of application : Disadvantages :
 Solution is applied continuously keeping the teeth moist for 4 min
 Instructed not to eat, drink or rinse for 30 min
No. of application :
 6mts or 12 mts.
Disadvantages :
 Unstable
 Metallic taste
 May cause gingival irritation
 Causes brown pigmentation of teeth particularly
in hypocalcified area
 Causes staining on margins of restorations

31. Acidulated phosphate fluoride
Solution
Gel
APF solution :
Method of preparation :
20 gms of NaF is dissolved in 1 litter of 0.1 molar phosphoric acid
To this 50% hydro fluoride acid is added to adjust the pH at
3 & fluoride conc. at 1.23%

32. Paint on technique For pt. who can not tolerate tray application
The most appr. For fluoride solution ,may used for gels and foams
Seat the pt. upright
Isolate the teeth on one side of mouth by inserting cotton rolls when needed, use cotton roll holder
Insert saliva ejector on the opposite side where application take place ,dry teeth with air syringe

33. Quickly apply fluoride with cotton-tipped applicator to moisten all teeth
Wait for 1 to 4 min.
Ensure tooth surface remain wet with product by applying continuously

34. Remove saliva ejector, cotton rolls
Gently proceed suction on all teeth surfaces or wipe the teeth with gauze to remove the residual product
Ask pt. to expectorate
Instruct pt. to not eat , drink, or brush teeth at least 30 min.

35. Technique of application : (Brudevold tech )
Prophylaxis
APF solution is continuously and repeatedly applied
with cotton applicators
Teeth are kept moist for 4 min
Floss is passed through interproximal embrasures to ensure wetting of these surfaces
Repeated for remaining quadrant
Instructed not to drink, eat or rinse for 30 min

36. No. of application : Advantages : Disadvantages : 1 or 2 per year
Stable
Cheap
50% more effective than NaF
Disadvantages :
Teeth must be kept wet for 4 min
Acidic, sour and bitter to taste

37. APF Gel Method of preparation :
A gelling agent methylcellulose or hydrox-ethyl cellulose is to be added to the solution and pH is adjusted between 4 – 5

38. Gels To improve the effect of the gels, the
recommended application time is 4 minutes or
more preferably applied in customized trays. 46

39. Technique hints
Use mouth prop for pt. unable to hold the mouth open for application time
Maintain the cotton rolls away from tooth surface
to ensure maximum contact of fluoride
Polishing is not necessary before fluoride application
Do not use acidulated phosphate fluoride on
pt. with porcelain and composite restoration

40. Tray technique
Allow simultaneous application to both max. and mand. Teeth
The most appr. For gel and foams
Seat the pt. in up right position
Chose comfortable tray cover patient dentition
Place the fluoride gel or foams without over loading, the biting process will cause the product to flow sufficiently to cover the tooth surface

41. Isolate the mand. Teeth using cotton rolls, then dry with air syringe
Insert the mand. Tray
,pressing it against occlusal
,facial ,and lingual surface to
force the product to flow
Insert the max. tray ,using the same technique

42. Carefully place saliva
ejector between the trays
Instruct the pt. to close the mouth and bite gently on the trays
Leave the trays in place for about 1 to 4 minutes

43. To remove the trays, tilt the chin downward, this allow excess product to flow forward and facilitate removal
Ask pt. to expectorate, then suction any residual fluoride by saliva ejector
Instruct the pt. to not eat ,drink
,rinse ,or brush teeth at least for 30 min.

44. FLUORIDE TRAYS

45. Fluoride gel in disposable trays
D Caroline Mohamed 47

46. Advantages of acidulated phosphate fluoride
Requires only 2 application in a year;
The gel preparation can be self applied and thus the cost of application also gets reduced;
It has the ability to deposit fluoride in
enamel to a deeper depth;
Disadvantages of acidulated
phosphate fluoride :
Practical difficulties like the teeth should be kept wet for for 4 minutes;
It is acidic, sour and bitter in taste;
It cannot be stored in glass containers.

47. Semislow-release and slow-release fluoride agents
These are such as fluoride varnishes, glassionomer
cements.
Examples of fluoride varnishes are:
Duraphat (5% NaF; 2.3% F), Fluor Protector (silan fluoride; 0.1% F) and Bifluorid 12 (6% NaF + 6% CaF2;
about 6% F).
Based on clinical studies, the caries reduction achieved
by fluoride varnishes 46% in permanent teeth and 33% in primary teeth (Marinho, et al. 2009). 56

49. It is recommended that the initial varnish application be repeated 3 times within 7-10 days in patients with caries risk, to heal gingivitis, thereby reducing the plaque formation rate, and to arrest enamel caries by sealing the outer micropore surface as soon as possible.
Thereafter the varnish should be reapplied at needs related intervals, 2-4 times/year. 58

50. Advantages : Disadvantages :
Forms a water tight protective film insulating against
thermal and chemical influences
Varnish remains on tooth for several days
Disadvantages :
Pt co-operation is required
Expensive

63. Thank you