Fluoride is often called nature’s cavity fighter and for good reason. Fluoride, a naturally occurring mineral, helps prevent cavities in children and adults by making the outer surface of their teeth more resistant to the acid attacks that cause tooth decay. Fluoride has been a controversial topic for many years, but people often don’t have the facts and understanding on which to base their decisions.
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The fluoride ion comes from the element fluorine. Fluorine is an abundant element in the earth’s crust in the form of the fluoride ion. Fluoride ions necessary for remineralization are provided by fluoridated water as well as various fluoride products such as toothpaste.
There are three basic additives used to fluoridate water in the United States1,2:
Before teeth break through the gums, the fluoride taken in from foods, drinks, and dietary supplements strengthens tooth enamel, making it easier to resist tooth decay and providing a systemic benefit.
Fluoride can come from various sources (figure 1). In fluoridated cities, fluoride found in commercially processed foods and drinks can contain higher levels of fluoride than those processed in nonfluoridated communities. In addition, the fluoride taken in from foods and drinks continues to provide a topical benefit as it becomes part of the saliva, constantly bathing the teeth with tiny amounts of fluoride that help rebuild weakened tooth enamel.
Topically applied fluoride provides local protection on the tooth surface. Topical fluorides include toothpastes, mouth rinses, and professionally applied fluoride foams, gels, varnishes, and rinses. Systemic fluorides also provide topical protection.
Fluoride from the air/atmosphere normally contains very small concentrations of airborne fluorides. Studies reporting the levels of fluoride in air in the United States suggest that ambient fluoride contributes little to a person’s overall fluoride intake.3
Fluoride from water in the US, the natural level of fluoride in ground water, varies from very low levels to over 4 ppm. Fluoride is naturally found in most all water sources, rivers, lakes, water wells, and even the oceans. For the past 80-plus years, fluoride has been added to public water supplies to bring fluoride levels up to the amount necessary to help prevent tooth decay.
Before water fluoridation, children had about three times or more cavities.4 Because of the important role fluoride has played in the reduction of tooth decay, the Centers for Disease Control and Prevention has named community water fluoridation as one of the 10 great public health achievements of the 20th century.1 Studies prove water fluoridation continues to help prevent tooth decay by at least 30% in children and adults, even with fluoride available from other sources, such as toothpaste and fluoride rinses. Today, at least 75% of the US population is served by fluoridated community water systems.5
After teeth erupt, fluoride helps remineralize and rebuild weakened tooth enamel and reverses early signs of tooth decay. Brushing teeth with fluoride toothpaste or rinsing with other fluoride dental products applies fluoride to the surface of the teeth, offering a topical benefit.
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Tooth decay is caused by dental plaque, a deposit of bacteria that constantly forms on teeth. When sugar and other carbohydrates are eaten, the bacteria in plaque produce acids that attack the tooth’s enamel. After repeated attacks, the enamel breaks down and a cavity is formed. Several factors can increase an individual’s risk for dental decay, making patient education even more important.
Dental decay is, by far, the most common and costly oral health problem in all age groups of patients.6 It is one of the main causes of tooth loss from early childhood through middle age. Decay continues to be a major issue for middle-aged and older adults, particularly in the form of root decay due to receding gums. Studies have shown that the availability of topical fluoride in an adult’s mouth during the initial formation of decay not only can stop the decay process but also make the enamel surface more resistant to future acid attacks.7 In addition to gum recession, older adults often experience decreased salivary flow, or xerostomia, due to the use of medications or the presence of medical conditions.
Toothpastes with fluoride have been responsible for a significant drop in cavities since .8To make sure that people have toothpaste with fluoride, toothpastes approved by the American Dental Association have the ADA Seal of Acceptance.
Guidelines to help keep children’s teeth healthy include brushing at least twice a day in the morning after breakfast is consumed and at night right before bedtime. Parents should always supervise their children when brushing to make sure they’re using the correct amount of toothpaste and that they are old enough to be able to spit out the toothpaste. If the child is younger than 3, the parent or guardian should start brushing their teeth with a fluoride toothpaste as soon as teeth appear in the mouth. Use only a tiny amount of toothpaste since young children will swallow some.
Before teeth have erupted, parents can use a washcloth wet with water to remove any traces of plaque, which will also allow some fluoride to be placed topically. For children older than 3, increase fluoride toothpaste to a pea-sized amount. Mouthwash with fluoride can help make teeth more resistant to decay, but children aged 6 or younger should only use it if it’s been recommended by a dentist. Children younger than 6 are more likely to swallow toothpaste than spit it out because their swallowing reflexes aren’t fully developed.
A concern for some is dental fluorosis (figure 2), which is caused by a disruption in enamel formation during tooth development in early childhood and is related to a higher-than-optimal intake of fluoride. After tooth enamel is completely formed, dental fluorosis cannot develop even if excessive fluoride is consumed or ingested.
For people living in areas where there is no fluoride or less than the suggested amount, there are other options to consider such as fluoride supplements, which are available by prescription only. Fluoride supplements come in tablet, drop, or lozenge form and are recommended for children ages 6 months to 16 years old who live in areas without the recommended amounts of fluoride in their drinking water and who are at high risk of developing cavities. If a child lives in an area with fluoridated water, supplements are not necessary. For children with a high risk for cavities, another option is to visit their dentist for a professional application. Fluoride can be applied directly to the teeth with a varnish, gel, foam, or rinse during the dental visit.
The ADA first adopted a policy recommending community water fluoridation in . It has continued to reaffirm its position in support for water fluoridation and strongly urges that the benefits of fluoride be extended to communities served by public water systems.9
Many individuals live in areas with either too much fluoride or not enough fluoride in their water. The Department of Health and Human Services and the US Public Health Service have recommended an optimal level of fluoride in community water systems. The agency’s recommended ratio of fluoride to water has been determined to be at 0.7 parts per million. This is based on 70-plus years of scientific research and analysis for the optimal levels of fluoride received from all sources, including community water.10
Tooth decay can be reduced safely and effectively by at least 25% in both children and adults simply by having it added to drinking water. Fluoridation is the most effective public health measure to prevent dental decay for children and adults, reduce oral health disparities, and improve oral health over a lifetime, and continues to be effective in reducing dental decay by 20%–40%.11
According to data compiled by the ADA and the CDC Division of Oral Health as of May , 42 of the 50 largest cities in the US are supplied with fluoridated water.12 Fluoride levels vary in different forms of water (figure 3).
Oral health affects the quality of one’s life and general health. Good oral health lowers one’s risk of things such as:
Patients have an increased risk for oral diseases with tobacco and alcohol use, as well as unhealthy diets. Chronic diseases such as cancer, cardiovascular disease, diabetes, and chronic respiratory diseases can also increase the risk of oral diseases. This is also the case with poor oral hygiene.
Many products are available that can help rebuild areas exposed to decay, including foams, rinses, and gels. Fluoride varnish is a dental treatment that can help prevent tooth decay, slow it down, or stop it from getting worse. It is made with fluoride, a mineral that can strengthen tooth enamel. Fluoride varnish treatment typically comes as a saline or salt preparation in a resin or alcohol-based solution that’s fast-drying.
Each manufacturer varies in how they dispense this fluoride concentration. Although 5% is the typical sodium fluoride concentration, others contain only 1%–2.5%. Some come in a polyurethane base, while others come in a shellac base. Keep in mind that fluoride varnish treatments cannot completely prevent cavities. Fluoride varnish treatments can help prevent decay, remineralize teeth, eliminate sensitivity, and destroy bacteria that can cause periodontal disease. These benefits—along with brushing with the right amount of fluoride toothpaste, flossing regularly, getting regular dental care, and eating a healthy diet—are all part of maintaining oral health.
Adult patients can also benefit from fluoride varnish treatments, perhaps even more so than children. If patients display the following characteristics, they may be good candidates for fluoride varnish treatment:
Silver diamine fluoride (SDF) has caught everyone's attention lately. Here's what you need to know about incorporating it into your dental practice.
Commercially available as Advantage Arrest by Elevate Oral Care, 38% SDF is approved by the Food and Drug Administration (FDA) for the reduction of dentinal hypersensitivity. It has also been shown to reduce bacteria and matrix metalloproteinases (MMPs), which are responsible for the degradation of dentin, and it is believed to arrest carious lesions.14
SDF will only stain defects in the tooth structure, such as carious lesions and restorative margins. Sound tooth structure will not be stained. SDF is also cost-effective as one drop can be used for multiple teeth.
SDF will stain carious tooth structure a dark brown or black color. Caution should be used on other tooth surfaces and near the margins of composite restorations or crowns. Explain the risks of discoloration to tooth structure to patients before application of SDF. If a restoration is stained, the stain should polish off, but staining around margins may remain.
Educating yourself on the risks and benefits before using SDF will be helpful so that the application process is smooth.14
Some patients have conditions that put them at increased risk of tooth decay, so additional fluoride treatments and toothpastes with higher levels of fluoride can be beneficial:
Since varnish can stay on the tooth surface for several hours, it has an advantage over rinses, gels, pastes, and foams. Varnish treatments are ideal for patients experiencing sensitivity to dental products such as whitening treatments. If sensitivity occurs after dental procedures such as scaling and root planing, fluoride varnish can help to reduce the hypersensitivity.18,19
When used properly, most experts claim that fluoride treatments don’t present many side effects or, if any, they’re typically mild and rare. Because of the adherence and color of varnishes, there might be a slight, but temporary, change in tooth coloration. However, as eating and toothbrushing occurs, the varnish slowly wears away and the yellowish color fades. Patients should avoid drinking hot liquids, such as coffee, tea, or hot soup, and refrain from drinking alcohol, chewing gum, or brushing and flossing their teeth for six hours. This will allow the fluoride to sink into the tooth structure.
Potential side effects (although rare) of fluoride varnish may include:
Patients may experience more serious side effects, such as gastrointestinal bleeding or bone problems. These are extremely rare, however, and typically only occur when patients are exposed to higher doses of fluoride for an extended time. Despite these rare side effects, fluoride is supported by many public health agencies for its benefits to oral health.20
Topical fluoride varnish application should be part of the dental professional’s entire preventive care routine that involves education on maximizing toothbrushing benefits, professional interventions, and dietary control. Explain to patients that fluoride varnish treatments use a stronger concentration of fluoride than what is found in everyday toothpastes, mouthwashes, and over-the-counter products.
Fluoride varnish treatment typically takes a few minutes and is applied with a brush or cotton swab. The varnish is left on the teeth several hours, allowing it to release fluoride into the cervical and interproximal areas where fluoride is needed the most. If patients continue to experience dentinal sensitivity, advise them to come in every six months for a reapplication.21,22
With all the information about fluoride, it’s important that patients understand why we are recommending it for their dental care. Take the time to answer their questions and place flyers and brochures in your reception area to help them understand why fluoride is an important part of dentistry.
If you want to learn more, please visit our website Fluoride Manufacturers.
Editor’s note: This article first appeared in Clinical Insights newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe.
More about fluoride from DentistryIQ ...
Community Water Fluoridation
Community water fluoridation has been used for over half a century, and results show that the greatest effect of fluoridated water on tooth protection is in deciduous and mixed dentition.[13][14][13] Water fluoridation is a simple, cost-effective method to prevent caries, and it is less than the cost of one dental restoration per person in their lifetime.[15] The United States Public Health Service recommends a fluoride concentration of 0.7 mg/L of water to prevent caries while reducing the risk of dental fluorosis.[16]
Recently there has been a rise in the consumption of bottled water that usually contains an insufficient concentration of fluoride.[17] In that case, alternative sources of fluoride supplementation should be considered. Also, over the decades, the protective benefits of water fluoridation have declined as other forms of fluoride delivery spread. For example, fluoride supplements are prescribed for children whose primary source of drinking water is deficient in fluoride.[13][18]
It is highly recommended by the United States Preventive Services Task Force (USPSTF) that primary care providers (PCPs) prescribe fluoride supplements starting at six months of age to infants whose primary water source is lacking in fluoride.[18] Fluoride supplements include the systemic ingestion of fluoride in the form of dietary tablets, lozenges, or drops.
Dietary Flouride Supplements
Dietary fluoride supplements may be tablets, lozenges, or liquids such as fluoride-vitamin preparations.[19] Tablets and lozenges contain 1.0, 0.5, or 0.25 mg fluoride concentrations, and sodium fluoride is usually the active ingredient.[19] For infants, liquid fluoride supplements are used with a dropper. For children and adults, tablets are prescribed by dentists and PCPs, with instructions to chew or suck for 1 to 2 minutes before they are swallowed. This is to maximize the topical effect of fluoride.[20] One study showed an 80% reduction of caries in children who dissolved fluoride in the mouth by sucking or chewing than those who swallowed the fluoride tablets.
Fluoride supplements have been prescribed to compensate for fluoride-deficient water intake. Therefore, careful consideration must be given to the percentage of fluoride content in drinking water in the patient's region and any additional sources of fluoride the patient is receiving, such as toothpaste and mouth rinse.[19]
For children at high risk of caries living in areas where the drinking water contains less than 0.3 ppm F, daily supplementation of fluoride may be recommended as follows:
Fluoride Toothpaste
Fluoride toothpaste delivers fluoride to dental surfaces, and it presents mainly as sodium fluoride (NaF). It has been effective in caries prevention of both primary and permanent teeth for decades.[21][22] Brushing with fluoride toothpaste increases the fluoride concentration in saliva by 100- to 1,000-fold. After one to two hours following using fluoride toothpaste, the saliva concentration returns to the baseline level.[23]
Toothbrushing must start when the first tooth erupts, usually as early as six months.[24] Brushing twice a day with fluoride toothpaste lowers the risk of dental caries by 14%.[25] Efficient plaque removal is attainable only while toothbrushing is supervised in children under four.[26]
Fluoride toothpaste containing 1,000 ppm of fluoride prevents dental caries in the permanent and primary dentition.[7] In the United States, the standard concentration of fluoride in toothpaste is 1,000 to 1,100 ppm.[19] Doses of 1,350 ppm to 1,500 ppm are advised for children at high risk of developing caries and seven years of age upwards.
In the early years of childhood, the swallowing reflex of children is not well controlled. For this reason, toothpaste containing 1,500 ppm fluoride is contraindicated in children under six to minimize the risk of fluorosis due to swallowing.[19] The recommended amount of toothpaste for toothbrushing according to age is only a smear of toothpaste in children less than three years and from three to six years of age a pea-sized amount.[27]
The maximum dose of fluoride toothpaste available over the counter in most countries is 1,500 ppm. Higher amounts (2,800 ppm and 5,000 ppm) are available on prescription. However, the indication of higher doses should be implemented as a short-term intervention to reduce risk in vulnerable young people and adults while other measures are being taken, like changing a cariogenic diet. On the other hand, patients at high chronic risk of dental caries could benefit from using such high doses for the long term, e.g., those with xerostomia or physical or learning disabilities. Sodium fluoride 2,800 ppm toothpaste can be indicated from 10 years of age and 5,000 ppm from 16 years of age.
Flouride Mouthwash
Flouride mouthwash helps prevent dental caries by increasing fluoride levels in dental plaque and saliva.[19] It is important that the mouthwash is used at a different time of the day than when toothbrushing to increase its availability in the biofilm and optimize its topical effect.[28]
The concentration depends on the frequency of use. Over-the-counter solutions of 230 ppm sodium fluoride are indicated for daily rinsing, and those containing 900 ppm for weekly use.[29] They are not recommended for children under six years due to the risk of swallowing – the risk/benefit ratio favors risk.[6] Parents must supervise the use of fluoride mouth rinses in permanent dentition as this has proven to be more efficacious than unsupervised utilization.
Fluoride Varnish, Gels, and Foams
The professional application of fluoride varnish (FV) and fluoride gels two or more times per year to children shows successful results in the prevention of caries in high-risk caries children of all ages regardless of the fluoride levels in drinking water. Fluoride varnish application twice a year reduces the incidence of caries by 37% in primary teeth and 43% in permanent teeth.[30]
Fluoride varnish, typically 22,600 ppm, is the only high-concentration fluoride formulation that can be used in children under six. It may be applied between twice or four times per year, according to caries risk. The United States Preventive Services Task Force (USPSTF) highly recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption.[18] In the UK, fluoride varnish is advocated for children over the age of 3 at risk of caries. The varnish must be placed as a thin layer on areas more at risk of caries, incipient lesions, and tooth defects.
Fluoride varnish is relatively safe but is contraindicated in individuals with a very rare allergic reaction to colophony (rosin), a substance in most varnishes.[31] It is also contraindicated in patients with contact dermatitis and stomatitis.
On the other hand, applying fluoride gels or foam twice a year (maximum application time is 4 minutes, and minimum application time is 1 minute) reduces caries incidence by 26% in permanent teeth of children who live in non-fluoridated areas. Fluoride gels are usually applied to teeth in the dental office in disposable trays to prevent dental caries and remineralize incipient lesions. They are available in 5,000 to 12,300 ppm. They are not recommended in children under six years of age due to the risk of swallowing the gel – the risk/benefit ratio favors risk.[6] They can be applied to children over six years twice to four times per year according to caries risk.
The American Dental Association (ADA) recommends 2.26% sodium fluoride varnish (22,600 ppm fluoride) for children under six years and 1.23% acidulated phosphate fluoride gel (12,300 ppm fluoride) for children over six years.[28] For home-use prescriptions, the ADA recommends a concentration of only 0.05% sodium fluoride gel (5,000 ppm fluoride) for children over six years or 0.15% stannous fluoride gel (1,000 ppm fluoride).[19]
Silver Diamine Fluoride
Silver diamine fluoride (SDF), a colorless alkaline liquid, is regarded as the most cost-effective approach to dental caries prevention in low-socioeconomic settings and high-risk populations, including children and the elderly with special needs.[32][33]
SDF works on two levels to arrest and prevent dental caries. The silver component has an antibacterial effect arresting carious lesions, and the fluoride component has a remineralizing action. However, the main drawback of using SDF is that it leaves a dark stain on the treated area, so it is used as a preventive measure where aesthetics is not the main concern.[34]
The use of silver diamine fluoride is a good solution to overcome barriers in dental treatment, such as dental fear, transportation, access to clinic facilities, insurance, and cost.[33] Comparisons of the annual application of SDF versus topical fluoride treatments, such as varnish and gels, placed two to four times per year show that SDF is more efficient.[35]
Slow-release Fluoride Beads
Slow-release fluoride beads are bonded to teeth to release low levels of fluoride in the oral cavity over a period of time, usually several years. Therefore, preventing dental caries and remineralizing incipient lesions.
The two main types of slow-release fluoride devices are copolymer membrane type and glass beads. Studies have shown that these devices raise intraoral fluoride concentrations enough to prevent enamel dissolution; however, further clinical trials are required to validate their use in clinical practice since the majority of research was done in vitro and in situ.[36] Also, although they may be a cost-effective solution in reducing dental caries in people at high risk of caries, their retention rates are the main drawback.[37]
Ecological Approaches To Caries Prevention
Probiotics
They are the 'good' bacteria that enhance the growth and survival of healthy oral microbiota. When probiotics are introduced to the oral biofilm, they create an imbalance in caries-related bacteria by disturbing its functional composition and metabolic activities, therefore, causing a shift in their local distribution.[38][39]
More research is needed to collect evidence on the effect of probiotic supplements on the diversity of the oral microbiome. Despite that, there are consistent results from clinical trials done on children under five years of age on the benefits of probiotic supplements to oral microbial diversity.[5] In addition, results from clinical trials have shown that school nutrition services that provided milk supplemented with probiotics and probiotic lozenges reduced caries development in preschool children and high caries-risk school children.[39]
Products That Modify The Oral Biofilm
The combination of fluoride and arginine cooperate in maintaining a healthy oral microbial balance. Studies have shown that oral hygiene products containing fluoride and arginine have greater anti-carcinogenicity than those containing only fluoride.[40]
Toothpaste Containing Enzymes And Proteins
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