Fluoride

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FLUORIDE
D.KARTHIKEYAN PERIODONTOLOGY

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INTRODUCTION
• Minerals are the chemical elements required by living organisms. This is also known as mineral nutrients. Minerals are necessary for our body for three reasons. They are – Building strong bones and teeth – Controlling body fluids inside and outside cells – Converting the food into energy.

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Types of minerals
• Minerals are broadly classified into two types – Macrominerals – Microminerals • Macrominerals • These are large and it is the diet mineral needed by human body in high quantities. It is a group made up of calcium, phosphorus, magnesium, sodium, potassium, chlorine and sulfur

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• Microminerals
• They are also called as trace elements . micronutrients are chemical elements. Body needs mineral each day in small amount for good health. These are iron, manganese , copper, iodine, zinc, fluoride, selenium etc.

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FLUORIDE
• Fluoride is the term for the ionized form of the elemental fluorine as it occurs in drinking water. The two terms fluorine and fluoride are used interchangeably.

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Historical background
• In the early 1900s people noticed that inhabitants of towns with naturally higher levels of fluoride in their water had healthier teeth. To test the correlation between fluoride and tooth decay , in 1945 four cities in U.S and one in canada took part in the controlled study of water fluoridation. The results were impressive, establishing that fluoride prevents tooth decay

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SOURCES
• Fluoride is present in small but widely varying concentrations in particularly all soils, water supplies, plants and animals. It is therefore a constituents of all normal diets. • Fluorine is one of the atmospheric contaminants of industries which use coal ore or earthly phosphates.

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• Fluoride is found in many foods, but sea food and tea are the richest dietary sources. • An average daily diet provides 0.25 – 0.35 mg of fluorine . In addition the average adult may ingest 1 – 1.5 mg daily from drinking and cooking water that contains 1ppm of fluoride . • In children of age group of 1-12 years, water may contribute anywhere from 0.4-1.1 mg of fluorine per day.
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RDA
• The range suggested are obtained without difficulty in the areas with the water supply containing atleast 1mg/ litre of fluoride either through naturally or fluoridation.

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METABOLISM
• Fluoride is a weak acid with pka of 3.4 • Fluoride metabolism are pH dependent and that the transmembrane migration of ion occurs due to difference in acidity of adjacent body fluid compartments.

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Absorption
• In absence of high concentrations of certain cations such as calcium and aluminium , that form insoluble compounds with fluoride about 80-90% of ingested amount is absorbed from GIT. • Half time is 30 min, most of the fluoride that escapes absorption will be absorbed from the proximal small intestines.

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EXCRETION
• After about 50% of an ingested fluoride dose has been absorbed, plasma concentrations decline rapidly. This is due to renal excretion and uptake by calcified tissues. Fluoride is freely filtered through the glomerular capillaries and then undergoes a variable degree of tubular re-absorption. Among the halogens, the renal clearance of fluoride is unusually high.

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FUNCTIONS
• Fluoride supports mineralization of teeth and bones by promoting deposition of calcium and phosphates. • Fluorides decreases the demineralization of tooth enamel and accelerates subsequent remineralization process. • Regular ingestion of fluoride is important during the eruption of new teeth in children.

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WATER FLUORIDATION
• Water fluoridation is the controlled addition of fluoride to a public water supply to reduce tooth decay. • To bring the concentration of fluoride to 1ppm has proved to be safe , economical and efficient way to reduce tooth decay. • The concentration of fluoride in public water supplies should be adjusted slightly to allow for difference in water consumption with seasonal temperature changes.
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SALT FLUORIDATION
• Sodium and potassium fluoride are used for fluoridation of household salt. • In wet process, solution of potassium fluoride is mixed homogenously with salt. • In dry process, sodium fluoride with a small grain size is used. • The concentration of fluoride in salt used is in range of 90-350ppm.

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MILK FLUORIDATION
• First mentioned by Zeigler in 1956 . • 36.3% caries reduction was observed with 2.5mg of sodium fluoride added to milk daily in school meals. • There was a controversy concerning the binding and complexing of fluoride with calcium and milk protein thus reducing its anti caries activity. • Erickson proved the availability of fluoride from milk using radioisotope. But the release of fluoride from milk is mild and slow compared to that of water.
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FLUORIDE TABLETS
• Tablets are prescribed for individual patients keeping in account the fluoride concentration in drinking water and other fluoride supplement consumed • Tablets should be swallowed or chewed and available as 0.25mg. 0.5mg and 1mg. • Sodium, acidulated phosphate , potassium or calcium fluoride is administered .

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TOPICAL FLUORIDE
• Topically applied fluoride are deposited onto the surface of the tooth and they tend to provide local protection at or near tooth surface. • Topical fluorides advocated for home use contain less amount of fluoride and used daily. • Professionally applied fluoride agents contain very high amount of fluoride and are applied less frequently.

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• • • • •

1. Solution / thixotropic gel 2. Dentrifice 3. Rinse 4. Varnish 5. Slow releasing systems

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Acute fluoride toxicity
• Safety tolerated dose is 8-16mg/kg body weight . When fluoride is consumed beyond this limit it can lead to toxicity. Lethal dose is 32-64 mg/kg body weight.

• SIGNS AND SYMPTOMS:
• • • • Nausea Vomiting Abdominal pain Increased salivation
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• • • • • • • •

Nasal discharge Generalized weakness Carpodeal spasm Reduced plasma calcium level Increased plasma potassium level Cardiac arrhythmia Coma Death
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Management
˂5mg/kg • Milk • Induce vomiting ˃5 mg/kg • Milk • 5% calcium gluconate • hospitalization ˃15mg/kg • Induce vomiting • Cardiac monitoring • Slow administration of 10ml of 10% ca. gluconate • Maintain adequate urine output
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Chronic toxicity
• Chronic toxicity is due to prolong ingestion of a smaller amount of fluoride. • Chronic toxicity is associated with hard tissue and kidney tubules • Skeletal fluorosis may occur at ingestion of 10-25mg F/day for 20 years.

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FLUOROSIS
• Fluorosis is a chronic disease resulting from the accumulation of toxic levels of mineral fluoride in teeth and bones. • Characterized by bone overgrowth , brittle bones, stiff joints, weakness, weight loss and anemia. • Mottling of enamel occur if exposure occur during formation.

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Causes are : 1. when the fluoride content of the drinking water exceeds 2.5ppm. 2. When amount of fluorine ingested exceeds 30-40ppm of the dry matter diet. 3. When a person consumes ( in food and water) flourine in excess of 20mg/day over an extended period of time.

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Review article
• Valeria CC Marinho, Julian PT Higgins in 2009 determined the effectiveness and safety of fluoride varnishes, gels, mouth rinses, and toothpastes in the prevention of dental caries in children and to examine factors potentially modifying their effect. Children of age 16 or less are included in the study.The benefits of topical fluorides have been firmly established on a sizeable body of evidence from randomized controlled trials.
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• Philip E Benson, Nicola Parkin in 2009 evaluate the effectiveness of fluoride in preventing white spots during orthodontic treatment and to compare the different modes of delivery of fluoride. 15 trials with 723 participants provided data for this review.There is some evidence that the use of topical fluoride or fluoride-containing bonding materials during orthodontic treatment reduces the occurrence and severity of white spot lesions.

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References
• http://onlinelibrary.wiley.com • INTAKE AND METABOLISM OF FLUORIDE Adv Dent Res 8(1):5-14, June, 1994 • Fluorides in the Environment: Effects on Plants and Animals Leonard H. Weinstein, Alan Davison • Pediatric Dentistry: A Clinical Approach Goran Koch, Sven Poulsen. • Advanced Nutrition and Human Metabolism Sareen Annora Stepnick Gropper, Jack L. Smith, James L. Groff.

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