Fluoride and childhood caries Nutritional Management of Periodontal Disease dr shabeel pn

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Fluoride and childhood cariesNutritional
Management of Periodontal Diseasedr shabeel pn
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By the end of the session, the students should be
able to

• Discuss the role of fluoride in the prevention of
  dental caries
• Identify nutritional considerations in the
  prevention and management of periodontal disease

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Fluorides in dentistry
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• What are fluorides?
• Why do we use fluoride in dentistry? How does it
  work?
• How should we use fluoride to prevent dental
  caries?
• What is fluorosis

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What are fluorides?

• Fluoride is a mineral
• Fluoride ion comes from the element fluorine
• Fluorine is 17th most abundant element in the
  earths crust
• Never encountered in its free state in nature
• Exits only in combination with other elements as
  a fluoride compound

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How does it work?

• Changes the crystalline structure of enamel to
  make it less soluble.
• Suppresses cariogenic bacteria in dental plaque.
• Acts on the enamel surface to inhibit bacterial
  adhesion

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Changes the crystalline structure of enamel to
make it less soluble.
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Nature of tooth mineral
Ca10-x(Na)x(PO4)6-y(CO3)z(OH)2-u(F)u Highly
substituted carbonated apatite Most soluble
Ca10(PO4)6(OH)2 hydroxyapatite (less soluble)?
Ca10(PO4)6(F)2 fluoroapatite Least soluble
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Mechanism of action

• OLD concept
• That major inhibitory effect was thought to be
  due to its incorporation in tooth mineral during
  the development of the tooth prior to eruption

• Recent evidences shows that the main effect of
  fluoride in caries prevention are
• POST ERUPTIVE
• Through Topical effect

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Mechanism of action

• Fluoride incorporated during mineral development
  at normal levels of 20-100 ppm does not alter the
  solubility of the mineral.

• Fluoride incorporated developmentally into the
  normal tooth mineral is insufficient to have a
  measurable effect on acid solubility

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Mechanism of action

• Only when fluoride is concentrated into a new
  crystal surface during Re mineralization, is it
  sufficient to alter solubility beneficially.

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Mechanism of action

• If fluoride is present in the plaque fluids at
  the time that bacteria generate acids, it will
  travel with the acid down into the subsurface of
  the tooth, adsorb to the crystal surface and
  protect it from being dissolve.

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Source Featherstone , 1999
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• Fluoride inhibits plaque bacteria.

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Fluoride inhibits plaque bacteria

• Fluoride can not cross the cell wall and membrane
  in its ionized form(F-) but can rapidly travel
  through the cell wall and into the cariogenic
  bacteria in the form of HF.
• Once inside the cell ,the HF dissociates again
  acidifying the cell and releasing fluoride ions
  that interfere with enzyme activity in the
  bacterium.
• Interferes with glycolysis

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HF H F-
H F-
HF
Bacterial Cell
pH 7 H F- HF
pH 4.5 H F- HF
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• Acts on the enamel surface to inhibit bacteria
  adhesion

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Sources of fluoride

• Natural foods
• Tea, sea foods,
• Water
• Fortified
• Milk
• Salt

• Dentrifices
• Professionally applied
• Fluoride supplements

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Sources of fluoride

• Milk formulas ( .05 to .35 ppm)?
• Soy Beans Formula ( 0.17 to 0.38 ppm)?
• Bottled Mineral
• In beverages
• Tea ( raw tea leaves 400 ppm)?
• Brewed tea ( 0.1 to 4.2 ppm_
• Daily consumption of 1 cup (200 ml) would yield
  0.6 mg F/day

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Sources of fluoride

• Fish and seafood products
• Dried seafoods (can contain 290 ppm)?
• Canned seafoods ( can contain 40 ppm)?
• Chicken products (0.6 to 10.6 ppm)?
• Salt with Fluoride, Sugar with Fluoride

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Sources of fluoride

• Dental Products
• Dentifrices
• Fluoride mouth rinse
• Professional applied fluorides
• Dietary fluoride supplements

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Fluoride metabolism and excretion
Fluoride in Food, water

• 50 of the absorbed fluoride will be associated
  with calcified tissue
• 50 excreted in urine

75 to 90 absorbed from the alimentary tract,
more from liquids than solids (10 to 25 excreted
via feces)?
5050 distribution is shifted strongly in favor
of retention in the very young, greater excretion
in later years of life
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Fluoride Toxicity

• Acute fluoride toxicity
• 5.0 mg per kg or more
• Very rare
• Most recorded fatalities are suicides
• Dental related fatalities are very rare
• Accidental swallowing of fluoride supplements
• Chronic Fluoride toxicity

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Fluoride Toxicity

• PTD Probable Toxic Dose
• minimum dose that would cause toxic signs and
  symptoms including death and should trigger
  treatment management and hospitalization.
• 5 mg fluoride/kg (Whitford,1987)?

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Acute Fluoride Toxicity

• Accidental poisoning with
• Toothpaste with Fluoride
• Mouthwash with Fluoride
• usual cases reported are due to accidental
  ingestion of fluoride rinses and tables- usually
  by very young children

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Fluorosis

• Skeletal Fluorosis
• Dental Fluorosis

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Chronic Fluoride Toxicity

• Chronic Toxicity
• other than dental fluorosis, there are no known
  adverse effects of ingesting fluoride in a
  chronic basis at levels associated with drinking
  water concentrations of 4 p.p.m or less.

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Things you should know

• Skeletal fluorosis
• Confined to individuals exposed to very high
  fluoride
• Usually associated with industrial situation or
  unusually very high fluoride level in drinking
  water of 10mg/l

• Osteosarcoma
• Studies have failed to identify any correlation
  with fluoride history

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Dental Fluorosis

• Will only affect teeth which are exposed to obove
  optimal levels of fluoride during enamel
  maturation
• Once the tooth has erupted, dental fluorosis can
  not take place.

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Types of Fluoride Used in Dentistry

• Water fluoridation
• School Water fluoridation
• Dietary fluoride supplements
• Self applied fluorides
• Dentifrices with fluorides
• Professionally applied fluoride

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Dietary Fluoride supplement ( Fluoride tablets
or drops)?
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Two methods

• Dry method
• Usually used for batch processes
• Usually used for small scale production (lt10
  ton/day)?
• Sodium fluoride the additive of choice for dry
  method
• Iodide compound may be added at the same time
• A premix is normally used (200 ppm F and 60 ppm
  Iodide)?
• Best suited for salt size lt30 mesh

• Wet method
• Usually used for continuous processes.
• Usually used in larger production facilities.
• Potassium fluoride the additive of choice for wet
  method.
• Iodide compound may be mixed in the same solution
  tank or added simultaneously.
• Best for coarse salt (gt20 mesh).

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Dry and wet method
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DIRECT COST OF CARIES PREVENTION PROGRAMS
PROGRAM ANNUAL COST PER
PERSON
Sealants 21.17 Fluoride
Supplements 2.53 Water Fluoridation 0.54 Salt
Fluoridation 0.06
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Some requirements

• Nutritional survey
• Baseline study on fluoride sources
• Urinary excretion study among 3 to 5 years old
• Only one source of systemic fluoride
• ( salt or water)?

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How to avoid Fluoride Toxicity

• 1. Parental supervision of the use of the
  product that are used by children at home.
• 2. Teach children at an early age to expectorate
  the product.
• 3. Keeping the product out of reach of children

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How to avoid Fluoride Toxicity

• Manufacturer
• 1. Decreasing the level of fluoride concentration
  for children.(???)?
• 2. Encouraging the use of pea size amount
• 3. Equip product containers with tops that are
  difficult to open ( child proof)?

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Issues

• Instituting regular tooth brushing drills will
  fluoride toothpaste in all school
• The monitoring of fluoride content in toothpaste?
• Is there a need for lower fluoride content
  toothpastes for children?
• Dental professionals are not fully informed about
  fluorides and fluorosis.

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Nutritional management of Periodontal diseases
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Periodontium
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PERIODONTAL DISEASE

• DISEASES OF THE GUMS
• DISEASES RELATED TO THE PERIODONTIUM

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Nutrition (modifiable variable Host response and
susceptibility to infection)?
Host
Environment
Pathogens Microorganism
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Periodontal disease

• Delicate balance between host, environmental and
  bacterial factors
• Complex interaction between pathogenic bacteria
  and host response to infection
• Primary etiology is bacterial (anaerobic) but
  susceptible host is necessary for disease
  initiation
• Nutrition is a modifiable factor that impacts on
  host immune response and the integrity of the
  hard and soft tissues

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Three main nutritional considerations

• Integrity of the oral mucosa
• Maintenance of the hard tissues
• Maintenance of the immune response

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2. Maintenance of Calcified Tissues

• Vitamins A, D,C,K
• Zinc, Magnesium,Phosporus and Calcium

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Vitamin C deficiency

• Goetzl, Wasserman , Gilgi and Austen (1974) Vit
  C enhances the motility of polymorphonuclear
  leukocytes
• Sandler , Gallin, Vaughan (1975)decreases host
  immune response

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National Health and Nutrition Examination Survey

• Sample of 12,419 adults
• Ages 20 to 90 years
• Dental Measurements
• Dietary assessment
• Demographic and medical histories

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NHANES III results

• Smokers, and former smokers with low vitamin C
  intake are at 1.6 times greater risk of having
  periodontal disease

• OR of having periodontal disease is 1.2 times
  greater in those with low dietary Vitamin C intake

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Nishida, Grossi, Dunford, Ho, Trevisan and Genco
(2000)?

• dietary Vit C intake was weakly but
  statistically significantly associated with
  periodontal disease
• There is no clear evidence that supplementary
  vit. C and possible other anti-oxidant will
  improve periodontal health and response to
  therapy in current and former smokers

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Boyd and Lampi (2001)?

• megadoses of vitamin C have not been shown to
  have a strong effect in the healing response in
  initial periodontal therapy and therefore
  pharmacological doses should not be recommended

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NHANES III results

• 27 greater for those taking less than 800 mg/day

• Risk of periodontal disease was 59 greater in
  women with less than 500mg/day of Calcium

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Boyd and Lampi (2001)?

• However it remains unclear how calcium
  supplements might impact the course of
  periodontal disease

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3. Maintenance of Host Immune Response

• Nutritional deficiencies quickly alter immune
  cell function and increases the risk of infection

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Maintaining host immune response

• Proteins
• Antioxidants
• Vitamin A, C, E
• Minerals Zinc, Copper, Iron, and Selenium

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