6.topical fluorides

TOPICAL FLUORIDES DELIVERY METHODS

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CHAITANYA.PII MDSDept of Public Health Dentistry

Previous Questions

• Dental fluorides Nov 2013. • Slow release fluoride devices. Apr 2015, Aug 2013• Controversies about the use of fluoridated dentifrices. Oct

2011.• Fluoride toxicity. Jun 2013.

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Contents• Introduction• Types of fluorides delivery• Types of topical fluorides a) Professional b) Self• Recent advances in topical application• Fluoride toxicity• Conclusion• References

Topical

Systemic

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Introduction• Fluoride is the reduced form of the element fluorine.

• Its atomic weight is 19 and atomic number is 9.

• In nature it occur in the form of fluorspar(CaF2), fluorappatite

(Ca10(PO4)6F2) and cryolite (Na3ALF6).

• Fluorides are used in various forms for prevention of caries.

• It occurs in natural water resources and influence the mineralization of

teeth.

Ref : MS Muthu pediatric dentistry principles and practice, 2nd edition,2011; pg:149, Elsevier publications.

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Fluorides Delivery Methods

TOPICAL FLUORIDES

SELF APPLIEDPROFESSIONAL

•Neutral Sodium fluoride

•Stannous fluoride

•APF Solu /Gels

•Varnish

•Dentifrices

•Mouth Washes

•Fluoride Gels

FLUORIDES

SYSTEMIC FLUORIDES

I. Water Fluoridation

i. Community Water

Fluoridation

ii. School Water Fluoridation

II. Salt Fluoridation

III. Milk Fluoridation

IV. Fluoride tablets/ drops/ lozenges5

Topical Fluorides

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• Topical fluorides are those fluoride containing agents which are applied to

the tooth surface in regular intervals in order to prevent the development of

caries.

• These exert an anticaries effect by increasing the concentration of fluoride in

the outermost surface of the enamel.

Indications for topical Fluorides

1. Caries-active individuals i.e. those with past caries experience or those who

develop new carious lesion on smooth tooth surfaces.

2. Children shortly after periods of tooth eruption, especially those who are not

carries free.

3. Medication to reduce salivary flow or had undergone head and neck radiation.

4. After periodontal surgery when roots of teeth have been exposed.

5. Patients with fixed or removable prosthesis and after placement or replacement

of restorations.

6. Patients with an eating disorder or who are undergoing a change in lifestyle

which may affect eating or Oral Hygiene Habits conductive to good oral health.

7. Mentally or physically challenged individuals.

Ref : MS Muthu, Pediatric dentistry principles and practice, 2nd edition,2011; pg:155-159, Elsevier publication.Ref: J.J.Murray, Fluorides in caries prevention, 3rd edition, 1999; pg:179-207,Butterworth-Heinemann publication.

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Professionally applied topical fluorides:

It was introduced by Bibby in 1942.

Bibby in 1942 was the first to demonstrate that the, repeated application of

sodium or potassium fluorides to teeth of children significantly reduced their

carries prevalence. This achievements became the fore runner of many studies to

test the effectiveness of various topical fluorides and the effective methods of its

application.

Involve the use of high fluoride concentration products ranging from 5000-

19,000ppm, which is equivalent to 5-19 mgF/ml.

Topical fluorides are divided into two categories

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Self applied products:

Include fluoride dentifrices, mouth rinses & gels

Are low fluoride concentration products ranging

from 200-1000ppm or 0.2-1 mgF/ml.

Professionally Applied Fluorides

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1.SODIUM FLUORIDE

2.STANNOUS FLUORIDE

3.ACIDULATED PHOSPHATE FLUORIDE

4. VARNISH

Ref: MS Muthu, Pediatric dentistry principles and practice, 2nd edition,2011; pg:155-159, Elsevier publication.Ref: J.J.Murray, Fluorides in caries prevention, 3rd edition, 1999; pg:179-207,Butterworth-Heinemann publication.Ref: Shobha tandon, Text book of Pediatric dentistry, 3rd edition,2009:pg.160-204, paras medical publishers

Topically fluoride application by a Dentist , Dental Hygienist or

any other Dental Auxiliary has become an established Caries-Preventive Procedure in the Dental History.

The fluoride may be used in an aqueous solution, a viscous gel, a

prophylactic paste or as a dental varnish and can be applied using the

Paint on Technique or the Tray Technique.

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Paint on Technique

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Hodgson (2005) has suggested an alternative technique utilizing a 5 ml plastic

syringe. This method allows a more efficient application of the varnish which

can be particularly useful in cases where speed is important, such as with a

difficult pediatric patient.

Tray Technique

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Neutral Sodium Fluoride (NaF)

Neutral Sodium Fluoride(NaF) was the first fluoride compound to be used for

topical fluoride application. A minimum of four applications of with 2% Sodium

Fluoride solution gives a caries reduction of about 30%.

Methods of preparation of 2% NaF

It is prepared by dissolving 20gm of Sodium Fluoride powder in one liter(1000ml)

of distilled water in plastic bottle. It is essential to use plastic bottles because if

stored in glass bottles it may react with silica and form Silicon Fluoride thus by

reducing the availability of free active fluoride of anti-caries action.

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Procedure for application of Sodium Fluoride [ Knutsons Technique ]:

oral prophylaxis done

teeth isolated either by quadrant or by half mouth

2% NaF solution is painted on the air dried teeth so that all surfaces are visibly wet

allowed to dry for 3-4 minutes

repeated for each of the isolated segments until all teeth are treated

2nd, 3rd and 4th NaF application, each not preceded by a prophylaxis, is scheduled at intervals of approximately one week.

The fourth visit procedure is recommended for ages 3,7,11 and 13 years, coinciding with the eruption of different age groups of primary and permanent teeth. Thus, most of the teeth will be treated soon after their eruption, maximizing the protection afforded by topical application. 15

Mechanism of ActionNaF Hydroxyapatite crystals Calcium Fluoride reacts forms

“Chocking Off Effect”[as thick layer of formation of Calcium fluoride forms , it interferes diffusion of F from

NaF solution to react with hydroxyapatite and blocks further entry of F ions]And acts as resorvior for F release [it is the reason allowed to dry for 3-4 minutes]

Calcium Fluoride Hydroxyapatite crystals Fluoridated Hydroxyapatite

increase of fluoride content on enamel surface resistance against caries attack

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Advantages :

• Relatively stable when kept on a plastic bottles

• Taste well accepted by patients.

• Non- irritant to Gingiva

• Doesn't results in discoloration of teeth

• Once applied allowed to dry for 3-4 minutes so can pursue a multiple-chair

procedure in public health programme.

• The series of treatment must be repeated only four times in general age range

of 3-13 years rather than annual or semiannual intervals, therefore in public

health program, other group of children can be treated in intervening years.

Disadvantages:

• The only disadvantage is that the patient has to make four consecutive visits

within a short period of time.

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Stannous Fluoride(SnF2)

Stannous Fluoride has been used at 8% and 10% concentrations in

solutions equivalent to 2 and 2.5% fluoride. Although 10% solutions used

for adults and 8% for children there is no any clinical difference between

the two. However 8% Stannous Fluoride is preferred.

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Methods of Preparation of Stannous Fluoride

Solutions of Stannous Fluoride are not stable so soon after

mixing they become cloudy due to formation of Tin Hydroxide reducing the agents

effectiveness. Since, Stannous is believed to contribute to anticarries benefits, aged

solutions are considered to be clinically less effective so Muhler et al

recommended to use fresh solutions of Stannous Fluoride for each patients.

To prepare 8%Stannous Fluoride solution the content of one capsule which is 0.8

gm(‘0’ no.gelation capsule) is dissolved in 10ml of distilled water in the plastic

bottles and shaken briefly.

Procedure for application of Stannous Flouride [ Muhler’s Technique ]

Teeth cleaned with aqueous pumice slurry

Un-waxed dental floss is passed between the inter-proximal areas.

Teeth are isolated and dried with air.

SnF2 is applied using the paint on technique and the solution is kept for 4 minutes.

Repeat applications are made every 6 months or more frequently if patients is susceptible to caries.

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Mechanism of Action

SnF2 Low concn tin Hydroxyphosphate oral fluids dissolve it forms gets

”metallic taste application”

SnF2 high concentration

Calcium tri-fluoro-stannate Tin tri-fluoro-phosphate

“Tin tri-fluoro-phosphate makes tooth surface more stable & less suspectibility to decay”

Calcium fluoride is also formed both at high and low conc which reacts with hydroxyapatite and

results in formation of fluorohydroxyapatite.

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• Advantages:

– Using 8% Stannous Fluoride solution at 6-12 months

intervals conforms to the practicing dentist’s usual patient – recall

system.

– Administrative difficulties, particularly in public health programs.

• Disadvantages:

– In aqueous solution the Stannous Fluoride is not stable.

– Since 8% solution is quite astringent and disagreeable in taste, its

application is unpleasant

– The solution usually causes reversible tissue irritation manifested by

gingival blanching usually on individuals with poor oral hygiene.

– It usually causes pigmentation on teeth which has characteristic light

brown color. Staining usually appears in association with carious

lesions, hypo calcified regions and around margins of restorations.

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Acidulated Phosphate Fluoride (APF)

Acidulated Phosphate fluoride was introduced in1960’s by Brudevold and his

co-workers at the Forsyth Dental Center, Boston, Massachusetts.

Methods of preparation of Acidulated Phosphate Fluoride

An aqueous solution of Acidulated Phosphate Fluoride is prepared by dissolving

20gms of Sodium Fluoride in 1 lit of 0.1 M phosphoric acid and then 50%

hydrofluoric acid added to adjust the pH at 3.0 and fluoride ion concentration at

1.23%. It is also called as Brudevold’s Solution.

For the preparation of Acidulated Phosphate Fluoride gel, a gelling agent

methylcellulose or hydroxyethyl cellulose is added to the solution and the pH is

adjusted between 4-5.23

Procedure for application of Acidulated Phosphate Fluoride

The patient seated upright position in chair & Oral prophylaxis is done& teeth are treated completely.

Clinical application of APF gel by tray technique [disposable foam line tray is preferred]

To reduce ingestion a minimal amount of fluoride gel kept [coverage of tooth surfaces ,<5ml ]

The patient is told not to swallow the gel but to exert slight pressure using the cheeks and the tongue as well as light biting forces in order to cause the gel to flow inter-proximally. The gel thins

out under the biting force because of thixotropic nature.

The fluoride gel should be in mouth for 4 minutes and remaining oral fluids should be expectorated.

saliva ejector is used to wipe out saliva and excess fluoride

The patient is instructed not to eat drink or rinse his mouth for at least 30 minutes.

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Mechanism of ActionAPF applied

Initially leads to dehydration & shrinkage of hydroxyapatite crystalshydrolysis

Dicalcium phosphate dihydrate (DCPD) highly reactive with fluoride ion

Fluoride penetrates into crystals deeply through openings produced by shrinkage and leads to formation of Fluoroapatite

The amount of Fluoroapatite deposited dependent on DCPD formation. For conversion of DCPD into fluoroapatite deeper penetration and continuous supply of Fluoride required. Hence APF solution was applied at 30 sec intervals and teeth kept wet for 4 minutes.High fluoride concentration and low pH, favors fluoride deposition, acidification of fluoride solution with phosphoric acid found to suppress dissolution of enamel, as well as formation of calcium fluoride

The intermediate product DiCalcium phosphate & principal reaction product Calcium fluoride 26

Advantages:• Requires only 2 application in a year and is thus suited for most dental

office routines.• The gel preparation can be self applied and the cost of application also gets

reduced.• It has the ability to deposit fluoride in enamel to a deeper depth than a

neutral Sodium Fluoride or Stannous Fluoride.• Acidulated Phosphate Fluoride is stable and need not be freshly prepared

for each individual.

Disadvantages:• Practical difficulties like the teeth should be kept wet for four minutes so

repeated application necessitates the use of suction thereby minimizing its use in the field. This also increase the chair side time making this methods more expensive.

• It is acidic, sour and bitter in taste.

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ComparisonCharacterstics Sodium Flouride

(NaF)Stannous Fluoride (SnF2)

APF

Percentage 2% 8% 1.23%

Fluoride concn.(ppm) 9,200 19,500 12,300

pH Neutral (7) 2.4 - 2.8 3.0

Frequency of Application 4 at weelky intervals3,7,11,13 yrs

Biannually Biannually

Adverse effect - Tooth pigmentationGingival irritation

-

Caries reduction 30% 32% 28%

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1.FLUORIDE VEHICLES:

Aqueous solutions & gels

The gel adheres to teeth & eliminates the

continuous wetting of enamel surfaces

required when solutions are used.

Thixotropic solutions are not gels, but

have a high viscosity under storage

conditions & become fluid under conditions

of high stress

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FLUORIDATED PROPHYLACTIC

PASTES:

If prophylaxis pastes containing

fluoride are used, the lost fluoride is

replenished & there is a significant gain

in the concentration of fluoride.

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FOAM:

Developed to minimize the risk of fluoride over dosage as well as to

maintain the efficacy of topical fluoride treatment.

Advantages :

Its lighter than a conventional gel & therefore only a small amount of

agent is needed for topical application

The surfactant has cleansing action by lowering surface tension, this

facilitates the penetration of material into interproximal surfaces.

It doesn’t require suctioning so it offers advantages for home use

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FLUORIDE VARNISH:

Increasing the time of contact between enamel surface & topical fluoride agents favours the deposition of fluorapatite & fluorhydroxyapatite.

DURAPHAT:

It s a viscous yellow material, containing 22,600 ppm fluoride as sodium fluoride in a neutral colophonium base.

FLUORPROTECTOR:

Its a clear polyurethane based product containing 7000 ppm fluoride from difluorosilane.Its dispensed in 1ml ampules each ampule containing 6.21mg of fluoride.

CAREX:It has low fluoride concentration than duraphat & has equal efficacy to that of duraphat as caries preventive agent.

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FLOURIDE APPLICATION

FLOURIDE VARNISH

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Recommendation For Topical Fluoride Application

According to Lecompte (1987), the recommendation for Topical Application of high

potency fluorides are:-

1. Not more than 2gm of gel per tray or approximately 40% of tray capacity should be

dispended. Even more conservative amount should be considered for small

children.

2. To prevent the swallowing of saliva during 4 min topical application , use of Saliva

Ejector is recommended.

3. Following the 4 min of application procedure, the patient should be instructed to

expectorate thoroughly for from 30 sec-1 min, regardless the use of suction cause

the Expectoration is the only single most effective way of reducing orally retained

fluoride.

4. When utilizing custom individually fitted trays for patients requiring daily or

weekly application of a high fluoride concentration product utilize only 5-10 drops

of products per tray.34

Care for Fluoride Carriers (Trays)

• Rinse and dry the trays thoroughly after each use. Clean them by brushing

them with a toothbrush and toothpaste.

• Occasionally, the trays can be disinfected in a solution of sodium

hypochlorite (Clorox) and water. Use one tablespoon of Clorox in about

one-half cup of water. Soak them for about 15 minutes.

• If the trays become covered with hard water deposits, soak them in white

vinegar overnight and brush them the next morning.

• Do not boil the trays or leave them in a hot car as they may warp or melt.

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Self Applied Topical FluoridesSelf applied fluorides products are usually bought and dispended by the individual

patient but at the recommendation of a dental professional. These fluoride products are of low concentration ranging from 200-1000 ppm or 0.2-1.0 mgF/ml. The self applied fluoride usually are:-

1.Fluoride Dentifrices2.Fluoride gels 3.Fluoride rinse

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History

The first clinical trial of a fluoride dentifrices was initiated by Bibby in 1942.

The active agent was Sodium Fluoride which had been added to a conventional

dentifrices containing Dicalcium phosphate as the abrasive.

In 1945 Muhler et al reported a clinical trial that tested stannous fluoride in a

paste with a new calcium pyrophosphate abrasive system.

In 1955, the stannous fluoride dentrifice became the the first dentrifice

recognized by FDA [Food and Drug Administration] as an effective tooth decay

preventive product which was later accepted by ADA [American Dental

Association].

It’s a mixture of abrasive or polishing agents, detergent,Binders, flavoring agent, and substances necessary to facilitate their preparation

Therapeutic paste/dentifrices contains addition one or moreCompounds intended for reduction of oral dental diseases.

Exact formulation depends on Manufacturer but basic components remains same

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Fluoride DentifricesFluoride Dentifrices plays a significant role in caries prevention

since it requires active participation by the patient to have any effect. It has

been demonstrated that the subject who brush twice a day or more with

1000 ppm or, 1500 ppm or, 2500 ppm fluoride dentifrices, have

significantly reduced caries prevalence.

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Fluoride Compounds in Dentifrice1. Sodium Fluoride Dentifrice2. Stannous Fluoride Dentifrice3. Monofluorophosphate4. Amine Fluoride Dentifrice

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COSMETIC THERAPEUTIC

THERAPEUTIC FUNCTIONS:

1) Physico -mechanical functions

* Removes fermentable materials

* Disrupts delicate balance of environmental conditions

necessary for acid formation

* Prevents formation of thicker and more cariogenic plaque

2) Chemical function:

Based on anticaries mechanism of fluorides

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1) NaF or Na – monofluoroPhosphate Cariostatic effect2) Sorbitol, Glycerin Humectants3) Silica, DCP Abrasive4) Na- Lauryl sulfate Surfactant5) Water Vehicle6) Hydrated Na Phosphate or Na- citrate Buffer7) saccharin Sweetener8) Spearmint oil, menthol, coriander Flavor eucalyptol, lemon9) Titanium di oxide Opacifier10) Xantham gum, Ca- carrageenan cardomer Binder11) Aqueous solution Na-benzoate Stabilizer

pH adjusted to approximately neutral

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SODIUM FLUORIDE:

Caries reduction was insignificant because of incompatibity of components of abrasive system

Na-bicarbonate, Na meta phosphate, Na phosphate are used

1973 FDA approvedNaF + Calcium pyrophosphate – 650ppmF

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STANNOUS FLUORIDE:

Mulher associates at Indiana university 1955 ---1ST To recognized by FDAUndergoes quick dissociation by hydrolysis and oxidation so needs to bestabilized , 1% stannous pyrophosphate is usedNot compatible with CaHPo4 so replaced with Ca – pyrophosphateor insoluble Meta phosphate

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DISADVANTAGES:

•Staining of teeth, particularly in mouth with poor oral hygiene

•Pigmentation of hypo plastic areas and margins of restoration

•Metallic taste, due to low pH & high conc. of Sn2F

•Astringent taste and difficult to mask with flavoring agents

•Poorly accepted by children

So now not available in market

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MONO FLUOROPHOSPHATE:

1981, most widely used, with good results

Doesn’t occur in nature so prepared synthetically in

laboratory, OKALAHOMA

CONTAINS:

1 Atom of phosphate

2 atom of 02

1 Atom of fluoride

Exist as divalent ion

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ADVANTAGES:

No staining of teeth.

Abrasive system includes

* CHALK ( calcium carbonate) &

* DICAL ( Di calcium phosphate)

MECH OF ACTION : not absolutely established , thought that

Monofluorophosphate anion has anticaries property of its own and

exchange phosphate groups in apatite crystals

Other Mech.. is by slow hydrolysis, releases F ions

PO3F2 + H2O▬> H2PO4 + F- 49

Also thought that their might be release catalyst present in the

saliva or dentifrices

Other mech..

Is due to Fluoride ion released by degradation of the complex

PO3F2- ion in the oral environment by bacterial enzymes,

Contains 800ppmF

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AMINE FLUORIDE:

1st tested in Zurich, Switzerland

Components:

Amine fluoride 297 (OLAFLUR) contains 1000ppmF

Amine fluoride 242(HETAFLUR) contains 250ppmF

Both are stable and have long life

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FEATURES:

Insoluble meta phosphate

* Is the abrasive & polishing agent

* Less foaming action

* Developed to improve the affinity of fluoride to enamel by the

Organic Cationic molecule thus making more resistant to

dental caries

* Marketed in Europe and not in north America

* Have shown Higher reductions in dental caries

Other superior properties includes:

Reduced enamel solubility

Increased F uptake by enamel

Antiglycolytic property52

DISADVANTAGES/LIMITATIONS:

Concern has been raised for

* Taste characteristics and

* Long range toxic effects

RETENTION OF FLUORIDE DENTIFRICES:

Continuous use at low conc. is beneficial as Fluoride conc.

in oral fluid is elevated to bring its effect

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Ref: J.J.Murray, Fluorides in caries prevention, 3rd edition, 1999; pg:179-207,Butterworth-Heinemann publication.Ref: Shobha tandon, Text book of Pediatric dentistry, 3rd edition,2009:pg.160-204, paras medical publishersRef:Marinho VCC, Higgins JP, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries in children and adolescents.Cochrane Dababase Syst Rev. 2003;(1):CD00278.

Fluoride Mouth Rinses• The use of fluoride mouth rinses was first described by Bibby et al in 1946.

• In1979 the Council of Dental Therapeutics of American Dental Association acepted

Neutral Sodium fluoride and Acidulated Phosphate Fluoride mouth rinses as

effective caries preventive agents.

Sodium Fluoride Mouth rinses• They are usually formulated at concentrations of either0.2%(900ppm F)

for weekly use or 0.05%(225 ppm F) for daily use.

• These rinses are intended to be used forcefully swishing 10ml of the liquid

around mouth for 60 sec before expectoring it.

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Advantages of Daily Rinsing

• If the patient misses several sessions it is probably less critical than if he

was on a weekly schedule.

• Advantage of 0.05% Sodium Fluoride concentration is that it can be used

to produce topical as well as systemic benefit when indicated for

individual patient.

55Ref: Marinho VCC, Higgins JP, Logan S, Sheiham A. Fluoride mouthrinses for preventing dental caries in children and adolescents.Cochrane Database Syst Rev. 2003;(3):CD00284.

Fluoride GelsFluoride gels products includes neutral sodium fluoride and acidulated phosphate fluoride

with a fluoride concentration of 5000 ppm and stannous fluoride with1000 ppm. The

stannous fluorides products usually called gels, but actually are glycerin based solutions.

• The gels are applied either by brushing or in trays.

• Professionally, applied fluoride given twice a year while self applied fluoride can be

once a day or more.

• Patients brush their teeth for 1 min with a gel or if trays used several drops are placed in

each tray and applied for 5 min. Patient should be informed to expectorate the gel and

not to swallow. And should rinse mouth after the application so as to minimize the risk of

swallowing gels by children and usually not recommended for children 6 years or

younger.

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Limitation of Fluoride Gels

• They violate the principle of delivering low concentration of fluoride at

regular intervals. High concentrations of fluorides deposit calcium fluoride

on teeth rather than forming hydroxyapatite.

• They present a toxicity hazard as relatively large amounts of fluorides are

given in uncontrolled manner to people of varying intelligence.

• They are tedious to use on daily basis over a long period of time. However

they may be a value when prescribed professionally for use at home

especially for high risk subjects.

57Ref: Marinho VCC, Higgins JP, Logan S, Sheiham A. Systematic review of controlled trials on the effectiveness of fluoride gels for the prevention of dental caries in children. J Dent Educ. 2003;67(4)

• Intra oral fluoride releasing devices are those which release a predetermined

quantity of fluoride inside the mouth over a long period when attached to the

tooth surfaces.

• It consist of a rate controlling membrane inside which a central depot of

fluoride containing plastic copolymer matrix is embedded.

• The release of fluoride ions into oral cavity regulated by the matrix core of

the copolymer membrane.

• These devices release 0.02-0.2ppm 0f fluoride for a period about 3-4months.

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Recent advances in topical fluoridesSlow release fluoride devices

• The copolymer membrane –USA

• The glass bead-UK

• Mixture of sodium fluoride and hydroxyapatite.

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Types

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COWSAR et al 1976

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Original glass device attached to the buccalsurface of the first upper right permanent molar

Kidney-shaped device bonded to the upper firstpermanent molar tooth

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The latest version of the fluoride glass slow releasedevice and plastic retention bracket

Latest glass device and bracket attached to upperfirst permanent molar tooth

Hydroxyapatite-Eudragit rs100 Diffusion Controlled F System

• This is the newest type of slow-release F device, which consists of a

mixture of hydroxyapatite, NaF and Eudragit RS100; it contains 18 mg of

NaF and is intended to release 0.15 mg F/day.

• It was demonstrated that the use of this device is able to significantly

increase salivary and urinary F concentrations for at least 1 month

63Ref:Juliano Pelim Pessan et al, SLOW-RELEASE FLUORIDE DEVICES: A LITERATURE REVIEW; Journal of Applied Oral Science;2008;16(4):238-44

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Conclusion

The role of fluoride in preventive dentistry is very

important as it has a long history of effective decline in

caries occurrence when used wisely either systemically or

topically

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Reference

1. MS Muthu, Pediatric dentistry principles and practice, 2nd

edition,2011; pg:155-159, Elsevier publication.

2. J.J.Murray, Fluorides in caries prevention, 3rd edition, 1999;

pg:179-207,Butterworth-Heinemann publication.

3. Shobha tandon, Text book of Pediatric dentistry, 3rd

edition,2009:pg.160-204, paras medical publishers

4. Juliano Pelim Pessan et al, SLOW-RELEASE FLUORIDE DEVICES:

A LITERATURE REVIEW; Journal of Applied Oral

Science;2008;16(4):238-44.

5. Marinho VCC, Higgins JP, Logan S, Sheiham A. Fluoride

mouthrinses for preventing dental caries in children and

adolescents.Cochrane Database Syst Rev. 2003;(3):CD00284.

66

6. Marinho VCC, Higgins JP, Logan S, Sheiham A. Fluoride

toothpastes for preventing dental caries in children and

adolescents.Cochrane Dababase Syst Rev. 2003;(1):CD00278.

7. Marinho VCC, Higgins JP, Logan S, Sheiham A. Systematic

review of controlled trials on the effectiveness of fluoride gels for

the prevention of dental caries in children. J Dent Educ.

2003;67(4)

8. B. Øgaard et al, A prospective, randomized clinical study on

the effects of an amine fluoride/stannous fluoride

toothpaste/mouthrinse on plaque, gingivitis and initial caries

lesion development in orthodontic patients;the European journal

of orthodontics,2005,8-12.

9. Cehreli ZC et al, Effect of 1.23 percent APF gel on

fluoridereleasing restorative materials, ASDC Journal of Dentistry

for Children ;2000, 67(5):330-7.

10. Bilgin Z, Ozalp N, Fluoride release from three different types

of glass ionomer cements after exposure to NaF solution and APF

gel; The Journal of Clinical Pediatric Dentistry; 1998, 22(3):237-

241.

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6.topical fluorides

Health & Medicine