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Fluoride and childhood caries

Nutritional Management of
Periodontal Disease
dr shabeel pn
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
Fluorides in dentistry

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
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
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
Changes the
crystalline structure of
enamel to make it less
soluble.
Nature of tooth mineral

{{ Ca
Ca10-x
10-x
(Na)
(Na)xx
(PO
(PO4 ))6-y
4 6-y
(CO
(CO3 ))
3 zz (OH)
(OH)
2-u
2-u
(F)
(F)u}
u}
Highly
Highly substituted
substituted carbonated
carbonated apatite
apatite
Most
Most soluble
soluble

Ca
Ca1010(PO
(PO44))66(OH)
(OH)22
hydroxyapatite
hydroxyapatite(less
(lesssoluble)
soluble)

Ca
Ca1010(PO
(PO44))66(F)
(F)22==fluoroapatite
fluoroapatite
Least
Least soluble
soluble
Mechanism of action
OLD
OLD concept
concept ::

Recent
Recent evidences
evidences That
That major
major inhibitory
inhibitory
shows
shows that
that the
the main
main effect
effect was
was thought
thought to to
effect
effect of
of fluoride
fluoride in
in be
be due
due to
to its
its
caries
caries prevention
prevention are
are incorporation
incorporation in in tooth
tooth
POST
POSTERUPTIVE
ERUPTIVE mineral
mineral during
during the
the
Through
ThroughTopical
Topical
development
development of of the
the
effect
effect tooth
tooth prior
prior to
to eruption
eruption
Mechanism of action

Fluoride
Fluoride incorporated
incorporated
Fluoride
Fluoride incorporated
incorporated
during
during mineral
mineral developmentally
developmentally into into
development
development at at the
the normal
normal tooth tooth
normal
normal levels
levels of
of 20-
20- mineral
mineral isis insufficient
insufficient
100
100 ppm
ppm doesdoes not
not to
to have
have aa measurable
measurable
alter
alter the
the solubility
solubility of
of effect
effect on
on acid
acid
the
the mineral.
mineral. solubility
solubility
Mechanism of action

Only
Only when when fluoride
fluoride is is
concentrated
concentrated into into aa new new
crystal
crystal surface
surface during
during Re Re
mineralization,
mineralization, is is itit sufficient
sufficient
to
to alter
alter solubility
solubility beneficially.
beneficially.
Mechanism of action

IfIf fluoride
fluoride isis present
present inin the
the plaque
plaque
fluids
fluids atat the
the time
time that
that bacteria
bacteria generate
generate
acids,
acids, itit will
will travel
travel with
with the
the acid
acid down
down
into
into the
the subsurface
subsurface of of the
the tooth,
tooth, adsorb
adsorb
to
to the
the crystal
crystal surface
surface and
and protect
protect itit
from
from being
being dissolve.
dissolve.
Source: Featherstone , 1999
Fluoride inhibits
plaque bacteria.
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


HF H+

H+ + F - HF F-

Bacterial Cell

pH 7 H+ + F- HF

pH 4.5 H+ + F- HF

Acts on the enamel
surface to inhibit
bacteria adhesion
Sources of fluoride

Natural foods
Dentrifices
Tea, sea foods,
Professionally applied
Water
Fluoride supplements

Fortified
Milk
Salt
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
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


Sources of fluoride

Dental Products
Dentifrices
Fluoride mouth rinse
Professional applied fluorides
Dietary fluoride supplements
Fluoride metabolism and
excretion
Fluoride in 50 % of the
Food, water absorbed
fluoride will be
associated
75 to 90 % absorbed with calcified
from the alimentary tissue
tract, more from liquids
than solids (10 to 25% 50% excreted
excreted via feces) in urine

50:50 distribution is shifted strongly in favor of retention


in the very young, greater excretion in later years of life
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


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)
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
Fluorosis

Skeletal Fluorosis

Dental Fluorosis
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.
Things you should know

Skeletal fluorosis
Osteosarcoma
Confined to individuals
exposed to very high
Studies have
fluoride failed to identify
Usually associated with
any correlation
industrial situation or with fluoride
unusually very high
fluoride level in drinking history
water of 10mg/l
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.
Types of Fluoride Used in
Dentistry

Water fluoridation

School Water fluoridation

Dietary fluoride supplements

Self applied fluorides

Dentifrices with fluorides

Professionally applied fluoride


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
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)
Issues
1. Instituting regular tooth brushing drills will
fluoride toothpaste in all school
2. The monitoring of fluoride content in toothpaste?
3. Is there a need for lower fluoride content
toothpastes for children?
4. Dental professionals are not fully informed about
fluorides and fluorosis.
Nutritional management of
Periodontal diseases
Periodontium
PERIODONTAL DISEASE

DISEASES OF THE GUMS

DISEASES RELATED TO THE


PERIODONTIUM
Nutrition
(modifiable variable
Host response and
susceptibility
to infection)

Host

Environment
Pathogens
Microorganism
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
Three main nutritional
considerations

Integrity of the oral mucosa

Maintenance of the hard tissues

Maintenance of the immune


response
1. Integrity of the oral mucosa
Vitamin B Co factor for Energy Metabolism, and
needed in DNA, RNA synthesis
Tissue maintenance and new cell

production
Healing

Most common sx of vit b deficiency: loss

of integrity of the oral mucosa


Stomatitis, angular cheilitis,glossitis
Integrity of the oral mucosa
C Prevents oxidative cell damage, aids in the
(Ascorb maintaining the integrity of the oral mucosa.
ic acid) Maintains microvasculature of the sulcus
Vit c def: Bleeding (increase permeability of
bld vessels)
Hydroxyline formation(stabilizes the

structure of collagen by cross linking) ,


collagen formation,

Citrus fruits, dark and leafy green vegetable,


potatoes, cantaloupe
Integrity of the oral mucosa
Vitamin A DNA and RNA replication
Zinc Transcription of RNA
Translation of protien necessary for
new cell growth

Early sign of vit a def: decrease in


the rate of proliferation of
epithelium
Wound healing
Integrity of the oral mucosa
Minerals Collagen Supplementation
metabolism of minerals above
RDA is not
Boron recommended
Copper Cross-linking of Zinc, copper and
collagen and elastin iron all compete for
Manganese
absorption so must
be balanced for
Silicon

optimum wound
Zinc
Protien synthesis healing
2. Maintenance of Calcified
Tissues

Vitamins A, D,C,K

Zinc, Magnesium,Phosporus and Calcium


Maintenance of Calcified
Tissues
Vit Regulates the absorption of calcium
D from the GIT to maintain calcium
Fortified balance
Inadequate Ca intake, Vit D
milk, eggs
liver stimulates osteoclastic activities,
mobilizes calcium stored in bone
Collagen synthesis and accumulation

of mineralized bone are dependent


on adequate levels of Vit D and
Calcium
Maintenance of Calcified
Tissues
Vit Bone density and strenght
K Anti coagulant theraphy (group at risk)

Green, leafy vegetables,liver


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
National Health and Nutrition
Examination Survey

Sample of 12,419 adults

Ages 20 to 90 years

Dental Measurements

Dietary assessment

Demographic and medical histories


NHANES III results

OR of having

Smokers, and former
periodontal disease is smokers with low
1.2 times greater in vitamin C intake are
those with low dietary at 1.6 times greater
Vitamin C intake risk of having
periodontal disease
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
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
Maintenance of hard tissue
(Bone remodeling)
Minerals
Calcium Milk products, tofu fortified with
calcium, legumes, fortified breakfast
cereal, orange juice
Copper
Boron
Magnesium
NHANES III results

Risk of periodontal
27% greater for
disease was 59%
those taking less
greater in women
with less than than 800 mg/day
500mg/day of
Calcium
Boyd and Lampi (2001)

However it remains unclear how calcium


supplements might impact the course of
periodontal disease
3. Maintenance of Host
Immune Response

Nutritional deficiencies quickly


alter immune cell function and
increases the risk of infection
Maintaining host immune
response

Proteins:

Antioxidants
Vitamin A, C, E
Minerals : Zinc, Copper, Iron, and Selenium
3. Maintenance of Host Immune
Response

Protiens Mild protein malnutrition decreases


effectiveness of the inflammatory
response to invading pathogens
Neutrophil functioning

Collagen synthesis

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