FLUORINE PREVENTIVE MECHANISM/REMINERALISATION

TECHNIQUES AND MATERIALS FOR CLEANING THE ORAL CAVITY: TOOTHPASTE AND MOUTHWASHES, TOOTHBRUSHES AND ADJUVANTS.

I/ Introduction

I- GENERALITIES 

II Advantages 

I-II Disadvantages 

II- Fluoride by general route: systemic 

1. Fluoridated water 
2. Drug supplementation 
3. Fluoridated milk 
4. Fluoride salt 
5. Fluoride foods 

III- Topical fluoride

1. Mouthwashes 
2. Fluoride gels 
3. Fluoride toothpastes 
4. The varnishes
5. Chewing gums
6. Fluorinated materials

2nd Part^​

I. BRUSHING YOUR TEETH

1. Efficiency
2. Material
3. Manual dexterity
4. Frequency and duration of brushing

II. MANUAL BRUSHING

1. Material
2. Rules to apply when choosing a manual toothbrush.
3. Techniques

c1) Methods not recommended

c2) Methods not recommended

c3) Recommended methods

III. ELECTRIC BRUSHING

1. Material
2. Techniques

IV. INTERDENTAL PLAQUE CONTROL

V. BRUSHING ADDITIVES

1. Dental floss
2. Interdental brushes
3. Interdental sticks

VI. BRUSHING THE TONGUE

Conclusion 

Further reading: WHO Report January 11, 2023: “Draft Global Oral Health Action Plan 2023-2030”,

INTRODUCTION 

FLUORINE is a trace element abundant in nature (water, earth, air, etc.). It is one of the components of the body’s hard tissues (bones, cartilage, teeth, etc.). It is a commonly consumed product: vegetables, fruits, tea 

I- Generalities 

The different forms of fluorides: 

Water (bottled, tap), salt, toothpastes, professional treatments (varnishes, gels, restorative materials, prophylaxis, rinsing solutions, etc.) 

II Advantages 

– Numerous studies throughout the world have proven the role of fluoride in carioprophylaxis: numerous epidemiological studies 

I-II Disadvantages 

Excess fluoride is toxic because it determines: 

• Dental fluorosis 

• It is a lesion of the hard dental tissues due to excessive intake of fluorides during the period of mineralization of the crowns of the teeth. 
• least serious clinical expression for the health of the population
• 1st ^{manifestation} of intoxication 
• It is generally accepted that the risk of dental fluorosis appears beyond 2ppm. (doses > 2mg/l)
• Osteofluorosis (osteoporosis, osteopetrosis) Bone fluorosis: 
• linked to the absorption of very high doses (10 to 40 mg/day). >5mg/l
• Other attacks 

– Kidney damage

– Nerve damage 

II- Fluoride by general route: systemic 

A good knowledge of the fluoride composition of the water consumed to compensate for deficiencies or avoid poisoning is essential. The minimum threshold below which the risk of caries exists is 0.5 mg/l. 

1. Fluoridated water 

The permissible fluoride concentration in water in Europe is 

• 0.7 ppm in areas where ambient temperature varies from 25 to 30°C 
• 1.5ppm in areas where ambient temperature varies from 8 to 12°C 

Of all the forms, water fluoridation remains the most effective method. 

It concerns the entire population (mass prevention) 

More profitable and less expensive. 

2. Drug supplementation 

It is reserved for patients at high risk of caries, aged over 6 months (after tooth eruption) 

Given the diversity of fluoride intake (water, salt, ingested toothpaste, etc.), any prescription of medicinal fluoride (drops, tablets) must be preceded by a personalized assessment of daily fluoride intake. 

It is increasingly neglected, due to the risk of fluorosis, although negligible according to many studies. 

3. Fluoridated milk 

The remineralization mechanism involves calcium and phosphate from milk in addition to fluoride. 

4. Fluoride salt 

The optimum content is 250 to 350mg F- /Kg of salt for both temporary and permanent teeth. 

1g of salt = 0.25mg of Fluoride (insufficient quantity to induce a preventive effect). 

5. Fluoride foods 

In general, the fluoride content of different foods is insignificant. 

The richest are tea: the average fluoride content for heavy tea drinkers = 1mg 

III- Topical fluoride

The use of fluoride is subject to the appearance of teeth on the arch. 

Indeed, the emphasis today is on the need for a regular intake of low doses of fluoride, mainly topical, throughout life in order to act on the permanent process of mineralization/demineralization of the enamel.

1. Mouthwashes: 

♣ They are composed of sodium fluorides, associated with flavoring agents (leaving a clean mouthfeel). 

♣ We find: 

– Mouthwashes with a concentration of 0.05% fluoride or 250 ppm used in patients at high risk of caries for daily rinsing for 1 min.

– Mouthwashes containing 0.5% fluoride, or 1000 ppm, for weekly rinsing. 

♣ The risk of fluoride ingestion is significant, their use must be controlled especially for children under 6 years old 

Indications

• subjects at high risk of caries
• subjects with active caries
• children aged 6 years and over.

2. Fluoride gels 

• They are used in topical applications during check-ups in patients at high risk of caries aged 6 years and over.
• They are high in fluoride content up to 20,000 ppm and used through gutters which can be prefabricated or ready-made.
• They can be used by healthcare professionals or by patients. 
• In professional use, the technique consists of applying a gel for a few minutes in a gutter adapted to the patient. 
• The treatment is usually renewed every 6 months (or even every 3 months). 
• There are two types of gels – neutral and acid – which contain high concentrations of fluoride (1%). 
• Application using dental floss is also possible. 

NB: The use of fluorides, topical and/or systemic, must be modulated according to the caries risk 

Indications

• hyposialia
• dentin hypersensitivity
• patients treated for radiotherapy (head and neck).

The operating protocol

•  The patient is seated upright (avoid the risk of swallowing)
•  Thorough brushing of teeth
•  The selected gutters (must completely cover the arches) are loaded with 5 to 10 ml of gel so as to cover the teeth.
• Salivary aspiration is essential
• The patient bites lightly on the loaded gutters for 4 minutes.
• After removal, the patient is asked to suck his teeth to eliminate excess fluoride in the salivary aspirate, then he is advised to avoid drinking, eating or rinsing his mouth for 30 minutes.

3. Fluoride toothpastes 

• They are composed of sodium fluorides, sodium monofluorides, tin fluorides and amine fluorides. 
• There are 2 types of toothpaste: 
• toothpastes containing less than 1500 ppm, === > cosmetics, (supermarkets) 
• pharmaceutical toothpastes that require marketing authorization and have a concentration of 1500 to 5000 ppm. 
• For pediatric toothpastes, the fluoride concentration is 250 to 1000 ppm. Its use, according to an adequate technique, 3 times a day for a 2-minute brushing ensures effective prevention against caries. 
• For adults, rinsing should be moderate, to keep the fluoride in contact with the tooth surface after brushing. 

ATTENTION

• The risk of fluorosis is increased in children (from 6 months to 4 years old). Brushing in children must be done under parental supervision until the age of 8 years old with toothpaste with a content of less than 500 ppm until the age of 6 years old.

Recommendations: “never place in the oral cavity of a child more mg of fluoride than the figure of his weight in kg.”

4. The varnishes

They have a very high concentration of fluorides. (22600ppm Duraphat, 7000ppm for fluor Protector)

Indication:

– Patient at high risk of caries

Goals

•  Remineralization of early lesions
•  Prevention of caries disease

They are applied every two to four months to carious lesions on smooth surfaces (cervical and root) and to the pits and grooves of newly erupted teeth.

5. Chewing gums

• They must be free of cariogenic sugar.
• Concentration of 45 ppm, they are recommended to stimulate salivary secretion, while constituting a fluoride supplement. 
• The use of fluoridated and sugar-free chewing gum is recommended for 15 minutes after lunch to replace difficult brushing in the canteen.

6. Fluorinated materials

It is essentially:

• Glass ionomers which are indicated in patients at high caries risk as a temporization until the latter has been reduced
• Prophylactic sealants which, in addition to the mechanical action of filling the grooves, release fluoride when fluoridated (glass ionomers, resinous materials).
• Compomers which are neglected due to the supremacy of composites in terms of aesthetics and CVI in terms of fluoride release.

2nd Part^​

I. BRUSHING YOUR TEETH

1. Efficiency

The effectiveness of plaque control is based on: 

1. the suitability between the brushing equipment and the patient, 
2. the latter’s manual dexterity, and 
3. the frequency and duration of use.
4. Material

• We distinguish between manual toothbrushes and electric toothbrushes.
• The effectiveness of electric toothbrushes is significantly but modestly superior to manual toothbrushes. 
• In all cases, the prescription will need to be adapted to the patient himself, as some patients brush better manually than with an electric toothbrush. Today, there are sonic and ultrasonic toothbrushes. 
• No significant difference could be observed between them.
• The sonic toothbrush  performs on average several thousand vibrations per minute, while the ultrasonic toothbrush can perform up to 1.6 million per minute.

3. Manual dexterity

• The effectiveness of brushing decreases after age 65. In patients with disabilities, plaque control is difficult . Thus, the prescription will have to depend on the patient’s ability to apply brushing methods. The electric brush may possibly find its best indication there.

4. Frequency and duration of brushing

• Epidemiological studies show an improvement in gingival condition with twice-daily brushing. 
• If the frequency of brushing is increased further, no improvement is seen.

• In patients who have not received adequate information on plaque control techniques, the distribution of residual bacterial plaque after brushing is very heterogeneous because the areas brushed are always the same. 
• It is appropriate not to “brush your teeth” but to “brush each tooth”. 
• As for the duration of each brushing, it should in principle be longer than 1 minute.

II. MANUAL BRUSHING

1. Material

• There are many different types of manual toothbrushes on the market, both in terms of shape and size as well as bristle softness.
• Manufacturers sometimes give free rein to the imagination of their designers and end up with products that are sometimes artistically or commercially attractive. 

• There is currently no evidence that one model is more effective than the other.
• Since the commercial choice is important, it is rare that a practitioner does not find the equipment adapted to his patient.

A few rules regarding the choice of toothbrush can help the professional in the advice he gives to the patient. 

• The angulation of the bristles, their density or the shape of the brush head do not seem to have a decisive impact on the effectiveness of the product. 
• However, it seems that multidirectional implantation of the hairs allows for better plaque removal.

2. Rules to apply when choosing a manual toothbrush.

– The size of the handle should match the size of the hand

– The size of the brush head must be adapted:

• the size of the teeth (maximum the length of 2 mandibular molars)

• at the mouth opening

– The bristles of the brush should be nylon or polyester with a rounded end and flexible.

– The flexibility of the bristles will be chosen according to the gingival biotype:

• flexible for a fine biotype

• medium for a thick biotype

3. Techniques

Several brushing methods have been described. 

The differences are mainly based on the position of the brush and its movement.

In terms of plaque removal, the superiority of one method has not been proven. 

We will therefore try to improve quantitatively and qualitatively the technique used by the patient rather than abruptly modifying their brushing habits. 

The objectives are:

•  Increased efficiency in neglected areas, particularly the gingivodental junction and interdental spaces
• and the removal of any gingival trauma.

c1) Methods not recommended

• Horizontal brushing is probably the most natural method used in the absence of information on plaque control. It involves a horizontal back-and-forth movement. The disadvantage of this method, in addition to the erosion often observed on the vestibular surfaces, is the total absence of plaque removal in the interdental spaces.
• Vertical brushing consists of a vertical back and forth motion only .
• Most often, the bulge of the teeth does not allow the bristles of the brush to access the gingivodental region.

c2) Methods not recommended

• Charters method : initially developed to increase the effectiveness of interproximal brushing, the head of the brush is oblique but in an occlusal direction. A vibration and rotation movement is applied. This method is effective but rarely applicable because it is unnatural and complicated.

c3) Recommended methods

• The roller technique : the filaments of the brush are inclined at 45° towards the apex, at the gingivodental junction. Moderate pressure is applied and the head of the brush then rotates (rolls), i.e. a vertical sweep of the gum towards the occlusal surface of the tooth. This simple technique to communicate consists in a way of “combing” the teeth. It can be recommended as a first-line treatment, although it is quite tedious and time-consuming when it is intended to be effective.
• Modified Bass method : the filaments of the brush are inclined at 45° towards the apex, at the level of the gingivodental junction.
• Moderate pressure and a back-and-forth movement are applied without disengaging the bristles from the sulcular area. The brush then performs a rotation (roll), i.e. a vertical sweep from the gum towards the occlusal surface of the tooth. The subgingival penetration of the bristles of the brush is approximately 0.5 mm. This simple method is probably the most widespread.
• Modified Stillman method : the filaments of the brush are inclined at 45° towards the apex, at the level of the gingivodental junction.
• Moderate pressure and an oscillating/vibrating motion are applied, disengaging the bristles from the sulcular area by a simultaneous vertical sweeping rotation of the brush head toward the occlusal surface of the tooth. This is an excellent method, not much different from but more complex than the modified Bass method.
• It is sometimes difficult to implement, particularly in clumsy or non-compliant patients (learning curve).

III. ELECTRIC BRUSHING

1. Material

• The first electric toothbrushes were marketed in the 1960s. The goal, compared to manual brushing, was to facilitate and improve individual plaque control. It was a back-and-forth motion . on a traditional brush in its shape. 
• Since the 1990s, many modifications and improvements have been introduced in the design of electric brushes, in particular thanks to the appearance of the oscillating-rotating movement of the brush head.
• After at least 1 to 3 months, compared to manual brushing, brushing with an oscillating-rotating brush significantly reduces the amount of plaque.
• Compared to electric brushes with a reciprocating motion, oscillating-rotating brushes appear to be more effective in reducing plaque and gingivitis. 
• More recently, sonic toothbrushes may also offer similar benefits to oscillating-rotating brushes , while retaining a head shape similar to a manual brush.

2. Techniques

• No particular technique can be put forward. The brush should be placed at 45° at the gingivodental region and each tooth brushed on the vestibular and lingual/palatal surfaces using a small elliptical movement covering the dental surface and the gum-tooth junction. 
• The subgingival penetration of the brush bristles is approximately 1.0 to 1.5 mm. Electric brushing is safe for soft tissues and does not pose a risk of gingival recession.

IV. INTERDENTAL PLAQUE CONTROL

• The interdental area is therefore a strategic zone: the interproximal surfaces of the molars and premolars are the sites where residual plaque is most abundant, and in gingivitis and periodontitis, interproximal involvement is most pronounced. 
• Brushing alone, even electric, has no effect on this interdental area. 
• Good oral hygiene therefore involves the use of a penetrating instrument between two adjacent teeth.
• Several products have been proposed to try to obtain satisfactory interdental plaque control: dental floss, interdental brushes, sticks, gingival stimulators, water jets.

V. BRUSHING ADDITIVES

1. Dental floss

• Several types of thread are marketed: waxed, unwaxed, Teflon, ribbon, etc. There are also thread passers, thread holders, etc. There is no serious objective criterion to ensure that one product is superior to another in terms of eliminating interproximal plaque. Here again, the prescription must be adapted on a case-by-case basis.
• Dental floss removes 80% of interdental plaque and promotes effective prevention of gingivitis and a reduction in the plaque index. 

2. Interdental brushes

• Conical or cylindrical in shape , interdental brushes come in different diameters (from 0.6 to 4 mm).
• The diameter must be adapted to the embrasure in order to freely occupy the space between the teeth. The passage of brushes is not possible in all spaces and is contraindicated in the absence of an open embrasure in patients with gingivitis. 
• Overall, the anterior spaces are narrower than the spaces found between the multi-rooted ones: to promote optimal efficiency, do not hesitate to prescribe several diameters for the same patient. The brushes can be long, short, preformed (inserted into a handle), or even electric. The core that supports the bristles is generally a plastic-coated wire. 

3. Interdental sticks

• no visible effect on the amount of plaque and on the reduction of gingival indices. 
• effective in reducing interproximal bleeding. 
• It is difficult to recommend these sticks as a replacement for interdental brushes or dental floss, the effectiveness of which has been evaluated by a large number of studies.

VI. BRUSHING THE TONGUE

How to brush your tongue? 

Apply a small amount of toothpaste to your toothbrush. Start at the back of your tongue and brush forward. Use gentle but firm pressure in a back-and-forth motion, as if you were brushing your teeth.

Further reading  

On 11 January 2023, WHO unveiled the “Draft Global Oral Health Action Plan 2023–2030”, based on six guiding principles.

The six guiding principles of this “global strategy” are: 

1. approach oral health from a public health perspective,
2. integrate it into primary health care, 
3. implement innovative staffing models to meet needs, 
4. focus care on the person, 
5. tailored interventions throughout life 
6. and finally optimize digital technologies.

This strategy therefore has six objectives. 

1. The first concerns oral health governance (increasing political commitment and resources for oral health, strengthening leadership and creating mutually beneficial partnerships within and outside the health sector), 
2. the second , the promotion of oral health and the prevention of diseases related to the oral sphere (enabling everyone to enjoy the best possible oral health, acting on the social and commercial determinants as well as on the risk factors of oral diseases and conditions).
3. Improving health monitoring and information systems. For the health workforce, this will involve establishing innovative workforce models and reviewing and expanding competency-based education to meet the needs of the population. 
4. The fourth objective aims at the integration of essential oral care and financial protection as well as the provision of essential supplies for these acts. 
5. The fifth point concerns oral health intervention systems: health monitoring and information systems will need to be improved to provide decision-makers with information on oral health more quickly. The aim is to enable them to develop policies “on the basis of evidence”. 
6. Finally , an oral health research agenda will need to be established by creating and continually updating context- and needs-based research targeting public health aspects of oral health.

FLUORINE PREVENTIVE MECHANISM/REMINERALISATION

  Early cavities in children need to be treated promptly.
Dental veneers cover imperfections such as stains or cracks.
Misaligned teeth can cause difficulty chewing.
Dental implants provide a stable solution to replace missing teeth.
Antiseptic mouthwashes reduce bacteria that cause bad breath.
Decayed baby teeth can affect the health of permanent teeth.
A soft-bristled toothbrush preserves enamel and gums.
 

FLUORINE PREVENTIVE MECHANISM/REMINERALISATION