Topical Fluorides- Professionally applied & Self applied

TOPICAL FLUORIDES
DR SUSMITA S SHAH
III MDS
PEDIATRIC & PREVENTIVE DENTISTRY

CONTENTS:
1. Introduction
2. Fluoride as an element
3. An Overview of Topical Fluorides
4. Mechanism of action
5. Professionally applied topical fluoride
agents
I. Sodium Fluoride
II. Stannous Fluoride
III. Acidulated Phosphate Fluoride
IV. Fluoride Varnish
V. Silver diamine fluoride
6. Self-applied topical fluoride
agents
a. Fluoride Dentifrice
b. Fluoride Mouth Rinse
c. Fluoride Chewable tablets
7. Recommendations for use of
Fluorides in Pediatric Dentistry
8. Summary
9. Bibliography
2

1. Introduction
 Dental caries belongs to a group of complex diseases and it occurs because of
multiple contributing factors.
 Many strategies are nowadays being applied for the prevention of dental caries but
no single strategy can guarantee 100% success.
 The conventional approach of caries removal resulted in a considerable loss of
tooth structure.
 As a result of the recent studies, old concepts have changed and now there is a
paradigm shift in the etiology, diagnosis, preventive strategies and management of
dental caries and many novel materials have been formulated for its prevention.
3

2. Fluoride- As an Element
Fluoride
Trace element, Halogen
family, Most electro
negative
Atomic No
9
Atomic
weight 19
4

Types of fluoride
application
Systemic
Fluorides
Topical
Fluorides
Self
Administered
Dentifrice
Mouth
rinses
Tablets
Operator
Administered
Sodium fluoride Stannous fluoride
Acidulated
Phosphate
Fluoride (APF)
Fluoride varnish SDF
5

3. An Overview of Topical
Fluorides
 The topical fluorides refers to the use of systems containing
relatively large concentration of fluoride that are applied locally or
topically, to erupted tooth surface to prevent the occurrence of dental
caries.
 AIM: of topical fluoride therapy is the deposition of fluoride into the surface
layer of tooth enamel to form fluroapatite , or more correctly, fluoridated
hydroxyapatite, so as to decrease the caries susceptibility of the tissue.
6

F delivery methods with
caries reduction success:
 Community water fluoridation - 50 - 65%
 School water fluoridation - 40%
 Dietary fluoride supplementation - 50 –65%
 Professionally applied topical F - 30 –40%
 Self-applied topical F - 20 – 50%
Jalili Ved Prakash, Tewari A. "Fluorides and dental caries - A compendium". First edition, 34 - 37.
7

4. Mechanism of Action
Increased enamel resistance or Reduction in enamel solubility
Increased rate of post eruptive maturation
Remineralization of incipient carious lesion
Fluoride as inhibitor of demineralization
Interference with microorganisms
Modification of tooth morphology
8

Mechanism of cariostatic action of F
9

 This leads to speculation on several possible
mechanisms of action of systemically ingested fluoride;
A. Improved crystallinity
B. The Void theory
C. FAP versus HAP solubility in acid and
D. Improved tooth morphology.
Ekstrand, Fejerskov, Silverstone. "Fluoride in dentistry". 1998
10

A. Improved Crystallinity
 Myers (1975) showed improved enamel crystallinity due to
fluoride by X-ray diffraction methods. Fluoride actually
increases the crystal size and produces less strain in the crystal
lattice.
 Oneway improved crystallinity may take place is through
conversion of amorphous Calcium phosphate into crystalline
hydroxyapatite.
 In vitro studies have shown that hydroxyapatite formation is
preceded by more acidic calcium phosphate.
11

 Brown et al (1962) stated that an interlayered structure of octacalcium
phosphate and hydroxyapatite may exist as the precursor phase. The
conversion of this phase to hydroxyapatite is facilitated by the presence of
fluoride.
 Various calcium phosphate phases are listed below;
 Monetite (MCP) Ca(H2 PO4)2
 Dicalcium PhosphateDihydrate (DCPD) Ca HPO4. 2H2O
 Dicalcium phosphate anhydrous (DCP) Ca HpO4
 Tricalcium Phosphate (JCP) Ca 3 (PO4)2
 Octacalcium phosphate (OCP) Ca8H2 (PO4)6. 5H2O
 Hydroxyapatite (HAP) Ca10 (OH)2 (Po4)6.
 Fluorapatite (FAP) Ca10 F2 (Po4)6
12

b. Void theory
 Using nuclear magnetic resonance to study the apatite lattice and
fluoride interaction, investigations have developed a molecular
interpretation of the role of fluoride in the apatite lattice.
 To maintain symmetry, the hydroxyl ions must be located equally
on both sides of the Ca triangles. This may be accomplished by
their arrangement all above the Ca plane in one column and all
below the Ca plane in the adjacent column i.e. an equal number on
both sides.
13

 The number of voids must be small since the hydroxyapatite
crystals are relatively stable in water.
 Voids are not uncommon in crystals, but they do imply decreased
stability and therefore greater chemical reactivity.
 If fluoride fills these voids, the crystal structure will be stabilized by
the formation of additional as well as stronger hydrogen bonds.
 This may then contribute to the crystals chemical stability, which
implies lower solubility and greater resistance to dissolution in
acids.
14

 It seems likely that both mechanisms act in the formation of dental
enamel. Both mechanisms also occur at low concentrations of
fluoride and are applicable only during tooth formation.
 Once the tooth erupts into the oral environment, the filling of
voids is unlikely. Further more, the fluoride- promoted conversion
of a precursor phase to HAP is essentially complete soon after
eruption.
15

c. FAP versus HAP acid solubility
 The simplest explanation for the decreased solubility of fluoridated
enamel is that fluorapatite (solubility product constant of 10-60) is less
soluble than hydroxyapatite (solubility product is constant between
10-55 and 10-60) (Newburn 1976).
 However, the amount of fluoride in surface enamel from the teeth of
persons living in a fluoridated area is only 500 to 2000 PPM F-. This is
only a fraction of the theoretic amount of fluoride in fluorapatite
(38,000 PPM F). Obviously little of the enamel is composed of
fluorapatite.
16

 Brown et al (1977) Stated that fluorapatite is more insoluble than
hydroxyapatite but the actual difference in the amounts dissolving is
usually so small that it is not likely to be a factor in cariostasis.
 Wier (1972) showed that hydroxyapatite equilibrated with small
amounts of CaF2 behaves as fluorapatite since a thin coating forms on
the active sites of the hydroxyapatite crystals.
 Moreno (1974) investigated the effect of “systemic–like” incorporation of
fluoride and its influence on solubility using synthetically prepared
apatites.
 They found that degrees of fluoridation below 10% yield solubilities
essentially the same as those for hydroxyapatite.
17

 Joost Larsen (1972) found that enamel biopsy data at a depth of
2 m give a value of about 2500 PPM F- for teeth in a
community.
 Based on the difference in solubility products between HAP and
FAP
, the presence of fluoride in enamel at these levels therefore
does not explain the reduction in dental caries.
18

d. Tooth morphology
 Early dental surveys (Forrest 1956) in fluoridated communities
showed a tendency toward rounded cusps and shallower fissures in
the posterior teeth.
 These were only clinical impressions, however, subsequent animal
studies on rats have confirmed a tendency toward shallow occlusal
fissures.
 The size of teeth does not seem to be affected consistently by the
F- supply during tooth development.
19

5. Professionally Applied Fluorides
20

I. Sodium Fluoride
 Method of Preparation: (Knutson & Feldman tech 1948)
 To prepare 2% NaF – 20 gms of NaF is dissolved in 1-liter distilled
water in a plastic container
 Technique of application :
 No. of application :
 2nd, 3rd, 4th applications are done at weekly interval.
 Application is recommended at 3, 7, 11 & 13 years.
 Why it is applied once: a layer of CaF2 is formed it interferes with
further diffusion of F – to react with hydroxyapatitie. This is called as
choking off phenomenon
21

Mechanism of action of NaF :
Ca10(PO4)6(OH)2 + 20 F -- 10CaF2 + 6PO4 -- + 2OH
CaF2 + 2Ca5(PO4)3OH 2Ca5(PO4)3F + Ca(OH)2 [fluorapatite]
[Fluorapatite]
-- makes tooth structure more stable
-- less susceptible acid dissolution
-- interferes with plaque metabolism through anti- enzymatic action
-- helps in remineralization of initial decalcified areas
Disadvantages :
4 visits within a short
time
30% Caries reduction
Advantages :
Chemically stable
Acceptable taste
Non-irritant to gingiva
Does not discolor teeth
Inexpensive
22

II. Stannous Fluoride
Method of Preparation : (Muhler 1947)
 To prepare 8% SnF – 0.8 gms is dissolved in 10 ml of
distilled water in a plastic container and shaken.
Technique of application :
 Prophylaxis
 Teeth are isolated with cotton rolls
 SnF is applied with cotton tipped applicators
 Solution is applied continuously keeping the teeth moist for
4 min
 Instructed not to eat, drink or rinse for 30 min
 No. of application :
 6 months or 12 months
23

 Mechanism of action of SnF:
Low concentration
Ca5(PO4)3OH + 2SnF2 2CaF2 + Sn2(OH)PO4 + Ca3(PO4)2 [hydroxyapatite]
High concentration
Ca5(PO4)3OH + 16SnF2 CaF2 + 2Sn3F3PO4 + Sn2(OH)PO4
[hydroxyapatite] + 4CaF2(SnF3)2
2Ca5(PO4)3OH + CaF2 2Ca5(PO4)3F + Ca(OH)2
[fluorapatite]
Advantages :
Less appointments
required
Disadvantages :
-unstable
-fresh preparation
-Metallic taste
-gingival irritation
-brown pigmentation of teeth particularly in
hypocalcified area
-staining on margins of restorations
24

25
Title Aut
ors
&
Jour
nal
L
O
E
Aim Method Result Conclusion
Effect
of
profes
sional
flossin
g with
NaF or
SnF2
gel on
approx
imal
caries
in 13-
16-
year-
old
school
childre
n.
Gis
elss
on
H,
Birk
hed
D,
Emil
son
CG.
Act
a
Odo
ntol
Sca
nd.
201
7
3
b
The aim
of this
study
was to
evaluate
the effect
of
professio
nal
flossing
with NaF
and
gels on
caries
develop
ment on
approxim
al tooth
surfaces
Two-hundred-and-eighty
eighty 13-year-old
schoolchildren were
divided into 3 groups:
(1) NaF (n = 97),
(2) SnF2 (n = 85)
(3) placebo gel group (n
= 98).
The investigation was
carried out double-blind.
blind. The children were
treated 4 times a year
for 3 years with 1% NaF
gel, 1% SnF2 gel, or
placebo gel. The
treatment was carried
out by dental nurses
and the time required
per visit was
approximately 10 min.
After 3 years, the
mean approximal
caries increment,
including initial
caries lesions,
2.8 in the NaF, 2.4
in the SnF2, and
4.0 in the placebo
gel group (P< 0.05
for SnF2 vs
placebo); a
reduction
compared to the
placebo of 30%
and 39% in the
NaF and SnF2
groups,
respectively.
Professional
flossing with
NaF or
gel carried
out 4 times
a year may
be
considered
as an
interesting
caries-
preventing
method for
large-scale
application
in
schoolchildr
en.

 Brudevold M developed APF formula (1963)
 Gel
 Solution
APF Solution:
 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%
APF Gel
 A gelling agent methylcellulose or hydrox-ethyl cellulose is to be added to the
solution and pH is adjusted between 4 – 5
III. ACIDULATED PHOSPHATE
FLUORIDE
26

 Prophylaxis
 Application of APF gel is done using trays that fit patients’
U/L dental arches
 A disposable foam-lined tray is preferred
 Patient is seated upright in chair
 Minimum amount of APF gel should be dispensed in tray < 5
ml, custom fitted trays –1 ml
 U/L trays are inserted into the mouth and pt is asked to exert
slight pressure using light biting forces in order to cause the
gel to flow interproximal
 The gel is kept in mouth for 4 min
 Instructed not to drink, eat or rinse for 30 min
27

Mechanism of action of APF gel :
Ca(PO4)3OH + 4H+ 5Ca++ + 3HPO4
-- + H2O
[hydroxyapatite] [dehydration & shrinkage]
Ca++ + 3HPO4
-- Ca.HPO4.2H2O (DCPD)
[hydrolysis] [ Di calcium phosphate dihydrate]
(intermediate product)
5Ca.HPO4.2H2O + F- Ca5(PO4)3F + 3HPO4
-- + H+ + H2O
(DCPD) [fluorapatite]
Advantages :
Acceptable taste due to
flavoring
Easy to apply
Can be self applied
Disadvantages :
-Irritation to gingiva and
to open carious lesion
Advantages :
Acceptable taste due to
flavoring
Easy to apply
Can be self applied
Advantages :
-Acceptable taste due to
flavoring
-Easy to apply
-Can be self applied
28

29
Title Autho
rs &
Journ
al
L
O
E
Aim Method Result Conclu
sion
Does
fluori
e
gel/fo
am
applic
ation
time
affect
enam
el
demi
eraliz
tion?
Asha
nti
Braxt
on,
Latas
ha
Garre
tt,
Dara
nee
Versl
uis,
Anth
eunis
Versl
uis
2017
3
b
The purpose
of this
laboratory
study was to
ascertain if a
one-minute
application
of acidulated
phosphate
fluoride
(APF) is
equivalent to
a four-
minute
application
for reduction
of enamel
demineraliza
tion.
They measured baseline
hardness of polished bovine
enamel before treatment
with APF gel or foam for
one or four minutes (N =
10).
A control group received no
fluoride treatment.
The teeth were then
immersed in pooled human
saliva for 30 minutes, rinsed,
and subjected to lactic acid
gel to simulate the initial
stage of dental caries.
After three hours, the
hardness was measured and
the difference in hardness
was determined as an
indication of
demineralization.
We found that enamel
hardness was
significantly reduced
after exposure to lactic
acid gel.
The reduction was
significantly less in all
APF-treatment groups
compared to the
control.
However, there was no
significant difference
between a tooth
exposed to APF gel or
foam for 1 minute or
for 4 minutes
(ANOVA/Student-
Newman-Keuls,
significance level 0.05).
APF gel
and
foam
reduced
enamel
deminer
alization
regardle
ss of a
one- or
four-
minute
applicati
on time.

30
Title Autho
ors &
Journ
al
L
O
E
Aim Method Result Conclusi
n
Evaluat
on of
fluoride
release
from
teeth
after
topical
applicat
ion of
NaF,
SnF2
and
APF
and
antimicr
robial
activity
on
mutans
strepto
cocci
Shas
hikir
an
ND1,
Sub
a
Red
y
Patil
R
J
Pedi
atr
Dent
.
2016
V The
objectives of
this study
were to
evaluate and
compare the
amount and
pattern of
fluoride
release from
teeth after
topical
application of
of 2% NaF,
8% SnF2
1.23% APF
different time
time intervals
Forty premolars
divided into four
groups were
subjected to different
topical fluoride
treatments. All the
teeth were immersed
individually in
deionized water and
were transferred to
containers at 1 hour, 1
day and 1 week time
intervals. 240 samples
in total were used for
fluoride estimation by
ion selective electrode
method and the
samples from the
other subgroup were
used
All but four lesions were
categorised as arrested
caries during the 1-year
follow-up period: 18 in the
the Carisolv/Duraphat
group and 19 each in the
Duraphat and the
stannous fluoride groups,
respectively.
There was a minor
reduction in the mean
size of the lesions of
around 0.1 to 0.2 mm
height and width and a
moderate change in
colour from a lighter to a
darker appearance.
The mean percentage of
mutans streptococci in
plaque from all lesions
was 3.5% at baseline,
it decreased to 1.8%
during the year.
It can be
concluded
that the
frequent
topical
application
of fluoride
could be a
successful
treatment
for incipient
root carious
lesions,
irrespective
of the type
of fluoride
treatment
used

 Discovered by Schmidt in 1964
 Prolonged contact of fluoride with enamel.
 And a slow-release mechanism which would release fluoride when
wanted.
 Commercially available, Duraphat (22,600), fluorprotector (7000),
fluoritop, Duraflor, Carex
IV. Fluoride Varnish 31

 Oral Prophylaxis
 Teeth are isolated and dried
 A drop of varnish is taken on brush and painted thin on the teeth
 Painted first on lower arch & then on upper arch
 Patient is made to sit with mouth open for 4 min
 Patient is instructed not to rinse or drink or brush teeth for 1 hour
 Patient is instructed to take liquids or semisolid food and avoid eating
solid food
No. of application :
 Semiannual application
34

35
Advantages :
Forms a water tight protective
film insulating against thermal
and chemical influences
Varnish remains on tooth for
several days
Disadvantages :
Patient co-operation is
required
Expensive

Cleaning & drying
of Tooth Surface
Isolation was done
using cotton rolls
Application of Profluoride
varnish (5% NaF) by VOCO
Immediate after application of
NaF Varnish
Fig. 4
Fig. 3
Fig. 2
Fig. 1
Dr Susmita Shah
II MDS
Dr Susmita Shah
II MDS
Dr Susmita Shah
II MDS
Dr Susmita Shah
II MDS
36

TITLE AUTHORS &
JOURNAL
LOE Abstract
The effect
of tooth
cleaning
procedure
s on
fluoride
uptake in
enamel
Steele, Waltner
and Bawd
Journal of
Pediatric
Dentistry,4(3)1
992. 2001
3b Premolars were cleaned in different ways prior to
application of a topical fluoride gel. The teeth were
extracted one week later and the fluoride
concentrations in the surface enamel were
determined by proton activation analysis. The facial
and distal surfaces were analyzed. The results
showed that a tooth brush and floss cleaning
resulted in higher fluorine concentration than
a rubber-cup prophylaxis using either a
fluoridated or non-fluoridated prophylaxis
38

TITLE AUTHOR
S &
JOURNA
L
L
O
E
AIM Results Conclusion
Fluorid
e
varnish
es for
preven
ting
dental
caries
in
childre
n and
adoles
cents –
System
atic
Review
Valeria
CC
Marinho,
Helen V
Worthingt
on, Tanya
Walsh,
Jan E
Clarkson
Cochrane
Database
of
Systemati
c Reviews
2013,
Issue 7
1a To
determine
the
effectivene
ss and
safety of
fluoride
varnishes
in
preventing
dental
caries in
children
and
adolescent
s, and to
examine
factors
potentially
modifying
their effect
The evidence produced has been
found to be of moderate quality
due to issues with trial designs.
However in the 13 trials that
looked at children and
adolescents with permanent
teeth the review found that the
young people treated with
fluoride varnish experienced on
average a 43% reduction in
decayed, missing and filled tooth
surfaces.
In the 10 trials looking at the
effect of fluoride varnish on first
or baby teeth the evidence
suggests a 37% reduction in
decayed, missing and filled tooth
surfaces. There was little
information concerning possible
adverse effects or acceptability of
treatment.
The review
suggests a
substantial caries-
inhibiting effect of
fluoride varnish in
both permanent
and primary teeth,
however the quality
of the evidence was
assessed as
moderate, as it
included mainly
high risk of bias
studies, with
considerable
heterogeneity.
39

Title Autho
rs
Journal
and year
LOE Aim Material & Method Result Conclusio
n
Assessing
the effect of
fluoride
varnish on
early
enamel
carious
lesions in
the primary
dentition
JAAN
A T.
AUTIO
-
GOLD,
FRAN
K
COUR
TS.
JADA,
Vol. 132.
3b The aim
of this
study
was
to
evaluate
the effect
of
fluoride
varnish
on
enamel
caries
progressi
on in the
primary
dentition
One hundred
forty-two children in
Head Start schools (3 to
5 years old) were
randomized
into the varnish and
control groups. Children
in the varnish group
received fluoride varnish
(Duraphat, Colgate-
Palmolive Co.) at
baseline and after four
months, and children in
the control group
received no professional
fluoride
applications. Two
calibrated examiners
performed
the examinations at
baseline and at
nine months.
At nine months,
authors
found that in the
control group, 37.8
percent
of active enamel
lesions on occlusal,
buccal and lingual
surfaces became
inactive,
3.6 percent
progressed and
36.9 percent
did not change. In
the varnish group,
81.2 percent
became inactive,
2.4 percent
progressed and
percent did not
change.
These
results
suggest
that
fluoride
varnish
applicatio
ns may be
an
effective
measure
reversing
active pit
and-
fissure
enamel
lesions in
the
primary
dentition.
40

What is MI varnish ?
 MI Varnish is a 5% sodium fluoride varnish containing
RECALDENTTM (CPP-ACP).
 The application leaves a film of varnish on tooth surfaces and
remains on teeth for approximately four hours.
Somasundaram P, Vimala N, Mandke LG. Protective potential of casein phosphopeptide amorphous calcium
phosphate containing paste on enamel surfaces. J Conserv Dent. 2013 Mar;16(2):152-6.
41

 Contains amorphous calcium phosphate (ACP), casein phosphopeptide
(CPP) and fluoride.
 ACP is a reactive, super-saturated solution of calcium and phosphate,
which can release these ions as well as α s1-casein and β-casein.
 The ACP-CPP nanocomplex can penetrate into the enamel porosities
due to the small size of particles.
 It remineralizes the superficial enamel crystals and prevents
demineralization of tooth structure
42
Somasundaram P, Vimala N, Mandke LG. Protective potential of casein phosphopeptide amorphous calcium
phosphate containing paste on enamel surfaces. J Conserv Dent. 2013 Mar;16(2):152-6.

Title Author
s &
Journa
l
LO
E
Effects
of
treatme
nt with
three
types of
varnish
reminer
alizing
agents
on the
microha
rdness
of
deminer
alized
enamel
surface
Fahim
eh
Koosh
ki ,
Sahar
Pajooh
an ,
Sanaz
Kamar
eh
Comm
unity
and
Preven
tive
Dentist
ry
2019
Iran
V effects of
MI varnish
(3M
(United
states)) ,
Nano
paste(
FGM(Brezi
l) ), 5%
sodium
fluoride
varnish)
Duraphat
Colgate
(united
states) )
on
reminerali
zation of
enamel
lesions.
In this in-vitro study, 60 intact
human pre-molars ,were
randomly allocated to four
groups of 15. Baseline surface
microhardness in three points
in the center of the polished
area was measured. After two
days of immersion in
demineralizing solution,
microhardness of all samples
was measured. Afterward,
groups 1- MI
varnish(CPP_ACP) Group 2-
nano paste(calcium
nanophosphate )
Group 3- 5% sodium fluoride
varnish and then again
microhardness was measured.
The results were analyzed by
one-way analysis of variance
(ANOVA), repeated measures
ANOVA, and Bonfreni table
was used.
Duraphat varnish
in comparison
with control
group,
significantly
increased surface
microhardness
and in
with Nano and MI
paste varnish
groups significant
differences was
shown between
groups. (P< 0.05).
MI paste varnish
and Nano paste
similary showed
more increases in
surface
microhardness in
comparison with
Duraphat varnish
and control
groups.
According to the
results of this study
,all three varnishes,
Duraphat , MI
and Nano paste
increase the
surface
microhardness and
remineralization of
incipient caries. MI
paste and Nano
paste compared to
Duraphat Varnish,
significantly
showed more
increases in enamel
surface
microhardness but
Nano paste and MI
paste were almost
the same.
43

Title Author
s &
Journa
l
L
O
E
Preven
tion of
white
spot
lesions
using
three
remine
ralizin
g
agents
An in
vitro
compa
rative
study
Soode
h
Tahma
sbi,
Seyed
ezahra
Mousa
vi,
Marjan
Behro
ozibak
hsh,
Moha
mmad
reza
Badiee
J Dent
Res
Dent
Clin
Dent
Prospe
ct 2019
V compare the
efficacy of
sodium
fluoride (NaF),
casein
phosphopepti
de
calcium
phosphate
fluoride (CPP-
ACP-F; MI
Paste Plus)
and a water-
based cream
(Remin Pro),
which
contains
hydroxyapatit
e and fluoride
for prevention
of enamel
demineralizati
on.
Fifty-six sound human premolars
extracted for orthodontic
were collected.
After cleaning, the crowns were
mounted in acrylic resin and all
surfaces were coated with nail
varnish except for a 3×4-mm
window on the buccal surface.
The samples were randomly
divided into four groups of 14
Group 1- sodium fluoride (NaF),
Group 2- casein phosphopeptide
amorphous calcium phosphate
fluoride (CPP-ACP-F; MI Paste
Plus)
Group 3- a water-based cream
(Remin Pro)
Group 4- control group
subjected to pH cycling for 14
days, during which the teeth were
immersed in artificial saliva for 21
hours and in demineralizing agent
for three hours daily.
The mean
microhardne
ss was
significantly
different
between the
test and
control
groups
(P<0.0001).
Other
differences
were not
significantly
different
(P>0.05).
The results showed
that NaF was more
efficient than
Pro and MI Paste
Plus for prevention
of white spot
lesions (WSLs).
Remin Pro and MI
Paste Plus were not
significantly
difference from the
control group in
this regard.
44

Title Aut
hor
s &
Jou
rnal
L
O
E
Compar
ative
Evaluati
on of
Reminer
alization
Potential
of Two
Varnishe
s
Containi
ng CPP–
ACP
Tricalciu
m
Phospha
te: An In
Vitro
Study
He
de
S,
Bha
t S,
Sar
god
S,
Rao
A.
IJP
D,
201
9
V to
evaluate
the
reminera
lization
potential
of
Clinpro
XT
varnish
containi
ng
tricalciu
m
phospha
te (TCP)
and MI
varnish
containi
ng
(CPP_AC
P)
Thirty premolar teeth were taken
and divided into three groups.
Samples were sliced mesiodistally
into buccal and lingual halves
a diamond disk bur. The buccal
halves of the teeth were used for
the study. Artificial caries like
lesions were produced and
evaluated with Diagnodent. The
samples in each group were
with the respective remineralizing
agent (except for the control
group) at every 24 hours for 7
and the surfaces were assessed
using Diagnodent to record the
values after the remineralization
procedure.
The Diagnodent values obtained
were tabulated and statistically
analyzed using one-way ANOVA
and Tukey’s multiple comparison
tests.
The
study
findings
showed
that MI
varnish
containi
ng CPP–
ACP
the
highest
release
of
fluoride
as
compar
d to the
Clinpro
fluoride
releasin
g
varnish.
MI varnish is a 5%
NaF varnish
containing CPP–
ACP to give an
exceptional
fluoride varnish
that releases
bioavailable
fluoride, calcium,
and phosphate.
hence, can be
used successfully
in
of early carious
lesions. CPP–ACP
can be used in
clinical practice
reversing or
arresting the early
carious lesions.
45

46
Title Authors
&
Journal
L
O
E
Aim Method Result Conclusio
n
Evalu
ation
of
differ
ent
fluori
de
treat
ment
s of
initial
root
cario
us
lesion
s in
vivo.
Fure
S1,
Lingstr
öm P
Oral
Health
Prev
Den
2019
3
b
The aim
of this
study
was to
evaluate
the
efficacy
of three
topical
fluoride
treatmen
ts to
arrest
initial
root
carious
lesions.
Forty patients
participated in a
randomised study. Of
the 60 root carious
lesions that were
included, 20 were
randomised for
treatment with the
Carisolv chemo-
mechanical technique
and the Duraphat
(2.23% F) fluoride
varnish,
20 with Duraphat
20 with stannous
fluoride solution (8%).
The lesions were
at baseline and after
three and six months; a
clinical evaluation was
carried out on these
occasions and after 1
year.
The results showed that
the highest fluoride
release (7.83 +/- 0.55
ppm) was seen in SnF2
treated specimens, as
compared to that of NaF
(3.71 +/- 0.60ppm) and
APF (3.30 +/- 0.51ppm),
the difference being
statistically significant
(P<0.01). This was
observed immediately
after 1 hour, followed by a
drastic reduction
thereafter. No zones of
inhibition were observed
at the released fluoride
concentrations at different
time intervals in the
different groups.
8% SnF2
expected
to have
greater
anticaries
property
from the
high
fluoride
releasing
property
for
prolonged
period of
time.

V. Silver Diamine Fluoride
 SDF has been used as an alternative treatment for
caries prevention and arrest.
 In 2014, SDF was approved by the US Food and Drug
Administration as a treatment for dentinal sensitivity.
 SDF had been used off-label for caries arrest; however,
it was recently approved (code D1354) as an interim
caries arresting medicament.
 It is only applied on carious lesion without evidence of
pulp involvement.
Rs. 2500/-
Crystal YO, Niederman R. Silver diamine fluoride treatment considerations in children’s caries
management. Pediatr Dent 2016;38(7):466-71.
47

How does it work?
38% Silver Diamine Fluoride
• equivalent to five percent
fluoride in a colorless liquid, with
a pH of 10
fluoride ions act mainly on the
tooth structure
• silver ions are
antimicrobial
SDF reacts with hydroxyapatite in
an alkaline environment to form
calcium fluoride (CaF2) and silver
phosphate as major reaction
products
• CaF2 provides
sufficient fluoride
to form
fluorapatite
49

 Adverse Effects:
 Discoloration of demineralized or cavitated surfaces as a result of silver
phosphate precipitation.
 Metallic/bitter taste
 Temporary staining to skin which resolves in 2-14 days
 Mucosal irritation/lesions resulting from inadvertent contact with SDF,
resolved within 48 hours.
Indications:
-difficult-to-treat lesions
-patients with high caries risk
-those who require multiple
treatment visits
- No access to dental care
- limited cooperation
Contraindications:
1. Allergy to silver
2. Pregnancy
3. Breastfeeding
4. Ulcerative gingivitis
5. Stomatitis
50

AAPD Guidelines
 SDF is a valuable caries lesion– arresting tool that can be used in the
context of caries management.
 Evaluate carefully which patients/teeth will benefit from SDF application.
 Effectiveness of one-time SDF application in arresting dental caries
lesions ranges from 47 percent to 90 percent, depending on the lesion
size and the location of the tooth and the lesion. One study showed that
anterior teeth had higher rates of caries lesion arrest than posterior
teeth.
51
American Academy of Pediatric Dentistry. Policy on the Use of Silver Diamine Fluoride for Pediatric
Dental Patients.. REFERENCE MANUAL V 40 / N O 6 1 8 / 19. 2018.

TITL
E
AUTHO
RS &
JOURN
AL
L
O
E
AIM Methodology Conclusion
Antibact
erial
Effect of
Silver
Diammi
ne
Fluoride
on
Carioge
nic
Organis
ms
Yali Lou,
Brian W
Darvell,
Michael G
Botelho
The Journal
of
Contempora
ry Dental
Practice,
May
2018;19(5):5
91-598
V To screen the
possible
antimicrobial
activity of a
range of
clinically used,
silver-based
compounds on
cariogenic
organisms:
silver
diammine
fuoride (SDF),
silver fuoride,
and silver
nitrate.
Preliminary screening disk-diffusion
susceptibility tests were conducted on
Mueller–Hinton agar plates inoculated with
Streptococcus mutans, Lactobacillus
acidophilus, and Actinomyces naeslundii,
organisms known to be cariogenic. In
order to identify which component of the
silver compounds was responsible for any
antibacterial (AB) effect, and to provide
controls, the following were also
investigated at high and low
concentrations: sodium fluoride,
ammonium fluoride, ammonium chloride,
sodium fluoride, sodium chloride, and
sodium nitrate, as well as deionized water
as control. A volume of 10 μL of a test
solution was dispensed onto a paper disk
resting on the inoculated agar surface, and
the plate incubated anaerobically at 37°C
for 48 hours. The zones of inhibition were
then measured.
Silver ions appear
to be the principle
AB agent at both
high and low
concentration;
fluoride ions only
have an AB effect
at high
concentration,
while ammonium,
nitrate, chloride
and sodium ions
have none. The
anti-caries effect of
topical silver
solutions appears
restricted to that
of the silver ions.
52

TITLE AUTHOR
S &
JOURNA
L
L
O
E
AIM Material & Methodology Conclusion
Effective
ness of
silver
diamine
fluoride
in caries
preventi
on and
arrest: a
systema
tic
literatur
e review
Violeta
Contreras,et
al.
Gen Dent.
2017 ; 65(3):
22–29.
1a This study
aimed to
evaluate the
scientific
evidence
regarding the
effectiveness
of silver
diamine
fluoride (SDF)
in preventing
and arresting
caries in the
primary
dentition and
permanent
first molars.
systematic review (SR) was performed by 2
independent reviewers using 3 electronic
databases (PubMed, ScienceDirect, and
Scopus). The database search employed the
following key words: “topical fluorides” AND
“children” AND “clinical trials”; “topical
fluorides” OR “silver diamine fluoride” AND
“randomized controlled trial”; “silver diamine
fluoride” AND “children” OR “primary
dentition” AND “tooth decay”; “silver diamine
fluoride” OR “sodium fluoride varnish” AND
“early childhood caries”; and “silver diamine
fluoride” AND “children”. Inclusion criteria
were articles published in English, from 2005
to January 2016, on clinical studies using SDF
as a treatment intervention to evaluate caries
arrest in children with primary dentition
and/or permanent first molars. Database
searches provided 821 eligible publications,
of which 33 met the inclusion criteria.
The literature
indicates that
SDF is a
preventive
treatment for
dental caries in
community
settings.
At
concentrations
of 30% and
38%, SDF shows
potential as an
alternative
treatment for
caries arrest in
the primary
dentition and
permanent first
molars.
53

Title Autho
s
Journa
and
year
L
O
E
Aim Material & Method Result
Effect of
fluoridate
d varnish
and silver
diamine
fluoride
on
enamel
demineral
ization
resistance
in
primary
dentition
Najme
h
Moha
mmadi,
Moha
mmad
Hossei
n
Farahm
and
Far.
Journal
of
Indian
Society
of
Pedod
ontics
and
Prevent
ive
Dentist
ry
(2018)
3
b
to
compare
the effect
of
fluoridate
d varnish
and silver
diamine
fluoride
(SDF)
solution
on
primary
teeth
enamel
resistance
to
deminerali
zation.
Forty-five caries-free deciduous
canine teeth extracted due to
orthodontic reasons, devoid of
any defects were selected. Teeth
were mounted on acrylic blocks
as their buccal surface was
exposed and baseline surface
microhardness (SMH)
determination was
accomplished. Enamel samples
were randomly distributed into
three groups with 15 specimens
each. One group was used as
control (distilled and deionized
water) (C); in the other groups,
either a fluoridated varnish (V)
or an SDF solution was applied
to the enamel blocks.
According to the
present findings,
the percentage
of decrease in
SMH of control
group is
numerically
greater than
other groups
and also SDF
group shows the
most resistance
against mineral
loss. However,
based on
one-way
ANOVA test, this
difference is not
statistically
significant (P =
0.217).
54

56
Morphis T. Fluoride Pit & Fissures: A review. IJPD 2000: 10; 90-98.

6. Self Applied Fluoride Agents
57

 fluoride dentifrice- around 1945
 Effective means of providing partial
protection against dental caries
 Fluoride compounds which have been
incorporated into toothpaste include –
NaF, SnF, sodium
monofluorophosphate, and ammine
fluoride
a. FLUORIDE DENTIFRICE 58
Composition Range in formulation
%
Abrasive 40 – 50 %
Humectant 20 – 40 %
Detergent 1 – 2 %
Binding agent 0.5 – 2 %
Flavor, color 1 – 4 %
Fluoride 0.1%
Water 20 – 30 %

59
www.amazon.in
www.indiamart.com
Rs. 165/-
Rs. 89/-
Rs. 91.2/-
Rs. 77/-
Rs. 102/-
Rs. 80/-
Rs. 200-500/-

Title Auth
ors
&
Jour
nal
L
O
E
Comp
arative
effect
of a
stann
ous
fluorid
e
tooth
paste
and a
sodiu
m
fluorid
e
tooth
paste
on a
multis
pecies
biofil
m.
Chen
g X,
Liu
J2, Li
J,
Zhou
X,
Wan
g L,
Liu J,
Xu X.
Arch
Oral
Biol.
2017
V to
compare
the
mode of
action of
a
stannous
fluoride-
containi
g
toothpas
te with a
conventi
onal
sodium
fluoride-
containi
g
toothpas
te on
anti-
biofilm
properti
es.
A three-species biofilm model
that consists of Streptococcus
mutans, Streptococcus sanguinis
and Porphyromonas gingivalis
was established to compare the
anti-biofilm properties of a
stannous fluoride-containing
toothpaste (CPH), a conventional
sodium fluoride-containing
toothpaste (CCP) and a control.
The 48h biofilms were subjected
to two-minute episodes of
treatment with test agents twice
day for 5 consecutive days.
Crystal violet staining and XTT
assays were used to evaluate the
biomass and viability of the
treated biofilm. Live/dead
staining and
polysaccharides (EPS) double-
staining were used to visualize
the biofilm structure and to
quantify microbial/ extracellular
components of the treated
biofilms.
The biomass and
viability of the biofilms
were significantly
reduced after CPH
toothpaste treatment.
The inhibitory effect
further confirmed by
the live/dead staining.
The EPS amounts of the
three-species biofilm
were significantly
reduced by CCP and
CPH treatments, and
CPH toothpaste
demonstrated
significant inhibition on
EPS production. More
importantly, CPH
toothpaste significantly
suppressed S. mutans
and P
. gingvalis, and
enriched S. sanguinis in
the three-species
biofilm.
Stannous fluoride-
containing
toothpaste not
only showed
better inhibitory
effect against oral
microbial biofilm,
but was also able
to modulate
microbial
composition
multi-species
biofilm compared
with conventional
sodium fluoride-
containing
toothpaste
61

b. Fluoride mouth rinses
 Fluoride mouth rinses generally have been found efficacious as a
means of controlling dental caries incidence.
 the daily use of a 0.05% NaF solution (230 ppm F) a 0.44% APF solution,
while high potency/low frequency protocols tested weekly or biweekly
use of a 0.2% NaF rinse (900 ppm F).
 reductions in caries increments of up to 80%
 evaluated fluoride mouth rinse in combination with fluoride-
containing dentifrices, tablets, varnishes, or gels.
 fluoride rinses offered little benefit over the use of fluoride-containing
dentifrices, tablets (in a "chew, swish, swallow" regimen), or varnishes.
 The combination of mouth rinse and gel was impressive, given a 30%
caries reduction in an optimally fluoridated community
62
The role of fluoride mouth rinses the control of dental caries: a brief review. Pediatric Dentistry -20.’2, 1998 American Academy
of Pediatric Dentistry. 101-104.
J Murray, A J Rugg Gunn, G N Jenkins. Fluorides n caries Prevention. 3rd Edition. 1991. Vaghese Publishing House, Mumbai.

63
TITLE AUTH
ORS &
JOURN
AL
L
E
Effect of
Herbal and
Fluoride
Mouth Rinses
on
Streptococcus
mutans and
Dental Caries
among 12–15-
Year-Old
School
Children: A
Randomized
Controlled
Trial
Somraj V
et al.
Internati
onal
Journal
of
Dentistr
y 2017
3b To assess
compare
the effect of
of herbal &
fluoride
mouth
rinses on
Streptococc
us mutans
count and
glucan
synthesis
by
Streptococc
us mutans
and dental
caries,
a parallel group placebo
controlled randomized trial
was conducted among 240
schoolchildren (12–15 years
old). Participants were
randomly divided and
allocated into Group I (0.2%
fluoride group), Group II
(herbal group), and Group III
(placebo group). All received
10ml of respective mouth
rinses every fortnight for a
period of one year
The present
study showed that
both herbal and
fluoride mouth
rinses, when used
fortnightly, were
equally effective and
could be
recommended
for use in school-
based health
education program
to control dental
caries.

64
TITLE AUTH
ORS &
JOURN
AL
L
E
Combinations
of topical
fluoride
(toothpastes,
mouthrinses,
gels,
varnishes)
versus single
topical fluoride
fluoride for
preventing
dental caries
in children and
and
adolescents
Marinho
V,
Higgins
P,
Sheiham
A, Logan
S.
Cochran
e
Databas
of
Systema
ic
Reviews
2004,
Issue 1
3b To compare
the
effectivene
ss of two
TFT
modalities
combined
with one of
them alone
(mainly
toothpaste)
when used
for the
prevention
of dental
caries in
children.
Randomized or quasi-
randomized controlled
trials with blind outcome
assessment, comparing
fluoride varnish, gel,
mouthrinse, or toothpaste
in combination with each
other in children up to 16
years during at least 1
year. The main outcome
was caries increment
measured by the change in
decayed, missing and filled
tooth surfaces (D(M)FS).
Topical fluorides
(mouthrinses, gels,
or varnishes) used
in addition to
fluoride toothpaste
achieve a modest
reduction in caries
compared to
toothpaste used
alone. No
conclusions about
any adverse effects
could be reached,
because data were
scarcely reported in
the trials.

8. Recommendations for
use of Fluorides in Pediatric
Dentistry
65

c. Flouride Chewable Tablets
 Composition
 Sodium Fluoride - 0.25 mg / 0.5 mg /
1.0 mg
 citric acid, magnesium stearate, malic
acid, microcrystalline cellulose, orange
flavor, sucralose, talc, xylitol.
 Clinical Pharmacology
 Sodium Fluoride acts systemically
(before tooth eruption) and topically
(post-eruption) by increasing tooth
resistance to acid dissolution, by
promoting remineralization, and by
inhibiting the cariogenic microbial
process.
Aasenden, R., and Peebles, T.C. "Effects of Fluoride
Supplementation From Birth on Dental Caries and Fluorosis in
Teenaged Children", Arch. Oral, Biol., 23, 111–115 (2014).
67

 Indications: Sodium Fluoride Chewable Tablets were developed
to provide systemic fluoride for use as a supplement in pediatric
patients from age 3 years to age 16 years and older living in
where the drinking water fluoride contents does not exceed 0.6
ppm F¯.
Aasenden, R., and Peebles, T.C. "Effects of Fluoride Supplementation From Birth on Dental Caries and Fluorosis in
Teenaged Children", Arch. Oral, Biol., 23, 111–115 (2014).
J Murray, A J Rugg Gunn, G N Jenkins. Fluorides in caries Prevention. 3rd Edition. 1991. Vaghese
Publishing House, Mumbai.
68

 Welton 2004; Bernabe 2009; Bagramian et al 2009-
dentin lesions under non cavitated enamel
 Fluoride syndrome, Fluoride bomb, Hidden caries
69
An Insight to Occult Caries- An Overview with a Novel Approach in
the
Management
Journal of Oral Hygiene & Health. Volume 3 • Issue 3. 2015

70
Aasenden, R., and Peebles, T.C. "Effects of Fluoride Supplementation From Birth on Dental Caries and Fluorosis
in Teenaged Children", Arch. Oral, Biol., 23, 111–115 (2014).

e. CPP- ACP-F
 The soluble form of RECALDENT™ with incorporated fluoride
(CPP-ACPF) is used as an active ingredient to provide extra
protection for teeth, buffers dental plaque acid from bacteria in
the mouth and also protects teeth from acidic foods and drinks.
72
INDICATIONS
•To provide extra protection for teeth
•After tooth whitening
•For desensitizing
•During and/or after orthodontics
•For medically compromised patients
•For salivary deficiency; dry mouth
•For patients with acidic, oral environments
•For erosion and gastric reflex
•For patients with poor plaque control
•For high-caries risk patients
Rs. 695

f. Dental floss 75
www.indiamart.com

 Overdosage
 Prolonged daily ingestion- varying degrees of fluorosis.
 Accidental ingestion of fluoride- acute burning in the mouth and sore tongue.
 Nausea, vomiting, and diarrhea (within 30 minutes)
 accompanied by salivation, hematemesis, and epigastric cramping abdominal pain.
 These symptoms may persist for 24 hours.
 If less than 5 mg fluoride/kg body weight have been ingested, give
(e.g. milk) orally to relieve gastrointestinal symptoms and observe for a few
hours.
 If more than 5 mg fluoride/kg body weight have been ingested, induce
vomiting, give orally soluble calcium (e.g., milk, 5% calcium gluconate or
calcium lactate solution) and immediately seek medical assistance.
 For accidental ingestion of more than 15 mg fluoride/kg body weight,
induce vomiting and admit immediately to a hospital facility.
Aasenden, R., and Peebles, T.C. "Effects of Fluoride Supplementation From Birth on Dental
Caries and Fluorosis in Teenaged Children", Arch. Oral, Biol., 23, 111–115 (2014).
76

8. Summary
 Dental caries is second world wide chronic disease, If caries
remains untreated, oral and overall health–related quality of life is
compromised.
 Caries in deciduous teeth is a vital predictor for adult caries in
permanent dentition. So measures for prevention, early diagnosis
& intervention may prevent the deleterious effect of dental caries
 In this era of advances FV & SDF is boon for caries prevention &
arrest respectively.
78

9. Bibliography
 Níkíforuk G, Understanding Dental Caries Prevention Basic and
Clinical Aspects, KARGER 1985.
 Ole Fejerskov & Edwina A M Kidd. Dental Caries. The disease & Its
Clinical Management. Blackwell Munksgard. 2003
 J Murray, A J Rugg Gunn, G N Jenkins. Fluorides n caries Prevention.
3rd Edition. 1991. Vaghese Publishing House, Mumbai.
 Ekstrand, Fejerskov, Silverstone. "Fluoride in dentistry". 1998
 American Academy of Pediatric Dentistry. Policy on Early Childhood
Caries (ECC): classification, consequences, and preventive strategies.
Pediatr Dent. 2014; 37(6 Reference Manual):50–52.
 Somasundaram P
, Vimala N, Mandke LG. Protective potential of
casein phosphopeptide amorphous calcium phosphate containing
paste on enamel surfaces. J Conserv Dent. 2013 Mar;16(2):152-6.
79

 American Academy of Pediatric Dentistry. Policy on the Use of Silver
Diamine Fluoride for Pediatric Dental Patients.. REFERENCE
MANUAL V 40 / N O 6 1 8 / 19. 2018.
 Mcdonald RE, Avery DR, Dean JA. Dentistry for the Child and
Adolescent. 8th ed. 2004: Mosby; Elsevier. p. 390-412.
 Crystal YO, Niederman R. Silver diamine fluoride treatment
considerations in children’s caries management. Pediatr Dent
2016;38(7):466-71.
 Marinho VCC, Chong L, Worthington HV, Walsh T. Fluoride mouthrinses
for preventing dental caries in children and adolescents. Chochrane
database. 29 July 2016.
 The role of fluoride mouth rinses the control of dental caries: a brief
review. Pediatric Dentistry -20.’2, 1998 American Academy of Pediatric
Dentistry. 101-104
 Is there hidden caries or is this limitation of the conventional
exams? Journal of Dentistry & Oral Hygiene Vol 7(4);48-53 April
80

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