Fluoride is sold in tablets for cavity prevention.
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|ATC code||A12CD (WHO)|
Fluoride therapy is the use of fluoride for medical purposes. Fluoride supplements are recommended to prevent tooth decay in children older than 6 month in areas where the drinking water is low in fluoride. It is typically used as a liquid, pill, or paste by mouth. Where public water supplies are fluoridated further fluoride by mouth is typically not needed. Has also been used in a number of bone diseases.
Normal doses may occasionally result in white marks on the teeth. Excessive doses can result in brown or yellow coloring of the teeth. Fluoride therapy typically uses the sodium fluoride form, though stannous fluoride and hydrogen fluoride may also be used. Fluoride appears to decrease breakdown by acids, increase remineralisation, and decrease the activity of bacteria. It is believed to work mostly through direct contact with the teeth after they have emerged.
Fluoride came into use to prevent tooth decay in the 1940s. Fluoride, as sodium fluoride, is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in a health system. In the United Kingdom a typical month supply costs the NHS about 0.36 pounds. It is also not very expensive in the United States.
Fluoride therapy has been proven to have a beneficial effect on the prevention of dental caries. Robust evidence supports the use of fluoride toothpaste (with concentrations of 1000 ppm and above) and fluoride supplements, in the form of drops and tablets, to reduce the risk of dental caries in school-aged children and adolescents. The ingestion of fluoride as primary teeth are being developed has shown that the teeth have formed stronger and more resistant for caries. Water and milk fluoridation are two forms of systemic fluoride therapy that have been demonstrated to be effective at preventing dental caries.
Fluoride supplementation has been extensively studied for the treatment of postmenopausal osteoporosis. This supplementation does not appear to be effective; even though sodium fluoride increases bone density, it does not decrease the risk of fractures.
- See main article Dental fluorosis.
The use of fluoride toothpaste (with concentrations of 1000 ppm and above) and fluoride supplements in children below the age of six years, and especially within the first three years of life, is associated with a greater risk of dental fluorosis. It has been estimated that optimal water fluoridation for the prevention of dental caries increases the prevalence of dental fluorosis by 4 to 5%. The observed effects are mild to moderate, usually of minimal aesthetic concern.
Reports have claimed that water fluoridation can be linked to the development of osteoporosis and various cancers, however a recent systematic review has found no evidence to support these claims.
Consumption of large amounts of fluoride can lead to fluoride poisoning and death; the lethal dose for most adult humans is estimated at 5 to 10 g (which is equivalent to 32 to 64 mg/kg elemental fluoride/kg body weight). Ingestion of fluoride can produce gastrointestinal discomfort at doses at least 15 to 20 times lower (0.2–0.3 mg/kg) than lethal doses. Chronic intake and topical exposure may cause dental fluorosis, and excess systematic exposure can lead to systemic effects such as skeletal fluorosis. Young children are at risk for receiving excess fluoride, and the ADA has recently issued an interim guidance on their fluoride consumption.
In 1974 a three-year-old child swallowed 45 milliliters of 2% fluoride solution, estimated to be triple the fatal amount, and then died. The fluoride was administered during his first visit to the dentist, and the dental office was later found liable for the death.
Strictly speaking, fluoride therapy repairs rather than prevents damage to the teeth, causing the mineral fluorapatite to be incorporated into damaged tooth enamel. Fluorapatite is not a natural component of human teeth, although it is found in the teeth of sharks. The main mineral found in natural tooth enamel is hydroxyapatite rather than the fluorapatite created in the presence of fluoride. Even without fluoride, teeth experience alternating increases and decreases in mineral content, depending upon how acidic or basic the mouth is, and depending upon the concentration of other substances in the mouth, such as phosphate and calcium. F
Fluoride reduces the decay of tooth enamel by the formation of fluorapatite and its incorporation into the dental enamel. The fluoride ions reduce the rate of tooth enamel demineralization and increase the rate of remineralization of teeth at the early stages of cavities. Fluoride exerts these effects by the demineralization and remineralization cycle. The remineralization cycle as it applies to preventive methods is occurring when fluoride is present in the oral cavity. After fluoride is swallowed it has a minimal effect.
There are three principle reactions with fluoride ion for remineralization:
- Iso-ionic exchange of F− for OH− in apatite: Ca10(PO4)6(OH)2 + 2F− → Ca10(PO4)6F2 + 2OH−
- Crystal growth of fluorapatite from a supersaturated solution: 10 Ca2+ + 6PO43− + 2F− → Ca10(PO4)6F2
- Apatite dissolution with CaF2 formation: Ca10(PO4)6(OH)2 + 20F− → 10 CaF2 + 6PO43− + 2OH−
Iso-ionic exchange by the replacement of F- for OH¯ in apatite and crystal growth of fluorapatite from supersaturated solutions are able to occur during exposure to low levels of fluoride (0.01-10 ppm F) over long periods of time. Reaction of apatite dissolution with CaF2 formation occurs in higher levels of fluoride (100-10,000 ppm F) and the addition of CaF2 or a CaF2 containing compound.
Fluoride's effect on oral microflora and the role of its importance in fluoride's effectiveness against cavities does not currently have a consensus. Many studies on bacterial cells in laboratories have shown the fluoride has many effects on them as an antimicrobial agent. The antimicrobial effects require concentrations of fluoride at least 10 ppm F, which only occurs briefly in the mouth with oral fluoride-containing products. A study looked at fluoride's effects on oral microflora and concluded that fluoride may not solely interact as an antimicrobial agent, rather additionally acting to reduce bacterial adhesion to teeth along with the primary action of decreasing of demineralization. Further investigation will need to be done to verify these claims.
Fluoride can be delivered by many chemical methods (sodium fluoride, stannous fluoride, amine fluoride, monofluorophosphate, and more). The anti-caries performance differences between them have been shown to have less effect than variations in behavior shown by individuals in brushing, using fluoride products and post use behavior. Often the chemical form of fluoride is driven by compatibility with the other elements mixed with, price, and such.
All fluoridation methods provide low concentrations of fluoride ions in saliva, thus exerting a topical effect on the plaque fluid. Fluoride does not prevent cavities but rather controls the rate at which they develop, and so repeated exposure throughout the day is essential for its effective function. The more constant the supply the more beneficial fluoride will be in cavity prevention.
Water fluoridation is the controlled addition of fluoride to a public water supply in order to reduce tooth decay. Its use in the U.S. began in the 1940s, following studies of children in a region where water is naturally fluoridated. It is now used for about two-thirds of the U.S. population on public water systems and for about 5.7% of people worldwide. Although the best available evidence shows no association with adverse effects other than fluorosis, most of which is mild, water fluoridation has been contentious and opposition to water fluoridation exists despite its support by public health organizations.
Most toothpastes contains between 0.22% (1,000 ppm) and 0.312% (1,450 ppm) fluoride, usually in the form of sodium fluoride or sodium monofluorophosphate (MFP). Frequent use of toothpaste with 1,100 ppm fluoride content enhances the remineralization of enamel and inhibits the demineralization of enamel and root surfaces. Most toothpastes with fluoride contain mild abrasives in order to remove heavier debris and light surface staining. These abrasives include calcium carbonate, silica gels, magnesium carbonates and phosphate salts.
Fluoride is available in three forms during toothbrushing. First, it is available as a free ionic fluoride which can react with the tooth structure, interfere with the metabolism of bacteria in plaque, or absorb to the oral mucosa. Second, it is available as profluoride compounds which can precipitate in the mouth during toothbrushing and release ionic fluoride. Lastly, fluoride in toothpaste can exist as unavailable fluoride compounds which do not release fluoride ions. This is due to the fluoride ions being swallowed or expelled when spitting.
High-fluoride content toothpaste generally contains 1.1% (5,000 ppm) sodium fluoride toothpaste. This type of toothpaste is used in the same manner as regular toothpaste. The application of high-fluoride content toothpaste in adults twice daily improves the surface hardness of untreated root decay when compared to toothpaste with regular fluoride content.
Fluoridated toothpaste is also available in the form of 0.454% stannous fluoride. It appears to be effective in reducing tooth hypersensitivity. Additionally, brushing twice daily with a toothpaste containing stannous fluoride may reduce gingivitis, gingival bleeding and dental plaque.
Anti-sensitivity toothpastes with fluoride are also available for those who have sensitive teeth. Some anti-sensitivity toothpastes with fluoride on the market contain the ingredients called strontium chloride or potassium nitrate which help to alleviate tooth sensitivity.
Fluoride mouth rinses can be professionally-applied by a dental professional or used at home. The most common fluoride compound used in mouth rinse is neutral sodium fluoride. Fluoride mouth rinses range from 0.05% to 0.2% (225-1,000 ppm) in concentration. The fluoride rinse with a 0.05% fluoride content is used for daily rinsing, while the rinse with 0.2% fluoride content is used for weekly rinsing and in school-based weekly rinsing programs. Fluoride at these concentrations is not strong enough for people at high risk for tooth decay. Regular use of a daily (230 ppm) or weekly (900 ppm) fluoride mouth rinse under supervision results into a reduction of tooth decay in children’s permanent teeth. After a fluoride mouthrinse treatment, the fluoride in the mouthrinse is retained in the saliva which helps prevent tooth decay.
Fluoride mouth rinses are recommended for use in conjunction with other fluoride therapies, but is usually contraindicated for children under 6 years old as they may swallow the rinse and increase their risk of dental fluorosis. In areas without fluoridated drinking water, these rinses are recommended for children.
There are several types of professionally-applied fluoride gels and foams on the market. The types of professionally-applied fluoride gels include 2.0% neutral sodium fluoride and 1.23% acidulated phosphate fluoride. 1.23% acidulated phosphate fluoride gel or foam is used for patients without tooth-colored restorations, while 2.0% neutral sodium fluoride is used for patients with composites, porcelain, titanium, sealants or sensitivity.
Professionally-applied fluoride gel or foam is applied through the use of a foam mouth tray which is held in the mouth by gently biting down. The application usually lasts for approximately four minutes, and patients should not rinse, eat, smoke, or drink for 30 minutes after application. The reason for this is to allow the teeth to absorb the fluoride into the tooth structure when it is at its highest concentration, without being interrupted. This aids in the repair of microscopic dental decay. There is no clinical evidence on the effectiveness of one-minute fluoride gel/foam applications. A specific benefit when using foam is that less product is required during application, which results in a lower fluoride dose and lessens the risk of accidental ingestion. Additionally, more research regarding the efficacy of fluoride foam is needed as the evidence for its effectiveness is not as strong compared to those of fluoride gels and varnish.
Some gels are made for home application with the use of a custom tray. A model of a person's teeth can be made by a dental professional, who then uses that to make trays, similar to a sport guard tray, which is put over their teeth. The patient can then use this to hold a fluoride treatment against their teeth overnight or several minutes during the day. The concentration of fluoride in these gels is much lower than in professional products. The self-applied sodium fluoride gel/foam typically contains 0.5% fluoride and stannous fluoride gel/foam contains 0.15%.
Head and neck radiation treatment may destroy the cells of the salivary gland which can result in dry mouth. Patients with reduced salivary flow are at an increased risk of tooth decay. The home application of 1.1% fluoride gel with a custom tray is recommended for patients undergoing or are finished with head and neck radiation treatment and patients with decreased salivary flow. Head and neck radiation treatment may destroy the cells of the salivary gland which can result in dry mouth. Patients with reduced salivary flow are at an increased risk of tooth decay and will benefit from home application of fluoride.
More research is required regarding the efficacy of fluoride gels in treating initial dental decay lesions.
Fluoride varnish has practical advantages over gels in ease of application and use of smaller volume of fluoride than required for gel applications. The principle of fluoride varnish is to apply fluoride salt in a very high concentration (approximately 50,000 ppm) onto the surface of the teeth. Fluoride varnish is a resin based application that is designed to stay on the surface of the teeth for several hours. As this varnish rests on the tooth’s surface, saliva dissolves the fluoride salt which in turn allows fluoride ions to be released and absorbed by the teeth and soft tissues. Later, the fluoride is re-released into the oral cavity from these reservoirs which acts as protection for the teeth against cavities. Currently, there is also no published evidence that indicates that professionally applied fluoride varnish is a risk factor for enamel fluorosis. The varnish is applied with a brush and sets within seconds.
Fluoride varnish has shown to be effective in reducing initial dental decay lesions in both primary and permanent dentition. Application of fluoride varnish every six months is effective in preventing dental decay in primary and permanent teeth of children and adolescents.
Devices that slowly release fluoride can be implanted on the surface of a tooth, typically on the side of a molar where it is not visible and does not interfere with eating. The two main types are copolymer membrane and glass bead. These devices are effective in raising fluoride concentrations and in preventing cavities, but they have problems with retention rates, that is, the devices fall off too often.
Fluoridated lozenges may contain about 1 mg fluoride each, and are meant to be held in the mouth and sucked. The dissolved lozenge is swallowed slowly, so the use of lozenges is both a topical and a systemic therapy. A 1955 study comparing the effects of fluoride lozenges and fluoride pills provided clear evidence early that fluoride acts topically.
Medical fluoride supplements in the form of tablets, lozenges, or liquids (including fluoride-vitamin preparations) are used primarily for children in areas without fluoridated drinking water. The evidence supporting the effectiveness of this treatment for primary teeth is weak. The supplements prevent cavities in permanent teeth. A significant side effect is mild to moderate dental fluorosis.
- Mosby's Review Questions for the National Board Dental Hygiene Examination. Elsevier Health Sciences. 2013. p. 231. ISBN 9780323226318.
- Weiner, Eugene R. (2008). Applications of Environmental Aquatic Chemistry: A Practical Guide, Second Edition (2 ed.). CRC Press. p. 389. ISBN 9781420008371.
- WHO Model Formulary 2008 (PDF). World Health Organization. 2009. p. 501-502. ISBN 9789241547659. Retrieved 8 January 2017.
- British national formulary : BNF 69 (69 ed.). British Medical Association. 2015. p. 699-700. ISBN 9780857111562.
- "Fluorides". The American Society of Health-System Pharmacists. Retrieved 8 January 2017.
- Murray, John J.; Nunn, June H.; Steele, James G. (2003). The Prevention of Oral Disease. OUP Oxford. p. 53. ISBN 9780192632791.
- "WHO Model List of Essential Medicines (19th List)" (PDF). World Health Organization. April 2015. Retrieved 8 December 2016.
- Hamilton, Richart (2015). Tarascon Pocket Pharmacopoeia 2015 Deluxe Lab-Coat Edition. Jones & Bartlett Learning. p. 217. ISBN 9781284057560.
- Ismail AI, Hasson H; Hasson (2008). "Fluoride supplements, dental caries and fluorosis: a systematic review". J Am Dent Assoc. 139 (11): 1457–68. doi:10.14219/jada.archive.2008.0071. PMID 18978383.
- ADA.org http://www.ada.org/~/media/ADA/Member%20Center/FIles/fluoridation_facts.ashx. Retrieved 8 December 2016. Missing or empty
- National Health and Medical Research Council (Australia) (2007). "A systematic review of the efficacy and safety of fluoridation" (PDF). Retrieved 24 February 2009. Summary: Yeung CA (2008). "A systematic review of the efficacy and safety of fluoridation". Evid Based Dent. 9 (2): 39–43. doi:10.1038/sj.ebd.6400578. PMID 18584000. Lay summary – NHMRC (2007).
- Haguenauer, D; Welch, V; Shea, B; Tugwell, P; Wells, G (2000). "Fluoride for treating postmenopausal osteoporosis.". The Cochrane database of systematic reviews (4): CD002825. doi:10.1002/14651858.CD002825. PMID 11034769.
- Vestergaard, P; Jorgensen, NR; Schwarz, P; Mosekilde, L (March 2008). "Effects of treatment with fluoride on bone mineral density and fracture risk—a meta-analysis.". Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 19 (3): 257–68. doi:10.1007/s00198-007-0437-6. PMID 17701094.
- Gosselin, RE; Smith RP; Hodge HC (1984). Clinical toxicology of commercial products. Baltimore (MD): Williams & Wilkins. pp. III–185–93. ISBN 0-683-03632-7.
- Baselt, RC (2008). Disposition of toxic drugs and chemicals in man. Foster City (CA): Biomedical Publications. pp. 636–40. ISBN 978-0-9626523-7-0.
- IPCS (2002). Environmental health criteria 227 (Fluoride). Geneva: International Programme on Chemical Safety, World Health Organization. p. 100. ISBN 92-4-157227-2.
- Bradford D. Gessner; Michael Beller; John P. Middaugh; Gary M. Whitford (13 January 1994). "Acute fluoride poisoning from a public water system". New England Journal of Medicine. 330 (2): 95–99. doi:10.1056/NEJM199401133300203. PMID 8259189.
- (2006). Interim Guidance on Fluoride Intake for Infants and Young Children
- New York Times. (1979). $750,000 Given in Child's Death in Fluoride Case: Boy, 3, Was in City Clinic for Routine Cleaning. NYT archive, free full-text available at NYT here.
- ten Cate, JM (Feb 2013). "Contemporary perspective on the use of fluoride products in caries prevention.". British dental journal. 214 (4): 161–7. doi:10.1038/sj.bdj.2013.162. PMID 23429124.
- Rošin-Grget, K; Peroš, K; Sutej, I; Bašić, K (Nov 2013). "The cariostatic mechanisms of fluoride". Acta medica academica. 42 (2): 179–88. doi:10.5644/ama2006-124.85. PMID 24308397. Retrieved 31 March 2014.
- Featherstone JD (1999). "Prevention and reversal of dental caries: role of low level fluoride". Community Dent Oral Epidemiol. 27 (1): 31–40. doi:10.1111/j.1600-0528.1999.tb01989.x. PMID 10086924.
- Loskill, Peter; Zeitz, Christian; Grandthyll, Samuel; Thewes, Nicolas; Müller, Frank; Bischoff, Markus; Herrmann, Mathias; Jacobs, Karin (7 May 2013). "Reduced Adhesion of Oral Bacteria on Hydroxyapatite by Fluoride Treatment". Langmuir. USA: ACS Publications. pp. 5528–5533. doi:10.1021/la4008558. Retrieved 28 April 2014.
- "ADA.org:A-Z Topics: Fluoride and Fluoridation" (PDF). American Dental Association.
- ten Cate FM. Contemporary perspective on the use of fluoride products in caries prevention British Dental Journal 214, 161 - 167 (2013) PMID 23429124
- Centers for Disease Control and Prevention (2001). "Recommendations for using fluoride to prevent and control dental caries in the United States". MMWR Recomm Rep. 50 (RR-14): 1–42. PMID 11521913.
- Ripa LW (1993). "A half-century of community water fluoridation in the United States: review and commentary". J Public Health Dent. 53 (1): 17–44. doi:10.1111/j.1752-7325.1993.tb02666.x. PMID 8474047.
- Cheng KK, Chalmers I, Sheldon TA; Chalmers; Sheldon (2007). "Adding fluoride to water supplies". BMJ. 335 (7622): 699–702. doi:10.1136/bmj.39318.562951.BE. PMC . PMID 17916854.
- Armfield JM (2007). "When public action undermines public health: a critical examination of antifluoridationist literature". Aust New Zealand Health Policy. 4 (1): 25. doi:10.1186/1743-8462-4-25. PMC . PMID 18067684.
- Nóbrega, DF; Fernández, CE; Del Bel Cury, AA; Tenuta, LM; Cury, JA (2016). "Frequency of fluoride dentifrice use and caries lesions inhibition and repair". Caries Research. 50 (2): 133–140.
- American Dental Association. "Learn more about toothpastes". Retrieved November 30, 2016.
- Carey, CM (2014). "Focus on fluorides: update on the use of fluoride for the prevention of dental caries". Journal of Evidence Based Dentistry. 14: 95–102.
- Srinivasan, M; Schimmel, M; Riesen, M;; Ilgner, A; Wicht, MJ; Warncke, M; Elwood, RP; Nitschke, I; Müller, F; Noack, MJ (2014). "High-fluoride toothpaste: a multicenter randomized controlled trial in adults". Community Dentistry and Oral Epidemiology. 42 (4): 333–340.
- Yeung, CA (2014). "Some beneficial effect on root caries from use of higher concentration fluoride toothpaste (5000 ppm F)". Evidenced Based Dentistry. 15 (1): 8–9.
- West, NX; Seong, J (2015). "Management of dentine hypersensitivity: efficacy of professionally and self-administered agents". Journal of Clinical Periodontology. 42 (S16): S256–S302.
- Selwitz, RH (2009). "Twice Daily Toothbrushing With a Stabilized Stannous Fluoride/Sodium HexametaPhosphate Dentifrice May Reduce Gingivitis, Gingival Bleeding, and Dental Plaque". Journal of Evidence-Based Dental Practice. 9 (1): 28–29.
- Twetman, S; Keller, MK (2016). "Fluoride rinses, gels and foams: an update of controlled clinical trials". Caries Research. 50 (1): 38–44.
- Centers for Disease Control and Prevention (17 August 2001). "Recommendations for using fluoride to prevent and control dental caries in the United States". Archived from the original on 8 February 2007. Retrieved November 30, 2016.
- Marinho, VCC; Chong, LLY; Worthington, HV; Walsh, T (2016). "Fluoride mouthrinses for preventing dental caries in children and adolescents". The Cochrane Database of Systematic Reviews (11).
- Darby, ML; Walsh, MM (2015). Dental Hygiene Theory and Practice 4th edition. St. Louis: Saunders/Elsevier. pp. 580–597. ISBN 978-1-4557-4548-7.
- American Dental Association Division of Communications (2007). "Fluoride dental treatments in the dental office". Journal of the American Dental Association. 138: 420.
- American Dental Association Council on Scientific Affairs (2006). "Professionally applied topical fluoride: evidence-based clinical recommendations" (PDF). Journal of the American Dental Association. 137 (8): 1151–1159.
- Hancock, PJ; Epstein, JB; Sadler, GR (2003). "Oral and dental management related to radiation therapy for head and neck cancer". Journal (Canadian Dental Association). 69 (9): 585–590.
- Lenzi, TL; Fernandes Montagner, A; Zovico Maxnuck Soares, F; de Oliveira Rocha, R (2016). "Are topical fluorides effective for treating incipient carious lesions?". Journal of the American Dental Association. 147 (2): 84–91.
- Pessan JP, Al-Ibrahim NS, Buzalaf MAR, Toumba KJ; Al-Ibrahim; Buzalaf; Toumba (2008). "Slow-release fluoride devices: a literature review". J Appl Oral Sci. 16 (4): 238–46. doi:10.1590/S1678-77572008000400003. PMID 19089254.
- B.G. Bibby; Esther Wilkins; Evelyn Witol (February 1995). "A preliminary study of the effects of fluoride lozenges and pills on dental caries, republished 1995". OOOO. 8 (2): 213–216. Retrieved January 19, 2015.
- Dentistry portal
- Committee on Fluoride in Drinking Water, National Research Council. (2006). Fluoride in Drinking Water: A Scientific Review of EPA's Standards. National Academies Press.
- government guidelines
- Fluoride History History of fluoride therapy including early patents