Fluoride Prescribing

• Categories of fluoride:

  • Professionally applied
  • Duraphat varnish
  • 22,600 ppmF
  • Fluoride toothpaste preparations
  • 1450 ppmF
  • 1000 ppmF
  • 1.1% NaF
  • 0.619% NaF
  • Fluoride mouthwash preparations
  • Fluorigard
  • 225 ppmF
  • 450 ppmF
  • Systemic sources of fluoride
  • Fluoridated fruit juice, fluoridated salt, fluoridated water, fluoride supplements
• Fluoride toxicity:

  • Fluoride products are considered safe if they are used in appropriate quantities and doses. The safely tolerated dose (STD) is the dose below which symptoms of toxicity are unlikely to occur. This is up to 1mg/kg of body weight.
  • If between 1 and 5mg/kg body weight F is consumed this can lead to GI symptoms (nausea, abdominal pain, and diarrhoea).
• Fluoride toxicity:

  • The potentially lethal dose (PLD) is the lowest dose associated with fatality. This is 5mg/kg body weight. So for a 20kg 5 year old child, 4.5ml (just under a teaspoon) of 2800ppmF Duraphat varnish would be potentially fatal!
  • The certain lethal dose (CLD) is, needless to say, the dose of F which would be definitely fatal. This is 32-64mg/kg body weight.
• Managing increased fluoride consumption:

  • If a pt has consumed fluoride at a level above the safe tolerated dose, medical advice should be sought immediately and milk should be given to slow the absorption of fluoride
  • You can also telephone the Poisons Information Centre: 0844 892 0111
  • But it may be best to get the patient seen quickly at an A & E department.
• Calculating fluoride consumption:

  • Dose = amount x concentration
  • 1000 ppmF toothpaste = 1000mgF/L or 1000mgF/kg = 1mgF/g or 1mgF/mL
  • A pea-sized amount of toothpaste weighs approximately 0.25g so a pea sized piece of 1000ppmF toothpaste would contain 0.25mgF (0.25g x 1mg/g).
• A 2 year old child, who weighs approximately 10kg, consumes a whole 90mL tube of 1450 ppmF toothpaste.

  • In mg,  how much fluoride does the tube contain?
  • Concentration of fluoride in the tube: 1450 ppmF = 1450g/L = 1.45mg/L
  • Mass of fluoride in the tube = volume of tube x concentration
  • 90 ml tube x 1.45mg/mL = 130.5 mgF consumed
• A 2 year old child, who weighs approximately 10kg, consumes a whole 90mL tube of 1450 ppmF toothpaste.

  • How much F/kg body weight has the child consumed?
  • You need to divide the mass of fluoride consumed with the child's body weight:
  • 130.5 mgF / 10kg = 13.05mgF/kg body weight
  • This is below the potentially lethal dose of fluoride. True or false?
  • False
• Fluoride in toothpaste can be sodium fluoride (NaF), stannous fluoride, or sodium monofluorophosphate. The chemical composition of the fluoride salt determines how much of the fluoride ion is present per unit weight of toothpaste, and often the concentration of fluoride salt is written on the toothpaste tubes as a percentage. This can be quite confusing when you are used to thinking in ppm. In the table below you will see examples of how fluoride concentrations presented as percentages can be converted into parts per million.

  
• Case 1: Adam

  • Adam is 3 years old, lives in a low fluoride area (<0.3ppmF in the water). He has a 6 year old sibling who has a history of extractions under general anaesthetic.
  • No relevant medical history.
  • Mum has noticed brown marks on his upper front teeth, and recently they started to crumble. The same happened to her older child. You diagnose dental caries.
  • What is Adam's caries risk?
  • High risk
  • Similar environment to sibling who had extractions
  • Low fluoride area

  
• Case 1: Adam

  • Adam is 3 years old, lives in a low fluoride area (<0.3ppmF in the water). He has a 6 year old sibling who has a history of extractions under general anaesthetic.
  • No relevant medical history.
  • Mum has noticed brown marks on his upper front teeth, and recently they started to crumble. The same happened to her older child. You diagnose dental caries.
  • Which toothpaste would you recommend for the patient?
  • 1350 ppmF - 1450 ppmF ('adult' toothpaste)
  • Will you apply fluoride varnish?
  • Yes, every 3 months because high caries risk

  
• Case 1: Adam

  • Adam is 3 years old, lives in a low fluoride area (<0.3ppmF in the water). He has a 6 year old sibling who has a history of extractions under general anaesthetic.
  • No relevant medical history.
  • Mum has noticed brown marks on his upper front teeth, and recently they started to crumble. The same happened to her older child. You diagnose dental caries.
  • What long-term treatment options do you think Adam requires?
  • OHI, diet advice, extraction under GA if it comes to that, preformed metal crowns
  • How often would you like Adam to see you for an examination?
  • Every 3 months

  
• Case 2: Ayesha

  • Ayesha is a 9 year old girl with Down's syndrome. She also has a heart defect. Her family live in a low fluoride area (<0.3ppmF in the water). She is the only child of highly motivated parents. She has no caries in the primary dentition, but there are signs of hypoplasia in the first permanent molars.
  • What is the relevance of Ayesha's medical history?
  • Dexterity (obstacles for oral hygiene), cooperation, xerostomia, large tongue (difficult for treatment), mouth breathing
  • What does the term hypoplasia mean?
  • Teeth haven't formed properly - more likely to decay; thinner enamel

  
• Case 2: Ayesha

  • Ayesha is a 9 year old girl with Down's syndrome. She also has a heart defect. Her family live in a low fluoride area (<0.3ppmF in the water). She is the only child of highly motivated parents. No caries in the primary dentition, but signs of hypoplasia in first permanent molars.
  • What's Ayesha's caries risk?
  • High; hypoplastic & lives in low fluoride area & Down's syndrome
  • What fluoride regime would you recommend?
  • 1450 ppmF toothpaste
  • Topical fluoride varnish every 3 months
  • When Ayesha turns 10, how will your advice change?
  • 2800 ppmF toothpaste & fluoride mouthwash

  
• Case 3: Huck

  • Huck is a 5 year old boy who lives with his mum and no other siblings. This is his first visit to a dentist. On examination you note caries in the primary molars but he is not experiencing any pain or sensitivity. He and his mum do not use fluoride toothpaste, instead they use a herbal one.
  • What is Huck's caries risk?
  • High; no fluoride products used - current caries
  • What preventative advice are you going to give?
  • Recommend fluoride toothpaste (1350ppmF - 1450ppmF), OHI, diet advice, regular check-ups

  
• Case 4: Solomon

  • Solomon is a 15 year old boy. He walks home from school with his friends and spends his Metro fare in Greggs on the way (he buys things like lucozade, coca cola, cookies and chocolate doughnuts) because he is hungry straight after school. You notice that he has started to develop caries in his second permanent molars and he has early interproximal caries in his upper central incisors.
  • His dad is v disappointed about this decay.
  • In what way(s) is prevention for teenagers different to younger children?
  • Teenagers have more independence
• Case 4: Solomon

  • Solomon is a 15 year old boy. He walks home from school with his friends and spends his Metro fare in Greggs on the way (he buys things like lucozade, coca cola, cookies and chocolate doughnuts) because he is hungry straight after school. You notice that he has started to develop caries in his second permanent molars and he has early interproximal caries in his upper central incisors.
  • His dad is v disappointed about this decay.
  • What is Solomon's caries risk?
  • High; diet
  • What preventative advice are you going to give?
  • Diet advice & OHI
• Case 4: Solomon

  • Solomon is a 15 year old boy. He walks home from school with his friends and spends his Metro fare in Greggs on the way (he buys things like lucozade, coca cola, cookies and chocolate doughnuts) because he is hungry straight after school. You notice that he has started to develop caries in his second permanent molars and he has early interproximal caries in his upper central incisors.
  • His dad is v disappointed about this decay.
  • What preventative treatment are you going to provide?
  • 2800 ppmF Duraphat toothpaste
  • Fluoride mouthwash
  • Fissure sealant
• Case 5: Faith

  • Faith = 10 year old girl. Lives with parents in optimally fluoridated area. She has autism, sensory processing issues & lacks co-ordination. She's particular about colour + texture of foods, so has limited diet, but parents keep sugar to a minimum. They try to brush her teeth at least x1/day w/ fluoride toothpaste but sometimes she can't cope with this. No caries on examination.
  • What questions would you ask to help decide what treatment to provide?
  • What about toothbrushing doesn't she like? Is it sensory based?
  • Is there anything you shouldn't say to help her?
• Case 5: Faith

  • Faith = 10 year old girl. Lives with parents in optimally fluoridated area. She has autism, sensory processing issues & lacks co-ordination. She's particular about colour + texture of foods, so has limited diet, but parents keep sugar to a minimum. They try to brush her teeth at least x1/day w/ fluoride toothpaste but sometimes she can't cope with this. No caries on examination.
  • From the info provided, what would you say is her caries risk?
  • High risk; lack of cooperation and don't know how to handle her yet
• Case 5: Faith

  • Faith = 10 year old girl. Lives with parents in optimally fluoridated area. She has autism, sensory processing issues & lacks co-ordination. She's particular about colour + texture of foods, so has limited diet, but parents keep sugar to a minimum. They try to brush her teeth at least x1/day w/ fluoride toothpaste but sometimes she can't cope with this. No caries on examination.
  • What toothpaste would you recommend?
  • 2800 ppmF Duraphat
  • Oranurse toothpaste - flavourless and non-frothing
• Case 5: Faith

  • Faith = 10 year old girl. Lives with parents in optimally fluoridated area. She has autism, sensory processing issues & lacks co-ordination. She's particular about colour + texture of foods, so has limited diet, but parents keep sugar to a minimum. They try to brush her teeth at least x1/day w/ fluoride toothpaste but sometimes she can't cope with this. No caries on examination.
  • What preventative treatment would you provide?
  • Fluoride varnish and OHI and diet advice