陳弘森 副教授 高雄醫學大學 牙醫學系 tel: 07-3121101 轉 7008, 7020 e-mail:...
TRANSCRIPT
學習目標氟化物與牙齒面的作用機轉局部氟化與牙科公衛局部氟化的種類與使用方式局部氟化的風險學習資源：
Murray JJ: Appropriate use of fluoride for human health. WHO, Geneva, 1996
Topical fluoridationIntroductionMechanism of topical fluorideTopical fluoride in dental public healthTopical fluoride in dental clinicRisk of topical fluorideConclusion
Introduction
氮 Nitrogen N 拉丁文 nitrum = 硝石 1772
氧 Oxygn O 希臘文 oxy-genos = 造成酸的
1774
氟 Fluorine F 拉丁文 flurre = 流動 1886
氛 Neon Ne 希臘文 neos = 新的 1898
Mechanism of topical fluoride
Table 11-1 Hypotheses regarding fluoride’s anticaries mechanism of action
Fluoride acts on the hydroxyapatite of the enamel per se: Decreasing its solubility Improving its crystallinity Remineralizing calcium-depleted mineral
Action on the bacteria of dental plaque ： Inhibiting enzymes Suppressing cariogenic flora
Action on the enamel surface ： Desorbing proteins and/or bacteria Lowering the free surface energy
Alteration of tooth morphology
化學結構
Ca10(PO4)6 (OH)2 + 2F- → Ca10(PO4)6F2 + 2(OH)-
enamel hydroxyapatite + fluoride fluorapatite + hydroxyl
Fig. 2. Schematic representation of the acid solubility ranking of dentally relevant minerals (18).
Dental Mineral = carbonated apatite Ca10-XNAX(PO4)6-y(CO3)z(OH)2-u(F)u
Most soluble in acid
Ca10(PO4)6(OH)2 = hydroxyapatiteLess soluble
Ca10(PO4)6(F)2 = fluorapatiteLeast soluble
Ｈ＋ + F- Ｈ F
ＨF
Ｈ＋ + F-
pH7 Ｈ＋ + F- Ｈ F
pH 4.5 Ｈ＋ + F- Ｈ F
Fig. 6. Schematic representation of fluoride entering a bacterial cell in the form of HF at lower pH values, dissociating, and thereby providing H+ and F- ions inside the cell.
Topical fluoride in dental public health
TABLE 9-3. COMPARATIVE EFFECTIVENESS OF TOPICAL FLUORIDE APPLICATIONS ON PREVIOUSLY ERUPTED AND NEWLY ERUPTED TEETH
Caries Reduction (%)
Clinical Investigation
Topical Agent Previously Erupted Teeth
Newly Erupted Teeth
Averill (1967)52 NaF 22.9 37.1
Horowitz (1969)54 SnF2 20.7 61.3
Muhler (1960)55 SnF2 44.2 84.0
Szwejda (1972)56 SnF2 20.4 44.4
Szwejda (1972)56 APF 22.5 63.0
TABLE 9-4. COMPARATIVE EFFECTIVENESS OF DIFFERENT TOPICAL FLUORIDE SYSTEMS FOR CARIES PREVENTION IN CHILDREN RESIDING IN NONFLUORIDATED COMMUNITIES
Topical Fluoride System
Deciduous Teeth Permanent Teeth
Number of Studies
Average Reduction
Number of Studies
Average Reduction
NaF 6 23.1% 32 26.8%
SnF2 3 32.0% 22 35.7%
APF 1 32.8% 19 35.9%
TABLE 9-5. COMPARATIVE EFFECTIVENESS OF DIFFERENT TOPICAL FLUORIDE SYSTEMS FOR CARIES PREVENTION IN CHILDREN RESIDING IN OPTIMALLY FLUORIDATED COMMUNITIES
Topical Fluoride System
Deciduous Teeth Permanent Teeth
Number of Studies
Average Reduction
Number of Studies
Average Reduction
NaF 1 12.0% 2 4.5%
SnF2 1 37.0% 5 20.6%
APF 0 Unknown 2 22.3%
TABLE 9-6. COMPARATIIVE EFFECTIVENESS OF DIFFERENT TOPICAL FLUORIDE SYSTEMS FOR CARIES PREVENTION IN ADULTS
Clinical Investigation
Fluoride System
Number of Applications
Length of Study
Caries Reduction
(%)
Arnold64 NAF(1%) 1 1 year 0
Frank65 NAF(2%) 1 6 months 0
Driak66 NAF(2%) 1 3 years 0
Kinkenberg & Bibby67 NAF(1%) 5 1 year 44.5
Rickles & Becks68 NAF(2%) 4 2 years 36.8
Kutler & Ireland69 NAF(2%) 4 1 year -13.2
Carter et al70 NAF(2%) 4 1 year 12.0
Muhler71 SnF2(10%) 1 1 year 15.0
Muhler72 SnF2(10%) 1 1 year 16.0
Protheroe73 SnF2(10%) 1 2 years 45.3
Harris et al74 SnF2(10%) 1 1 year 15.0
Obersztyn et al75 SnF2(10%) 4 3 years 42.1
Viegas76 APF(1.2%F) 1 1 year 27.7
Curson77 APF(1.2%F) 5 1 year 8.0
TABLE 9-1. RELATIONSHIP BETWEEN SURFACE ENAMEL FLUORIDE CONTENT AND CARIES PREVALENCE IN YOUNG ADULTS*
Number of Subjects
Caries Prevalence (DMFT)
Enamel Fluoride Content (ppm)
47 0 3459
31 5 - 11 2229
29 12 - 26 1944*Calculated from data by Keene et al.1
TABLE 9-14. COMPOSITION AND USAGE OF APPROVED FLUORIDE RINSES
Source of Fluoride
Fluoride Content Recommended Usage
Percent ppm
NaF 0.20 900 Weekly
NaF 0.02 100 Twice daily
NaF 0.05 225 Daily
APF 0.02 200 Daily
SnF2 0.10 243 Daily
TABLE 2 CLINICAL ANTI-CARIES STUDIES WITH FLUORIDE DENTIFRICES
(after Volpe,1977)
Fluoride Abrasive No. of Studies
Caries Reduction
NaF Mostly phosphates 7 Varying, mostly 20-30
SnF2 Calcium pyrophosphate 24 “
SnF2 Insoluble metaphosphate 11 “
Na2PO3F Mostly calcium carbonate or insoluble metaphosphate
20 “
Table 1. Topical fluoridation effect on patients with head and neck cancer after radiation therapy
Patients No.
Teeth No.
Caries Non-caries
Fluoride 53 67 827
No fluoride 95 617 752
P Value<0.005(Chia-Square test)
Topical fluoride in dental clinic
Table 11-7 Topical fluoride agents and systems
Agents
Sodium fluoride (NaF)
Stannous fluoride (SnF2)
Sodium monofluorophosphate (Na2PO3F)
Acidulated phosphate fluoride
Amine fluoride
Titanium fluoride (TiF4)
System
F + varnish (rosin ; polyurethane)
F + complexing agent (aluminum)
F + pretreatment (dicalcium phosphate dihydrate)
F + cationic surfactant (Lodyne; Zonyl FSC)
F + soluble calcium (calcium chloride; calcium glycerophosphate)
F + cationic polyelectrolyte (polyacrylic acid)
Recommended application technique
1. Paint – on technique
2. Tray technique
3. Topical electrolytic application
2% neutral sodium fluoride (0.9% fluoride ion)
8% stannous fluoride (2% fluoride ion)
2.8% acidulated phosphate fluoride (1.23% fluoride ion)
Risk of topical fluoride
DangerThe acute lethal dose is about 50mg/kg.The average 5 years child B.W. 20kg
3mg/kg early symptoms
Symptoms of fluoride toxicology
1.Chemical burn (ulceration / necrosis)2.Inhibit enzyme (protoplasmic poison)3.Binds calcium (nerve action)4.Hyperkalemia (cardiotoxicity)
TreatmentImmediate treatmentInduced vomitingProtection of stomachMaintaince of blood calcium
Table3. DIFFERENT WAYS TO DELIVER FLUORIDE
F Concentration Frequency of Application
Water fluoridation Optimal 1 ppm Continuously
Fluoride toothpaste 500~1500 ppm Twice daily
Fluoride tablets 0.25~1 mg/tablet Daily
Fluoride drops 1000~2000 ppm Daily
Rinsing solutions 250~1000 ppm Daily
Salt fluoridation 250~350 ppm Continuously
Milk fluoridation 7.5 ppm At school
Concentrated solutions 10,000 ppm Biannual
Concentrated gels 4000~12,300 ppm Biannual
Lacquers 1000~22,600 ppm Biannual
1ppm[F-] = 1 mgF/l = 1mgF/kg = 1x10─4 %F
Table 3-9 Toxic effects of fluoride in the human
Concentration or dose of F
Medium Effects
2 ppm or more Water Mottled enamel
5 ppm Water No osteosclerosis
8 ppm Water 10% osteosclerosis
20-80 mg/day or more Water or air Crippling fluorosis
50 ppm Food or Water Thyroid changes
100 ppm Food or Water Growth retardation
More than 125 ppm Food or Water Kidney changes
2.5-5.0 g Acute dose DeathDate from Smith and Hodge.107
Conclusion
氟化物製品之種類、濃度及用法目前常用之氟化物製品有下列幾種，依濃度1)局部塗氟 ( 濃度 10,000 ~ 50,000 ppm)
2)家用局部塗氟 (1,000 ~ 5,000 ppm)
3)含氟牙膏 (800 ~ 1500 ppm)
4)自用含氟漱口水 ( 濃度 250 ~ 1,000 ppm)
5)專供發育中孩童長期服用之氟錠。
結論評量局部氟化在臨床上的重要性
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ACID
RemineralizationCalcium
phosphate +Fluoride
Fig. 4. Schematic representation of demineralization and Remineralization processes which lead to remineralized crystals with surfaces rich in fluoride and of low solubility
Fluoride mouth rinses1946 Bibby et al. Early trials
1962 Torell and Siberg 0.2% Fluorol
1965 Torell and Ericsson 0.05% Fluorol
Fluoride application in dentistry
Sodium fluoride
1942 Bibby was first to use
1948 Knutson 2% was used
Stannous fluoride
1950 Muhler & his workers1959 Jordan et al. & Gish et al. 8% SnF2
SnF2 are acidic, with a pH 2.4 – 2.8
Application : once every 6 months.
Acidulated Phosphate Fluoride (APF)
1963 Brudevola et al. found APF
APF systems consist sodium fluoride, hydrofluoric acid, and phosphoric acid (1.23% fluoride 0.98% phosphoric acid & pH 3 – 3.5)
表二、國內近年來推廣氟化物使用之重要記事：時間 重要事件
八十一年 研究國人學童以含氟水 (225ppm 與 900ppm 兩類 ) 漱口防齲效果，共計六年。該計畫於八十六年研究結果證實防取校果約達 27% 與 36.3% 。
八十二年 推廣刷牙時省用含氟牙膏，鼓勵執行專業牙科塗氟。製作相關單張小冊提醒民眾重視。
八十三年( 口腔保健年 )
衛生署重新宣示遵循世界衛生組織最新的口腔保健政策，推廣國人口腔衛生的潔牙，宣導健康飲食習慣，定期看牙醫，及鼓勵適量用氟等方法以保護全民口腔健康。
八十五年 委託牙醫師公會辦理推廣國小學童含氟水漱口工作試辦計畫。逐年擴辦，本 ( 八十八下半及八十九年 ) 年度補助一百萬名學童參與本項預防保健計畫。
TABLE 4 COMPARISON OF CARIES INHIBITION FROM OPERATOR APPLIED APF SOLUTIONS AND GELS
Study % DMFS Reduction
Solution Gel
Cons et al.(1970) 0 18
Ingraham and Williams (1970) 12 41
Szwejda (1972) 23* 4*
Horowitz and Doyle (1971) 28 24
Cobb et al. (1980) 34 35
Average All Studies 19.4 24.4
*Fluoridated community.
Table 48. Mean Fluoride Concentrations in Deciduous Enamel in Children who brushed 1-9 Times with APF Prophylaxis Paste: compare with Control Teeth (Mellberg et al. 1974)
Group No. of teeth
ppm F at four depths(wn)
5 15 30 60
Untreated 52 702 339 163 85
Paste-treated
710 752 362 174 86
Table 9-30. Fluoride Uptake in Enamel of Children Using NaF and SnF2 Dentifrices163
Dentifrice Used
Fluoride Content (ppm)
Sound Enamel Incipient Lesions
Placebo 364 731
SnF2-Ca2P2O2 373 878
NaF-SiO2 379 1148
Table 9-35. In Vivo Fluoride Uptake with NaF and Na2PO3F/NaF Dentifrices
Dentifrice Studied Fluoride System Fluoride Content of Lesions (mg/cm2)
Placebo None 2.28
Na2PO3F/NaF Na2PO3F(0.10% F)NaF(0.045% F)
3.47
NaF NaF(0.11% F) 5.11
Table 52. Retention of Fluoride from NaF Mouthrinses by Children in Two Studies
Age(yrs)
No. of children
Rinsing time (sec)
F retention (mg)
F retention (%)
Ericsson and Forsman (1969): 7 ml of 245 ppm F rinse
4-5 10 30 0.42 24
5-7 20 60 0.35 22
Forsman (1974): 7ml of 110 ppm F rinse
4 5 30 0.17 22
4 5 60 0.23 29
6 10 60 0.16 20
Duraphat® Fluoride varnish
The outstanding preparation for topical caries prophylaxis and treatment of hypersensitive necks of teeth
FDA/ADA-Accepted Office Fluoride Application Systems
F- Form pH Cone.
ppm F-
Delivery Form
Taste Advantages/Disadvantages
ACIDULATED PHOSPHATE-FLUORIDE
3.0-3.4
1.23% F-
12.300 gel. solution good Deglazes porcelain,May etch glass-filledcomposites Enhancedeep F- uptake. pH may aggravate dentin sensitivity.
SODIUMFLUORIDE
7.0 2% NaF 9.050 gel. solution good Bland taste.
STANNOUSFLUORIDE
2.3 8% SnF2
20.000 Powder to mix with water each use
poor May stain teeth and anterior fillings. May aggravate dentin sensitivity.
電離子游動應用法(Topical electrolytic application)
• 利用電離子游動儀器 (Galvafluor) 及電導印模皿(Impression support conductor) 促進氟離子 (F-) 之滲透入琺瑯質。
• 原理：手握正極，使身體及牙齒成正極，口咬負極之電導印模皿。則 gel 之帶正電之鈉離子等移向負極之印模皿，而帶負電之氟離子 (F- ) 移向正極之牙齒，如此氟之滲透入琺瑯質更為加強。
附表 – 口腔保健用品含氟量和急性氟中毒劑量的比較 (以 20kg 小孩為例 )
程度 20公斤兒童急性中毒所需劑量
使用 1000 ppm牙膏每條 200g的家庭號所需數量
用 0.2%NaF學校漱口水所需數量
致死劑量(CLD,32-64 mg/kg)
640-1,280 mg 3.2-6.4條 710-1420 cc
安全忍受劑量(STD,8-16 mg/kg)
160-320 mg 0.8-1.6條 180-360 cc
可能中毒劑量(PTD,5 mg/kg)
100 mg 半條 111 cc
