Use of fluorides in dental caries management
By C.H. Chu, BDS, MAGD, ABGD
May L. Mei, BDS, MDS
Edward C.M. Lo, BDS, MDS, PhD
Featured in General Dentistry, January/February 2010
Pg. 37-43
Posted on Friday, January 08, 2010
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Fluoride is commonly and widely used to prevent and even arrest caries. The clinical effects of fluorides depend on the chemical compounds utilized and the methods used to apply the fluoride ion to the surface of the tooth. Fluorosis has been reported in conjunction with increased doses of fluoride. A coordinated approach to fluoride delivery is essential to avoid the risk of fluorosis.
Received: March 30, 2009
Accepted: June 8, 2009
Traditional management of dental caries has focused primarily on treatment via the excision of diseased tissues and subsequent restoration of the defect.1 Mechanical tooth preparation is a destructive and irreversible method of removing the natural dental tissues, and while dental materials have improved significantly in recent decades (in many cases, with properties that closely resemble those of natural dental tissues), they are artificial. Dental restorations and even implants cannot replace natural teeth completely.2
Dental caries is a disease that involves the localized chemical dissolution of dental hard tissues due to acids produced by plaque bacteria in biofilm that covers the affected area.3 A comprehensive treatment plan for dental caries should include eliminating cariogenic bacteria, reducing plaque acidogenicity, enhancing tooth remineralization, and repairing the damaged teeth. Contemporary caries management philosophy has changed from the traditional surgical approach to a medical model, which often includes dietary analysis and advice, oral hygiene instruction, placement of fissure sealants, and the use of fluoride therapy, xylitol chewing gum, and antimicrobial agents such as chlorhexidine.
Various forms of fluoride therapy are used to prevent and sometimes to arrest caries, although the effects of fluoride therapy are related to the chemical composition of the fluoride product and the method used to apply the material to the tooth surface.4 This article reviews the effects of various fluoride agents and discusses the use of fluoride in caries management.
Mechanism of action of fluoride
Although fluoride’s specific mechanism of action in caries prevention is not fully understood, it is generally accepted that fluorides applied topically or taken systemically have an effect on tooth surfaces. Shellis and Duckworth reported that fluoride acts topically to prevent dental caries.5 Fluoride inhibits plaque metabolism, alters plaque composition, affects plaque formation, and reduces the plaque bacteria’s ability to produce large amounts of acid from carbohydrates.5
Fluoride also inhibits enamel demineralization. The calcium fluoride that is deposited on a tooth surface after fluoride therapy is not readily soluble and can act as a fluoride reservoir. This fluoride also can lower the critical pH value of hydroxyapatite crystal dissolution (the pH value at the time that demineralization occurs) from approximately 5.5 to 4.5 in the mouth. In addition, fluoride can be incorporated incrementally into fluroapatite crystals on the tooth surface, making the surface more resistant to acid dissolution. In addition to inhibiting demineralization, fluoride enhances enamel remineralization, increasing the speed of the remineralization process and the mineral content of early carious lesions. The incorporation of fluoride also makes the deposited mineral less acid-soluble.
Common fluoride compounds used in dentistry
The common fluoride compounds used in topical fluoride agents include sodium fluoride (NaF), which can be acidulated and buffered with a phosphate to form acidulated phosphate fluoride (APF); sodium monofluorophosphate (MFP) (Na2FPO3); and stannous fluoride (SnF2). Hexafluorosilicic acid (H2SiF6) and sodium silicofluoride (Na2SiF6) are used commonly in water fluoridation. Dental researchers are investigating other fluoride compounds, such as silver diamine fluoride (Ag(NH3)2F) and titanium tetrafluoride (TiF4) for controlling caries.
Common methods for delivering fluoride include water fluoridation, fluoridated salt, fluoridated milk, fluoride toothpaste, fluoride supplements (in the form of a drop or tablet), fluoride chewing gum, fluoride solution, fluoride mouth-rinse, fluoride gel, fluoride foam, fluoride mousse, and fluoride varnish (see Table 1). The fluoride concentration or content in the delivery systems that are intended for systemic absorption usually is much lower than that found in systems intended for topical application.
Few other chemical entities can be delivered in such a flexible manner to provide such important benefits. However, fluoride’s ability to control caries depends on whether the fluoride is available in the oral cavity at concentrations that can significantly affect the ongoing demineralization and remineralization process.6 Since the cariostatic mechanism of fluoride is mainly topical, a good fluoride delivery system should provide a substantial topical application of fluoride and ensure that a minimal amount of fluoride is ingested; ideally, the system should be cost-effective as well.
Water fluoridation
Water fluoridation is defined as the controlled addition of a fluoride compound to a public water supply in order to reduce dental caries.7 Sodium fluoride, hexafluorosilicic acid, and sodium silicofluoride are common fluoride compounds added to the water supply because of their solubility, safety, availability, and low cost. Water fluoridation provides a low concentration of and frequent intraoral exposure to fluoride. The recommended optimal fluoride concentration in water is temperature-related, ranging from 0.5–1.0 ppm for different regions of the world.8 The FDI World Dental Federation concluded that fluoridation of water supplies remains the most effective public health measure for preventing dental caries.9 Despite the success of drinking water fluoridation in preventing dental caries in various population groups, concerns about ethics, safety, and efficacy have made it a controversial topic.
Fluoridated salt
First used in Switzerland in 1955, fluoridated salt uses the same public health principle for caries control as water fluoridation. Potassium fluoride or sodium fluoride is added to the salt, usually in a fluoride concentration of 250 ppm (based on adult consumption of approximately 10 g of salt per day).10 Fluoridated salt is well-accepted by the Swiss communities, offering consumers a fluoride option that is not available to communities with fluoridated water.11 A 2006 study found that a meal prepared with 250 ppm fluoridated salt significantly increased the salivary fluoride level for approximately 30 minutes.11
Fluoridated milk
Typically, fluoride has been added in milk at 2.5–5.0 ppm.12,13 Fluoridated milk has been available to children through public school milk programs or national nutritional programs. Such programs are intended to target the oral health of young children, and theoretically should be more efficient than water fluoridation. Parents can choose between fluoridated or nonfluoridated milk for their children.
According to Burt and Eklund, many studies that investigated the efficacy of fluoridated milk were seriously flawed.14 Fluoride is incompletely ionized in milk; as a result, limited topical effect can take place. There are also other concerns, such as the considerable proportion of children who do not drink milk for one reason or another.15 Although the distribution of fluoridated milk through school milk or national nutritional programs can offer a convenient and cost-efficient means of targeted fluoride supplementation, a 2005 Cochrane review concluded that there are an insufficient number of good quality studies to provide evidence that fluoridated milk offers sufficient protection against caries.16
Fluoride supplements
Fluoride drops or tablets are used as a supplement to water fluoridation or as an alternative method in areas where fluoridated water is not available. The ADA approved a fluoride supplement dosage schedule in 1994 (see Table 2). According to Ellwood et al, fluoride drops or tablets help to maintain levels of fluoride in the oral fluids that prevent the development of caries.6 A 1998 study by Hu et al reported on preschool children in a fluoride-deficient area who received fluoride drops daily and developed less caries compared to a control group.17
Fluoride tablets (sometimes taken in combination with vitamins) can be chewed and swallowed or dissolved in water to form a drink. A 2007 study by Momeni et al investigated 1,237 12-year-old children and found that they experienced a reduction in caries when fluoride tablets were used.18 Another two-year study did not support a self-administered regimen of fluoride lozenges for caries prevention.19 This study followed 160 high caries risk children (10–12 years of age) who took 1.5 mg fluoride (via tablets) every day. The children did not show significant caries reduction compared to the control group.19
Ellwood et al reviewed the fluoride delivery system and concluded that fluoride drops and tablets are the least efficient method for delivering topical fluoride; in addition, each method inevitably results in a high level of fluoride ingestion when swallowed.6 There is also increasing evidence that the effect of fluoride is mainly the result of chemical reactions on the tooth surface. Most European scientific dental associations no longer recommend the use of fluoride supplements, such as fluoride tablets or drops, as a standard procedure in caries prevention.20
Fluoride chewing gum
Initially, chewing gum containing fluoride was intended for people with rampant caries and for children living in areas where water is not fluoridated.21 Most chewing gums contain 0.25 mg fluoride per pellet. The fluoride is readily released and increases fluoride content in saliva within the first 30 minutes.22 A 1989 study revealed that chewing gum containing fluoride led to enhanced remineralization.23 More recently, Oztas et al demonstrated that this type of gum was favorable for plaque pH recovery and increased salivary fluoride concentration after a sucrose rinse.24 A 2008 review by Ly et al concluded that chewing gum with fluoride could reduce the prevalence of tooth decay.25
Fluoride toothpastes
Among all of the topical fluoride delivery systems in use, fluoride toothpaste has been assessed most comprehensively.9 The efficacy of fluoride toothpastes is well-documented, and toothpastes with different fluoride compounds appear to have a similar effect in decreasing the prevalence of dental caries.26 In countries where toothpaste use is widespread, fluoride toothpastes are probably the most important method for the topical application of fluoride.
Sodium fluoride, acidulated phosphate fluoride, stannous fluoride, sodium MFP, and amine fluoride are among the compounds that have been incorporated into toothpaste.8 The most common concentration of fluoride used in toothpaste is 1,000 ppm, although toothpastes for adults may include concentrations of 1,500 ppm or more (low-fluoride toothpastes containing 250–500 ppm fluoride are available for children). A 2002 Cochrane review concluded that fluoride toothpaste had a preventive fraction (that is, the difference in caries increments between the treatment and control group, expressed as a percentage of the increment in the control group) of 24%.27 The review also noted that its effectiveness at reducing caries increased among those patients at higher caries risk, those whose toothpaste had a higher fluoride content, those who used fluoride toothpaste more frequently, and young children who performed supervised brushing. However, its effectiveness is not affected by water fluoridation.
Fluoride solutions
A 1958 study reported that stannous fluoride solutions of 2% (4,840 ppm fluoride), 4%, and 8% reduced the development of new caries by 50% over a two-year period.28 Fluoride solutions were popular in general dental practice until a 3-year-old child died after ingesting 45 mL of stannous fluoride in a dental clinic.29 Since then, concentrated stannous and sodium fluoride solutions have not been commonly used in the U.S. because of safety concerns.
Another concentrated fluoride solution, 40% silver fluoride (AgF) solution (59,800 ppm fluoride), was used in Australia to successfully arrest caries development.30 Various concentrations of silver diamine fluoride (SDF) solution are available in China, Japan, and some parts of South America. According to the literature, 38% SDF (44,800 ppm fluoride) is effective in preventing new caries and arresting active caries in children.31,32 Carious lesions arrested after SDF treatment are stained black, which can cause concern for the children and their parents; however, the low cost and simplicity of SDF treatment makes it a useful method for controlling prevalent early childhood caries, especially in disadvantaged communities.4 A recent systemic review concluded that SDF may be a valuable caries preventive agent; in addition, it appears to meet the criteria of both the World Health Organization (WHO) Millennium Goals and the U.S. Institute of Medicine for 21st century medical care.33
Other fluoride compound solutions have been investigated; recent laboratory studies have suggested that titanium tetra-fluoride (TiF4) solution can be an effective caries control agent.34,35 However, clinical studies are necessary before this solution can be used in dental care.
Fluoride mouthrinses
Fluoride solution in a lower concentration is available as a mouthrinse, which can provide direct topical exposure while minimizing systemic uptake by ingestion. These rinses have an excellent risk-benefit profile when used correctly (usually in doses of 10 mL, swished between the teeth and around the mouth for one minute).8 Such mouthrinses generally are not recommended for children under the age of 6, as they may swallow most of the mouthrinse, resulting in unwanted systemic side effects.9
Sodium fluoride mouthrinse is commonly formulated at 0.05% (226 ppm fluoride) for daily home use or at 0.2% (900 ppm fluoride) for weekly use (usually administered in supervised school oral health programs). Clinical studies have compared the daily and weekly regimens; a 1991 review of the clinical trials found that both regimens could reduce new caries development by approximately 30%.36-38
A 2002 Cochrane review suggested that the supervised regular use of fluoride mouthrinse (at concentrations of 0.05% and 0.2%) is associated with a clear reduction in caries among children.39 In populations with a caries increment of 0.25 decayed, missing, and filled surfaces (DMFS) per year, 16 children will need to use a fluoride mouthrinse (rather than a non-fluoride rinse) to reduce one DMFS; in populations with a higher caries increment of 2.14 DMFS per year, two children will need to rinse to reduce one DMFS. The FDI World Dental Federation has stated that fluoride mouthrinse may be an effective measure for at-risk individuals and populations.9
Fluoride gels
Fluoride gels have a relatively high viscosity, which makes them easy to handle. Fluoride gels typically are applied to children’s teeth twice a year to prevent dental caries, but they may be used more frequently when more severe caries is present. Common preparations contain 2% sodium fluoride or 0.4% stannous fluoride. The 0.4% stannous fluoride gel contains 1,000 ppm fluoride (the same concentration used in toothpaste) and can be prescribed for home use.
Because fluoride uptake by enamel is enhanced by an acidic environment, fluoride gel may be acidified to form an APF gel.40 A common APF gel mixes a 0.1% orthophosphoric acid with a 1.23% sodium fluoride that has been buffered with phosphate ions. APF gel can also be formulated by using certain gelling bases to make it thixotropic, so that the gel tends to flow under pressure but will remain viscous otherwise. This thixotropic property allows the gel to remain in the tray without running, while it thins out to penetrate pits and fissures under biting pressure. APF gel should not be used on patients with glass ionomer or porcelain restorations because the acid will etch and damage the restorations.
Some fluoride gel manufacturers claim that their product can be applied to teeth for one minute; however, according to the literature, four minutes is the optimal time for treatment.41 A 2003 Cochrane review examined 14 clinical trials and found that fluoride gels reduced caries by 21% on average.42 The FDI World Dental Federation has recommended fluoride gels for individuals at high risk for caries, although they should be used with care because of their high fluoride concentration.9
Fluoride foams
Fluoride gel contains approximately 10 times more fluoride by weight than adult fluoride toothpaste (12,300 ppm instead of 1,450 ppm). APF foam was developed in the 1990s to reduce the potential risk of young children ingesting excessive amounts of fluoride following gel application. This foam has the same fluoride concentration (1.23%, or 12,300 ppm) and pH (3–4) as APF gel but requires approximately 20% of the quantity by weight to cover a dental arch adequately. Due to its flowable consistency, the foam can provide coverage to all tooth surfaces, especially the proximal areas. Foams are unlikely to overflow while in the applicator tray, which reduces the risk of gagging or fluoride ingestion. A clinical study found that applying APF foam biannually to the dentition of 392 preschool children reduced caries by 24% after two years. Proximal tooth surfaces were affected most.43
Fluoride varnish
Fluoride varnish is one of the most concentrated fluoride products available commercially. Most fluoride varnishes contain 5% NaF (22,600 ppm fluoride) in a natural colophony base, which allows the varnish to adhere to tooth surfaces in the presence of saliva.44 Fluoride varnish can be applied quickly and easily. It sets rapidly on tooth surfaces so that gagging and swallowing are minimized. Its bland flavor means that it is well-tolerated by children as young as one year of age; as a caries preventive agent, there is evidence that it is as effective as APF foam.45 However, compared to APF foam (which requires children to bite into trays for four minutes), fluoride varnish appears to be the easier method of caries prevention for both the dentist and the child. The FDI World Dental Federation also recommends fluoride varnish for individuals at risk for caries. The simplicity and acceptability of fluoride varnish also make it an appropriate caries prevention treatment for special needs populations.46
A 2003 Cochrane review of nine clinical trials involving the use of fluoride varnishes on children and adolescents found a preventive fraction of 46% in permanent teeth and 33% in primary teeth.47 Furthermore, the review found no relationship between the effectiveness of fluoride varnishes and the baseline caries level or the level of fluoride in the water supply.46
Fluoride tooth mousse
Tooth mousse is a water-based cream that contains casein phosphopeptide-amorphous calcium phosphate (CPP-ACP). It can be rubbed onto teeth after toothbrushing or used as a toothpaste; in addition, it can deliver calcium phosphate onto tooth surfaces to remineralize early enamel caries. Fluoride can be added to the bio-available calcium and phosphate mousse. Tooth mousse containing 2% CPP-ACP plus 1,100 ppm fluoride has been effective for promoting remineralization.48
Safety of use of fluoride
A number of studies have reported a dose-response relationship between dental caries reduction and the concentration and frequency of fluoride use.46 However, a high concentration of fluoride can result in dental fluorosis or toxicity. There is an increased risk of developing mild forms of dental fluorosis when fluorides are used by young children. The risk of young children developing dental caries must be assessed before fluorides are administered for caries prevention. Professionally applied fluoride treatments typically are administered to children or to adults who demonstrate either caries activity or a moderate to high risk of developing caries. The toxicity of fluoride depends on the rate and amount of ingestion, the duration of exposure, and the patient’s weight and age.
Continuous exposure to high levels of fluoride may result in chronic toxicity, while a single excessive intake of a large amount of fluoride can lead to acute toxicity. Enamel mottling and crippling skeletal fluorosis are the first signs of chronic fluoride overdose. Acute fluoride overdose may be associated with such systemic signs and symptoms as nausea, vomiting, diarrhea, abdominal pain and cramps, weak pulse, hypotension, pallor, paresthesia, paresis, tetany, central nervous system depression, or coma; serious cases of acute toxicity may prove fatal.
The risk of developing toxicity is expressed as a probable toxic dose, the minimum dose that can cause toxic signs and symptoms. A 1992 study by Whitford reported gastrointestinal symptoms in young children and very frail adults following the ingestion of 3–5 mg F/kg, leading the author to conclude that the probable toxic dose of fluoride is 5 mg F/kg of body weight.49
Because home use topical fluoride agents have a very low fluoride concentration, large amounts must be consumed before a patient can reach the probable toxic dose. A 4-year-old child with an average weight of 15 kg needs to ingest more than four tubes of children’s toothpaste (45 g/tube; 400 ppm fluoride) to surpass the probable toxic dose of 75 mg fluoride. However, an average 4-year-old child needs to ingest only 85% of a tube of adult toothpaste (90 g/tube; 400 ppm fluoride) to surpass the probable toxic dose, suggesting that adult toothpastes should be placed out of reach of young children.
The estimated level of fluoride that can cause acute toxicity is 32–64 mg/kg body weight.50 According to the ADA’s Council of Dental Therapeutics, children weighing 22 lb (10 kg) or less should receive no more than 264 mg of sodium fluoride (120 mg fluoride) at any one time to prevent accidental poisoning.50
Fluoride exposure is available from multiple sources. Foods usually contribute only 0.3–0.6 mg of the daily intake of fluoride.51 Fluoride is present to some extent in all foods and water; as a result, people cannot avoid ingesting some fluoride every day. In recent years, fluoride has become more available via a variety of fluoridated sources, including foods, beverages, water, toothpaste, mouthwashes, and so forth. This increased presence may account for the recent decline in dental caries globally; however, it can also increase the risk of the milder forms of dental fluorosis. The FDI World Dental Federation has proposed a coordinated approach to fluoride delivery.9 It is imperative that dentists are aware of fluoride availability from all sources before embarking on a specific course of fluoride treatment.
The FDI World Dental Federation further states that a vast amount of scientific evidence clearly indicates that fluoride is safe and effective as long as it is used properly and at concentrations appropriate for the prevention of dental decay. Fluorosis can result when excessive fluoride is ingested during the pre-eruptive development of teeth. In the authors’ experience, when fluoride is used at optimal levels for caries prevention, dental fluorosis appears in only a relatively small proportion of the population, and this side effect is often very mild.
Summary
Fluoride has been used to prevent caries for more than 30 years. Clinical and laboratory studies have demonstrated fluoride’s ability to control caries. A variety of fluoride products are available for use by dental professionals and patients and are safe and effective when used appropriately. Since multiple sources of fluoride exposure exist, a coordinated approach to fluoride delivery is essential.
Author information
Dr. Chu is an associate professor, Faculty of Dentistry, University of Hong Kong, China, where Dr. Mei is a research associate and Dr. Lo is a professor.
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