dental structure and flouridation 18 nov-11-1
TRANSCRIPT
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Dental Structure and Fluoridation
Dr. Iyad ABOU RABII
DDS. OMFS. MRes. PhD
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Dental Structure
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Dental structure (Enamel)
The enamel is the most highly mineralized tissue in the
body consisting of
95% hydroxyapatite (HAP)
4.5% water
0.5% organic matrix.
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Enamel is the visibl white part of the crown.
It contains calcium phosphate, fluorine, protein and water.
Thanks to this combination, the enamel optimally protects the interior of each tooth from temperature differences, bacteria and acids, as well as from the pressure required to chew food.
Dental structure (Enamel)
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Mineralization
• It is the change of physical stat of a substance from liquid and semi-liquid status to solid status through deposition of minerals (calcium and phosphate) .
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Mineralization
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Localization of
mineral within
the collagen
fibril.
Mineralization
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Hydroxy Apatite (HA) and fibrillo-carbonato-apatite
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Hydroxyapatite CrystalsSamson
Chemical formula is Ca10 (Po4). X2
Hydroxyapatite Crystal has one longitudinal axis C and three transversal axis a1, a2, a3
the two axis a1,a2 are perpendicular with the axis C with an angle of 120 between theses two axiss
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Enamel rod Structure
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Enamel.
A, Its rod structure as seen in ground sections with the
light microscope.
B, Electron micrography shows that enamel consists of a
mass of crystallites organized into rod and interrod
enamel.
Enamel rod Structure
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Fluoridation
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A. Goals of fluoride administration
B. Non-professional fluoride administration
1. Systemic
2. Topical gels
3. Rinses
4. Dentifrice
C. Professional administration
1. Topical
2. Varnish
Contents
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GOALS OF FLUORIDE (F) ADMINISTRATION
Do no harm
Prevent decay on in tact dental
surfaces
F
F
Arrest active decay
Remineralize decalcified teeth
1.
2.
3.
4.
F
Fluorosis or
toxicity
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Do not harm the patient
Probable toxic dose (PTD):
• PTD is 5 mg F/kg body weight.
For a 20 kg 5 to 6 year old this would be 100 mg
for a 10 kg 2 year old, 50 mg.
F content of dental products or treatments may exceed these values for
young children. For example,
a gel tray containing 5 ml of APF contains 61.5mg F (F is absorbed
more quickly when in acidic form.),
100ml of 0.2 or 0.4% F mouth rinse contains 91 or 97mg F and a
tube of fluoridated toothpaste contains as much as 230mg F.
1.
TEXT
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POTENTIAL HARM
5 mg F / kg body
weight
20 kg 6 year old,
PTD= 100 mg F
10 kg 2 year old
PTD = 50 mg F
230 mg F/
tube
toothpaste
ACT91-97 mg F/
container of F
mouthrinse
Symptoms:
1. Vomiting
2. Excess salivary and
mucous discharge
3. Cold wet skin
4. Convulsion at
higher dose
Probable toxic dose:
Topical F,
12,300 ppm F
pH= 3.5
61.5
mg F/
5 ml
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Do not harm the patient
Probable toxic dose (PTD):
Sub-lethal toxic symptoms are manifested quickly after the dose and
consists of
1. vomiting
2. excessive salivation
3. tearing
4. mucous discharge,
5. cold wet skin
6. convulsions
1.
TEXT
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F
Ca
F
Ca
Counter Measures:
1. Emetics
2. 1% calcium
chloride
3. Calcium gluconate
4. milk
Divalent cations
like Ca cause
precipitation, of F
and prevent
absorbtion in the
intestine.
F Ca
F
Ca
F Ca
FCa
FCa
FCa
A serious systemic
consequence is binding of F
to Ca which needed for
heart function.
POTENTIAL HARM
F Ca
FCa
FCa
FCa
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Fluorosis:
Fluorosis occurs when teeth are developing.
The most critical ages are from 0 to 6 years. After 8 years, risk of
fluorosis is essentially past.
During the critical ages F intake in excess of 0.1mg/kg body
weight/day can lead to fluorosis.
This is roughly 1mg/day for a 1 to 2 year old or 1.5 to 2 mg for a 5
year old.
Do Not Harm the Patient
2.
TEXT
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10
9
8
7
6
5
4
3
2
FLUOROSIS
0.0 0.5 1.0 2.0 3.0 4.0
DMFT
PPM F IN DRINKING WATER
slight
severe
moderate
mild
F in excess of 0.1mg/ kg body
weight = fluorosis
POTENTIAL HARM
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FLUOROSIS
F
F
Excess F affects
mineralization of
developing teeth
Up to age 6 is the critical age for fluorosis.
After age 8, risk is past.
Enamel prism
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Fluorosis:
Remember that all forms of F intake comprise the daily
consumption.
This includes
1. water intake (up to 1.5mg/day)
2. Foods (0.3 to 1.0mg) and especially significant in young
children
3. Swallowed toothpaste. Children under 2 years swallow 50% of
toothpaste during tooth brushing and at 5years, 25%, both of
which may amount to 1mg F/day.
Do Not Harm the Patient
2.
TEXT
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FLUOROSIS
F in excess of 0.1mg/ kg body
weight = fluorosis
Maxium safe dose
for a 5 year old = 2
mg F / day
Maxium safe dose
for a 2 year old = 1
mg F / day 1 2 3 4 mg F
supplements toothpaste
fluids food
DW Banting
JADA
123:86,1991
Daily F intake of a 20 kg 4
year olds with different water F
0.5
ppm
water F1.2
ppm
water F
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FLUOROSIS
Children under 2 years
swallow 50% of
toothpaste
5 year olds swallow 25%
of toothpaste
Toothpaste = 1 mg F /
gram (1000 ppmF)
1 to 3 grams
“pea” size amount (0.5g) is
recommenred for fluorosis
susceptible children.
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moderate
severe
mild
pitting
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Prevention of Caries: 1st theory
1st theory :Deposition of fluorapatite (FHA) in sound tooth structure:
•Caries protection results from FHA being more acid resistant than
pure hydroxyapatite (HA).
•Deposition takes place when F replaces hydroxyl groups in HA.
•This can occur pre- or post-eruption at neutral pH, or post-
eruptively at neutral or acidic pH. At low pH, HA dissolves, then
re-precipitates as new crystals which are larger and more acid-
resistant due to higher FHA and lower magnesium and carbonate
content.
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Prevention of Caries: 1st theory
Deposition of fluorapatite (FHA) in sound tooth structure:
Deposition of FHA is accomplished both by
1. systemic intake of F during tooth development
2. topical F administration after eruption. Professional topical F
treatments with concentrated acidulated phosphate fluoride (APF)
gels (2.72% APF gel contains 12,300 ppm F), is the most efficient
way to accomplish this, especially when applied to newly erupted
teeth (i.e., age 2 for primary molars; age 6 to 8 for permanent first
molars and anterior teeth; age 11 to 14 for permanent premolars and
second molars).
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MECHANISMS OF F PROTECTION
F F F F F F
F F F F F
F
Saliva (S)
Plaque (P)
Tooth (T)
DEPOSITION
Increase FHA
levels maximally in intact
dental surfaces.
Theory:
Topical F is
the best
method for
deposition.
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F
F
F
F
F
FF
FCa
PO4
PO4
Ca
Neutral pH
remineralization
DEPOSITION OF F
F
F
FHA
FHA
FHA
HA
pH 5.0
Ca
P
FHA is more acid resistant than HA
H+
H+
CO3
Mg
H+
H+
Mg and CO3
do not
reprecipitate
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F
F
F
F
This has better F uptake due to
more porosity
DEPOSITION OF FBest F uptake is late pre-eruption
and early post-eruption
F
F
F
FF
FFF
F
F
F
F
Mature
enamel
Surface
build-up of
F
F
F
F
Ename
l fluid
Young enamel
Drinking
water
Permanent
teeth
Primary
teeth
F 3000 900
No F 2000 600
Maximal F levels of in outer 5 microns
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3000
2000
1000
PPM Fluoride
outer 2 microns = 6000 ppm
fluoride (max. uptake)
Fluoride uptake is higher in a decalcified
area
F
5 um
DEPOSITION OF F
CaCa CaCaCaF F
F
As fluoride reacts strongly with calcium it
does not penetrate far into the tooth.
3000 ppm F
1500 ppm F
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FDEPOSITION OF F:
Maxium uptake can
not be exceeded.
(3000 to 4000 ppm F
in outer 5 um)
The F-rich surface can be abraded
away.
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Bioavailability of F: A second theory of caries prevention asserts that
F in the vicinity of carious activity (in enamel fluid) prevents
dissolution of HA crystals. Although this mechanism requires only
low levels of F (less than 100ppm to as low as 1ppm), F must be
present when the acid challenge takes place and therefore must be
supplied continually.
Examples of topical applications which ensure bioavailability are
fluoridated drinking water and fluoridated dentifrices. A major source
of bioavailable F is residual F in plaque and pellicle. F in plaque
minerals such as CaF2 or calculus or in protein complexes is released
during bacterial acid production.
Prevention of Caries
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BIOAVAILABILITY
F
F
S
P
T F
ACID
SUGAR
Provide continual low level of F to
enamel fluid. The benefit occurs at
the time of decalcification.
Theory:
MECHANISMS OF F PROTECTION
Water fluoridation
is an example of a
source.
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BIOAVAILABILITY OF F
SUGAR
Low level of F F
S
H+
H+
H+
H+
F
F
F
F
SS
saliva
Plaque and
enamel fluid
plaque
Intact HA
crystals
H+
FDecalcifying HA
crystals
J Arends. JDR
69(SI):601,199
0
Decalcification of enamel crystals:
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F Stable FHA
F Loosely bound or
adsorbed F
F
F
F
F
FF F
F
F
F
FFACID
Protection from
dissolution
F from plaque
fluid
H+
H+
BIOAVAILABILITY OF F
F
F
Loosely-bound F
will eventually
become stable
FHA.
J Arends. JDR
69(SI):601,199
0
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F
F
F F
F
F
F
F
Protection only
where is
F
H+
H+
H+
H+
H+
BIOAVAILABILITY OF F
F
Ca
PO4
PO4
Ca
FHA with no
Incomplete protection
F
H+
H+
H+
H+
H+
F
J Arends. JDR
69(SI):601,199
0
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BIOAVAILABILITY OF F
F
F
F
H+
H+MS
Effect on bacteria:
H+
H+
F
F
F
F
SSH+
F
H+
H+
The presence of
fluoride at the time of
glycolytic activity will also
inhibit of plaque
acidogenesis.
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SOURCES OF BIOAVAILABLE F
1. saliva
0.08
0.02
ppm F in saliva
after drinking
1 3 5 h
F F F F
S
P
T
4. RESIDUAL
F
AC
T2. Fluoridated
water 3. Home care products
Calcium
Fluoride
F F F F F
Topical F
CaF2 precipitates in
plaque during topical
F treatment
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FHA
No FHA
No FHA
F F
10 ppm F
added to
drinking water
LESIONS (mean)
MS
8
30
5
DEPOSITION
BIOAVAILABILITY
Larson RH. Caries
Res 10:321, 1976
sugar
BIOAVAILABILITY VERSUS DEPOSITION OF F
Rodent studies:
plus
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0
1
2
3
4
5
0.05 0.1 1 5
calcium loss
F ppm in solution
pH
BIOAVAILABILITY OF F
pH 5.0
HA
calcium
phosphate
JM Ten Cate. JDR
69(SI):614,1990
Research evidence:
F
F
Add F:
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Summary of preventive F procedures and recommendations:
The older view of caries prevention was that FHA deposition in non-carious
dental surfaces should be maximized by systemic F administration during
tooth development, and post-eruptively by topical F treatments.
It was believed that increased FHA provided increased protection against
caries.
Although implementation of high FHA deposition has proved beneficial, it
does not afford as much protection as bioavailable F. Moreover, the high
doses of F required, systemically or topically (which often becomes
systemic intake) are partly responsible for the increasing incidence of
fluorosis.
Prevention of Caries
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Summary of preventive F procedures and recommendations:
Current clinical recommendations for preventive F measures are
1) to determine total F intake per day from all sources in order to assess
over or under F exposure
2) determine caries risk
3) institute a regimen commensurate with individual caries risk status which
emphasizes bioavailability of post-eruptive topical F (e.g. regular use of F
dentifrice and other home products if indicated)
4) administer professional topical F treatments, the timing of which should
also be gauged to caries risk (This may not be needed in low risk
individuals) and
5) administer systemic topical F if indicated. (The latter is currently under
review. Present Academy of Pediatric Dentistry recommendations are
presented below.
Prevention of Caries
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FLUORIDE SUPPLEMENTS
AGE <0.3ppm 0.3-
0.6ppm
>0.6ppm
6m-3y 0.25 0 0
3-6y 0.5 0.25 0
6-16y 1.0 0.5 0
F in drinking water
F
Academy of Pediatric Dentistry current
recommendations
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1. Determine F intake
2. Determine caries risk
3. Devise personalized plan based on risk
level.
4. Stress bioavailability of F.
5. Monitor F intake of young patients in
an effort to prevent fluorosis.
SUMMARY OF PREVENTIVE F
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Thank you
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