6.topical fluorides

1
CHAITANYA.P
II MDS
Dept of Public Health Dentistry

Previous Questions
• Dental fluorides Nov 2013.
• Slow release fluoride devices. Apr 2015, Aug 2013
• Controversies about the use of fluoridated dentifrices. Oct
2011.
• Fluoride toxicity. Jun 2013.
2

Contents
• Introduction
• Types of fluorides delivery
• Types of topical fluorides
a) Professional
b) Self
• Recent advances in topical application
• Fluoride toxicity
• Conclusion
• References
Topical
Systemic
3

Introduction
• Fluoride is the reduced form of the element fluorine.
• Its atomic weight is 19 and atomic number is 9.
• In nature it occur in the form of fluorspar(CaF2), fluorappatite
(Ca10(PO4)6F2) and cryolite (Na3ALF6).
• Fluorides are used in various forms for prevention of caries.
• It occurs in natural water resources and influence the mineralization of
teeth.
Ref : MS Muthu pediatric dentistry principles and practice, 2nd edition,2011; pg:149, Elsevier4

Fluorides Delivery Methods
TOPICAL FLUORIDES
SELF APPLIEDPROFESSIONAL
•Neutral Sodium fluoride
•Stannous fluoride
•APF Solu /Gels
•Varnish
•Dentifrices
•Mouth Washes
•Fluoride Gels
FLUORIDES
SYSTEMIC FLUORIDES
I.Water Fluoridation
i. Community Water
Fluoridation
ii. School Water Fluoridation
II. Salt Fluoridation
III. Milk Fluoridation
IV. Fluoride tablets/ drops/ lozenges
5

Topical Fluorides
6
• Topical fluorides are those fluoride containing agents which are applied to
the tooth surface in regular intervals in order to prevent the development of
caries.
• These exert an anticaries effect by increasing the concentration of fluoride in
the outermost surface of the enamel.

Indications for topical Fluorides
1. Caries-active individuals i.e. those with past caries experience or those who
develop new carious lesion on smooth tooth surfaces.
2. Children shortly after periods of tooth eruption, especially those who are not
carries free.
3. Medication to reduce salivary flow or had undergone head and neck radiation.
4. After periodontal surgery when roots of teeth have been exposed.
5. Patients with fixed or removable prosthesis and after placement or replacement
of restorations.
6. Patients with an eating disorder or who are undergoing a change in lifestyle
which may affect eating or Oral Hygiene Habits conductive to good oral health.
7. Mentally or physically challenged individuals.
Ref : MS Muthu, Pediatric dentistry principles and practice, 2nd edition,2011; pg:155-159
Elsevier publication. 7

Professionally applied topical fluorides:
It was introduced by Bibby in 1942.
Bibby in 1942 was the first to demonstrate that the, repeated application of
sodium or potassium fluorides to teeth of children significantly reduced their
carries prevalence. This achievements became the fore runner of many studies to
test the effectiveness of various topical fluorides and the effective methods of its
application.
Involve the use of high fluoride concentration products ranging from 5000-
19,000ppm, which is equivalent to 5-19 mgF/ml.
Topical fluorides are divided into two categories
8

9
Self applied products:
Include fluoride dentifrices, mouth rinses & gels
Are low fluoride concentration products ranging
from 200-1000ppm or 0.2-1 mgF/ml.

Professionally Applied Fluorides
10
1.SODIUM FLUORIDE
2.STANNOUS FLUORIDE
3.ACIDULATED PHOSPHATE FLUORIDE
4. VARNISH
Ref: MS Muthu, Pediatric dentistry principles and practice, 2nd edition,2011; pg:155-159,
Elsevier publication.
Ref: J.J.Murray, Fluorides in caries prevention, 3rd edition, 1999; pg:179-207,Butterworth-

Topically fluoride application by a Dentist , Dental Hygienist or any
other Dental Auxiliary has become an established Caries-Preventive
Procedure in the Dental History.
The fluoride may be used in an aqueous solution, a viscous gel, a
prophylactic paste or as a dental varnish and can be applied using the
Paint on Technique or the Tray Technique.
11

Paint on Technique
12
Hodgson (2005) has suggested an alternative technique utilizing a 5 ml plastic
syringe. This method allows a more efficient application of the varnish which
can be particularly useful in cases where speed is important, such as with a
difficult pediatric patient.

Neutral Sodium Fluoride (NaF)
Neutral Sodium Fluoride(NaF) was the first fluoride compound to be
used for topical fluoride application. A minimum of four applications of with
2% Sodium Fluoride solution gives a caries reduction of about 30%.
Methods of preparation of 2% NaF
It is prepared by dissolving 20gm of Sodium Fluoride powder in one
liter(1000ml) of distilled water in plastic bottle. It is essential to use plastic
bottles because if stored in glass bottles it may react with silica and form
Silicon Fluoride thus by reducing the availability of free active fluoride of anti-
caries action.
14

Procedure for application of Sodium Fluoride
[ Knutsons Technique ]:
oral prophylaxis done
teeth isolated either by quadrant or by half mouth
2% NaF solution is painted on the air dried teeth so that all surfaces are visibly
wet
allowed to dry for 3-4 minutes
repeated for each of the isolated segments until all teeth are treated
2nd, 3rd and 4th NaF application, each not preceded by a prophylaxis, is
scheduled at intervals of approximately one week.
The fourth visit procedure is recommended for ages 3,7,11 and 13 years,
coinciding with the eruption of different age groups of primary and permanent
teeth. Thus, most of the teeth will be treated soon after their eruption, maximizing
the protection afforded by topical application.
15

Mechanism of Action
NaF Hydroxyapatite crystals Calcium Fluoride
reacts forms
“Chocking Off Effect”
[as thick layer of formation of Calcium fluoride forms , it interferes diffusion of F from
NaF solution to react with hydroxyapatite and blocks further entry of F ions]
And acts as resorvior for F release [it is the reason allowed to dry for 3-4 minutes]
Calcium Fluoride Hydroxyapatite crystals Fluoridated Hydroxyapatite
increase of fluoride content on enamel surface resistance against caries attack
16

Advantages :
• Relatively stable when kept on a plastic bottles
• Taste well accepted by patients.
• Non- irritant to Gingiva
• Doesn't results in discoloration of teeth
• Once applied allowed to dry for 3-4 minutes so can pursue a multiple-chair
procedure in public health programme.
• The series of treatment must be repeated only four times in general age range
of 3-13 years rather than annual or semiannual intervals, therefore in public
health program, other group of children can be treated in intervening years.
Disadvantages:
• The only disadvantage is that the patient has to make four consecutive visits
within a short period of time.
17

Stannous Fluoride
(SnF2)
Stannous Fluoride has been used at 8% and 10% concentrations in
solutions equivalent to 2 and 2.5% fluoride. Although 10% solutions used
for adults and 8% for children there is no any clinical difference between
the two. However 8% Stannous Fluoride is preferred.
18

19
Methods of Preparation of Stannous Fluoride
Solutions of Stannous Fluoride are not stable so soon after
mixing they become cloudy due to formation of Tin Hydroxide reducing the agents
effectiveness. Since, Stannous is believed to contribute to anticarries benefits, aged
solutions are considered to be clinically less effective so Muhler et al recommended
to use fresh solutions of Stannous Fluoride for each patients.
To prepare 8%Stannous Fluoride solution the content of one capsule which is 0.8
gm(‘0’ no.gelation capsule) is dissolved in 10ml of distilled water in the plastic
bottles and shaken briefly.

Procedure for application of Stannous Flouride
[ Muhler’s Technique ]
Teeth cleaned with aqueous pumice slurry
Un-waxed dental floss is passed between the inter-proximal areas.
Teeth are isolated and dried with air.
SnF2 is applied using the paint on technique and the solution is kept for 4
minutes.
Repeat applications are made every 6 months or more frequently if patients is
susceptible to caries.
20

Mechanism of Action
SnF2 Low concn tin Hydroxyphosphate oral fluids dissolve it
forms gets
”metallic taste application”
SnF2 high concentration
Calcium tri-fluoro-stannate Tin tri-fluoro-phosphate
“Tin tri-fluoro-phosphate makes tooth surface more stable & less suspectibility to decay”
Calcium fluoride is also formed both at high and low conc which reacts with hydroxyapatite and
results in formation of fluorohydroxyapatite.
21

• Advantages:
– Using 8% Stannous Fluoride solution at 6-12 months intervals
conforms to the practicing dentist’s usual patient – recall system.
– Administrative difficulties, particularly in public health programs.
• Disadvantages:
– In aqueous solution the Stannous Fluoride is not stable.
– Since 8% solution is quite astringent and disagreeable in taste, its
application is unpleasant
– The solution usually causes reversible tissue irritation manifested by
gingival blanching usually on individuals with poor oral hygiene.
– It usually causes pigmentation on teeth which has characteristic light
brown color. Staining usually appears in association with carious
lesions, hypo calcified regions and around margins of restorations. 22

Acidulated Phosphate Fluoride
(APF)
Acidulated Phosphate fluoride was introduced in1960’s by Brudevold
and his co-workers at the Forsyth Dental Center, Boston, Massachusetts.
Methods of preparation of Acidulated Phosphate Fluoride
An aqueous solution of Acidulated Phosphate Fluoride is prepared by
dissolving 20gms of Sodium Fluoride in 1 lit of 0.1 M phosphoric acid and
then 50% hydrofluoric acid added to adjust the pH at 3.0 and fluoride ion
concentration at 1.23%. It is also called as Brudevold’s Solution.
For the preparation of Acidulated Phosphate Fluoride gel, a gelling agent
methylcellulose or hydroxyethyl cellulose is added to the solution and the pH is
adjusted between 4-5.
23

Procedure for application of Acidulated Phosphate Fluoride
The patient seated upright position in chair & Oral prophylaxis is done& teeth are treated
completely.
Clinical application of APF gel by tray technique [disposable foam line tray is preferred]
To reduce ingestion a minimal amount of fluoride gel kept [coverage of tooth surfaces ,<5ml ]
The patient is told not to swallow the gel but to exert slight pressure using the cheeks and the
tongue as well as light biting forces in order to cause the gel to flow inter-proximally. The gel
thins out under the biting force because of thixotropic nature.
The fluoride gel should be in mouth for 4 minutes and remaining oral fluids should be
expectorated.
saliva ejector is used to wipe out saliva and excess fluoride
The patient is instructed not to eat drink or rinse his mouth for at least 30 minutes.
24

Mechanism of Action
APF applied
Initially leads to dehydration & shrinkage of hydroxyapatite crystals
hydrolysis
Dicalcium phosphate dihydrate (DCPD)
highly reactive with fluoride ion
Fluoride penetrates into crystals deeply through openings produced by shrinkage and
leads to formation of Fluoroapatite
The amount of Fluoroapatite deposited dependent on DCPD formation. For conversion
of DCPD into fluoroapatite deeper penetration and continuous supply of Fluoride
required. Hence APF solution was applied at 30 sec intervals and teeth kept wet for 4
minutes.
High fluoride concentration and low pH, favors fluoride deposition, acidification of
fluoride solution with phosphoric acid found to suppress dissolution of enamel, as well
as formation of calcium fluoride
The intermediate product DiCalcium phosphate & principal reaction product Calcium
fluoride
26

Advantages:
• Requires only 2 application in a year and is thus suited for most dental
office routines.
• The gel preparation can be self applied and the cost of application also gets
reduced.
• It has the ability to deposit fluoride in enamel to a deeper depth than a
neutral Sodium Fluoride or Stannous Fluoride.
• Acidulated Phosphate Fluoride is stable and need not be freshly prepared
for each individual.
Disadvantages:
• Practical difficulties like the teeth should be kept wet for four minutes so
repeated application necessitates the use of suction thereby minimizing its
use in the field. This also increase the chair side time making this methods
more expensive.
• It is acidic, sour and bitter in taste.
27

Comparison
Characterstics Sodium Flouride
(NaF)
Stannous Fluoride
(SnF2)
APF
Percentage 2% 8% 1.23%
Fluoride concn.(ppm) 9,200 19,500 12,300
pH Neutral (7) 2.4 - 2.8 3.0
Frequency of Application 4 at weelky intervals
3,7,11,13 yrs
Biannually Biannually
Adverse effect - Tooth pigmentation
Gingival irritation
-
Caries reduction 30% 32% 28%
28

1.FLUORIDE VEHICLES:
Aqueous solutions & gels
The gel adheres to teeth & eliminates the
continuous wetting of enamel surfaces
required when solutions are used.
Thixotropic solutions are not gels, but
have a high viscosity under storage
conditions & become fluid under conditions
of high stress
29

FLUORIDATED PROPHYLACTIC
PASTES:
If prophylaxis pastes containing
fluoride are used, the lost fluoride is
replenished & there is a significant gain
in the concentration of fluoride.
30

FOAM:
Developed to minimize the risk of fluoride over dosage as well as to
maintain the efficacy of topical fluoride treatment.
Advantages :
Its lighter than a conventional gel & therefore only a small amount of
agent is needed for topical application
The surfactant has cleansing action by lowering surface tension, this
facilitates the penetration of material into interproximal surfaces.
It doesn’t require suctioning so it offers advantages for home use
31

FLUORIDE VARNISH:
Increasing the time of contact between enamel surface & topical fluoride
agents favours the deposition of fluorapatite & fluorhydroxyapatite.
DURAPHAT:
It s a viscous yellow material, containing 22,600 ppm fluoride as sodium
fluoride in a neutral colophonium base.
FLUORPROTECTOR:
Its a clear polyurethane based product containing 7000 ppm fluoride from
difluorosilane.
Its dispensed in 1ml ampules each ampule containing 6.21mg of fluoride.
CAREX:
It has low fluoride concentration than duraphat & has equal efficacy to that
of duraphat as caries preventive agent.
32

FLOURIDE APPLICATION
FLOURIDE VARNISH
33

Recommendation For Topical Fluoride
Application
According to Lecompte (1987), the recommendation for Topical Application of high
potency fluorides are:-
1. Not more than 2gm of gel per tray or approximately 40% of tray capacity should be
dispended. Even more conservative amount should be considered for small children.
2. To prevent the swallowing of saliva during 4 min topical application , use of Saliva
Ejector is recommended.
3. Following the 4 min of application procedure, the patient should be instructed to
expectorate thoroughly for from 30 sec-1 min, regardless the use of suction cause
the Expectoration is the only single most effective way of reducing orally retained
fluoride.
4. When utilizing custom individually fitted trays for patients requiring daily or
weekly application of a high fluoride concentration product utilize only 5-10 drops
of products per tray.
34

Care for Fluoride Carriers (Trays)
• Rinse and dry the trays thoroughly after each use. Clean them by brushing
them with a toothbrush and toothpaste.
• Occasionally, the trays can be disinfected in a solution of sodium
hypochlorite (Clorox) and water. Use one tablespoon of Clorox in about
one-half cup of water. Soak them for about 15 minutes.
• If the trays become covered with hard water deposits, soak them in white
vinegar overnight and brush them the next morning.
• Do not boil the trays or leave them in a hot car as they may warp or melt.
35

Self Applied Topical Fluorides
Self applied fluorides products are usually bought and dispended by the individual
patient but at the recommendation of a dental professional. These fluoride
products are of low concentration ranging from 200-1000 ppm or 0.2-1.0 mgF/ml.
The self applied fluoride usually are:-
1. Fluoride Dentifrices
2. Fluoride gels
3. Fluoride rinse
38

39
History
The first clinical trial of a fluoride dentifrices was initiated by Bibby in 1942.
The active agent was Sodium Fluoride which had been added to a conventional
dentifrices containing Dicalcium phosphate as the abrasive.
In 1945 Muhler et al reported a clinical trial that tested stannous fluoride in a
paste with a new calcium pyrophosphate abrasive system.
In 1955, the stannous fluoride dentrifice became the the first dentrifice
recognized by FDA [Food and Drug Administration] as an effective tooth decay
preventive product which was later accepted by ADA [American Dental
Association].

It’s a mixture of abrasive or polishing agents, detergent,
Binders, flavoring agent, and substances necessary to
facilitate their preparation
Therapeutic paste/dentifrices contains addition one or more
Compounds intended for reduction of oral dental diseases.
Exact formulation depends on Manufacturer but basic components
remains same
40

Fluoride Dentifrices
Fluoride Dentifrices plays a significant role in caries prevention since
it requires active participation by the patient to have any effect. It has been
demonstrated that the subject who brush twice a day or more with 1000
ppm or, 1500 ppm or, 2500 ppm fluoride dentifrices, have significantly
reduced caries prevalence.
41

Fluoride Compounds in Dentifrice
1. Sodium Fluoride Dentifrice
2. Stannous Fluoride Dentifrice
3. Monofluorophosphate
4. Amine Fluoride Dentifrice
42

COSMETIC
THERAPEUTIC
THERAPEUTIC FUNCTIONS:
1) Physico -mechanical functions
* Removes fermentable materials
* Disrupts delicate balance of environmental conditions
necessary for acid formation
* Prevents formation of thicker and more cariogenic plaque
2) Chemical function:
Based on anticaries mechanism of fluorides
43

1) NaF or Na – monofluoroPhosphate Cariostatic effect
2) Sorbitol, Glycerin Humectants
3) Silica, DCP Abrasive
4) Na- Lauryl sulfate Surfactant
5) Water Vehicle
6) Hydrated Na Phosphate or Na- citrate Buffer
7) saccharin Sweetener
8) Spearmint oil, menthol, coriander Flavor
eucalyptol, lemon
9) Titanium di oxide Opacifier
10) Xantham gum, Ca- carrageenan cardomer Binder
11) Aqueous solution Na-benzoate Stabilizer
pH adjusted to approximately neutral
44

SODIUM FLUORIDE:
Caries reduction was insignificant because of incompatibity
of components of abrasive system
Na-bicarbonate, Na meta phosphate, Na phosphate are used
1973 FDA approved
NaF + Calcium pyrophosphate – 650ppmF
45

STANNOUS FLUORIDE:
Mulher associates at Indiana university
1955 ---1ST To recognized by FDA
Undergoes quick dissociation by hydrolysis and oxidation so needs to be
stabilized , 1% stannous pyrophosphate is used
Not compatible with CaHPo4 so replaced with Ca – pyrophosphate
or insoluble Meta phosphate
46

DISADVANTAGES:
•Staining of teeth, particularly in mouth with poor oral hygiene
•Pigmentation of hypo plastic areas and margins of restoration
•Metallic taste, due to low pH & high conc. of Sn2F
•Astringent taste and difficult to mask with flavoring agents
•Poorly accepted by children
So now not available in market
47

MONO FLUOROPHOSPHATE:
1981, most widely used, with good results
Doesn’t occur in nature so prepared synthetically in
laboratory, OKALAHOMA
CONTAINS:
1 Atom of phosphate
2 atom of 02
1 Atom of fluoride
Exist as divalent ion
48

ADVANTAGES:
No staining of teeth.
Abrasive system includes
* CHALK ( calcium carbonate) &
* DICAL ( Di calcium phosphate)
MECH OF ACTION : not absolutely established , thought that
Monofluorophosphate anion has anticaries property of its own and
exchange phosphate groups in apatite crystals
Other Mech.. is by slow hydrolysis, releases F ions
PO3F2 + H2O▬> H2PO4 + F- 49

Also thought that their might be release catalyst present in the
saliva or dentifrices
Other mech..
Is due to Fluoride ion released by degradation of the complex
PO3F2
- ion in the oral environment by bacterial enzymes,
Contains 800ppmF
50

AMINE FLUORIDE:
1st tested in Zurich, Switzerland
Components:
Amine fluoride 297 (OLAFLUR) contains 1000ppmF
Amine fluoride 242(HETAFLUR) contains 250ppmF
Both are stable and have long life
51

FEATURES:
Insoluble meta phosphate
* Is the abrasive & polishing agent
* Less foaming action
* Developed to improve the affinity of fluoride to enamel by the
Organic Cationic molecule thus making more resistant to
dental caries
* Marketed in Europe and not in north America
* Have shown Higher reductions in dental caries
Other superior properties includes:
Reduced enamel solubility
Increased F uptake by enamel
Antiglycolytic property
52

DISADVANTAGES/LIMITATIONS:
Concern has been raised for
* Taste characteristics and
* Long range toxic effects
RETENTION OF FLUORIDE DENTIFRICES:
Continuous use at low conc. is beneficial as Fluoride conc.
in oral fluid is elevated to bring its effect
53
Heinemann publication.
Ref: Shobha tandon, Text book of Pediatric dentistry, 3rd edition,2009:pg.160-204, paras
medical publishers

Fluoride Mouth Rinses
• The use of fluoride mouth rinses was first described by Bibby et al in 1946.
• In1979 the Council of Dental Therapeutics of American Dental Association acepted
Neutral Sodium fluoride and Acidulated Phosphate Fluoride mouth rinses as
effective caries preventive agents.
Sodium Fluoride Mouth rinses
• They are usually formulated at concentrations of either0.2%(900ppm F)
for weekly use or 0.05%(225 ppm F) for daily use.
• These rinses are intended to be used forcefully swishing 10ml of the liquid
around mouth for 60 sec before expectoring it.
54

Advantages of Daily Rinsing
• If the patient misses several sessions it is probably less critical than if he
was on a weekly schedule.
• Advantage of 0.05% Sodium Fluoride concentration is that it can be used
to produce topical as well as systemic benefit when indicated for
individual patient.
55
Ref: Marinho VCC, Higgins JP, Logan S, Sheiham A. Fluoride mouthrinses for preventing
dental caries in children and adolescents.Cochrane Database Syst Rev.

Fluoride Gels
Fluoride gels products includes neutral sodium fluoride and acidulated phosphate fluoride
with a fluoride concentration of 5000 ppm and stannous fluoride with1000 ppm. The
stannous fluorides products usually called gels, but actually are glycerin based solutions.
• The gels are applied either by brushing or in trays.
• Professionally, applied fluoride given twice a year while self applied fluoride can be
once a day or more.
• Patients brush their teeth for 1 min with a gel or if trays used several drops are placed in
each tray and applied for 5 min. Patient should be informed to expectorate the gel and
not to swallow. And should rinse mouth after the application so as to minimize the risk
of swallowing gels by children and usually not recommended for children 6 years or
younger.
56

Limitation of Fluoride Gels
• They violate the principle of delivering low concentration of fluoride at
regular intervals. High concentrations of fluorides deposit calcium fluoride
on teeth rather than forming hydroxyapatite.
• They present a toxicity hazard as relatively large amounts of fluorides are
given in uncontrolled manner to people of varying intelligence.
• They are tedious to use on daily basis over a long period of time. However
they may be a value when prescribed professionally for use at home
especially for high risk subjects.
57
Ref: Marinho VCC, Higgins JP, Logan S, Sheiham A. Systematic review of controlled trials on
the effectiveness of fluoride gels for the prevention of dental caries in children. J Dent Educ.

• Intra oral fluoride releasing devices are those which release a predetermined
quantity of fluoride inside the mouth over a long period when attached to the
tooth surfaces.
• It consist of a rate controlling membrane inside which a central depot of
fluoride containing plastic copolymer matrix is embedded.
• The release of fluoride ions into oral cavity regulated by the matrix core of
the copolymer membrane.
• These devices release 0.02-0.2ppm 0f fluoride for a period about 3-4months.
58
Recent advances in topical fluorides
Slow release fluoride devices

• The copolymer membrane –USA
• The glass bead-UK
• Mixture of sodium fluoride and hydroxyapatite.
59
Types

61
Original glass device attached to the buccal
surface of the first upper right permanent
molar
Kidney-shaped device bonded to the
upper first
permanent molar tooth

62
The latest version of the fluoride glass slow release
device and plastic retention bracket
Latest glass device and bracket attached
to upper
first permanent molar tooth

Hydroxyapatite-Eudragit rs100
Diffusion Controlled F System
• This is the newest type of slow-release F device, which consists of a
mixture of hydroxyapatite, NaF and Eudragit RS100; it contains 18 mg of
NaF and is intended to release 0.15 mg F/day.
• It was demonstrated that the use of this device is able to significantly
increase salivary and urinary F concentrations for at least 1 month
63
Ref:Juliano Pelim Pessan et al, SLOW-RELEASE FLUORIDE DEVICES: A
LITERATURE REVIEW; Journal of Applied Oral Science;2008;16(4):238-44

64
Conclusion
The role of fluoride in preventive dentistry is very
important as it has a long history of effective decline in
caries occurrence when used wisely either systemically or
topically

65
Reference
1. MS Muthu, Pediatric dentistry principles and practice, 2nd edition,2011; pg:155-
159, Elsevier publication.
2. J.J.Murray, Fluorides in caries prevention, 3rd edition, 1999; pg:179-
207,Butterworth-Heinemann publication.
3. Shobha tandon, Text book of Pediatric dentistry, 3rd edition,2009:pg.160-204,
paras medical publishers
4. Juliano Pelim Pessan et al, SLOW-RELEASE FLUORIDE DEVICES: A
LITERATURE REVIEW; Journal of Applied Oral Science;2008;16(4):238-44.
5. Marinho VCC, Higgins JP, Logan S, Sheiham A. Fluoride mouthrinses for

66
6. Marinho VCC, Higgins JP, Logan S, Sheiham A. Fluoride toothpastes for
preventing dental caries in children and adolescents.Cochrane Dababase Syst
Rev. 2003;(1):CD00278.
7. Marinho VCC, Higgins JP, Logan S, Sheiham A. Systematic review of controlled
trials on the effectiveness of fluoride gels for the prevention of dental caries in
children. J Dent Educ. 2003;67(4)
8. B. Øgaard et al, A prospective, randomized clinical study on the effects of an
amine fluoride/stannous fluoride toothpaste/mouthrinse on plaque, gingivitis
and initial caries lesion development in orthodontic patients;the European
journal of orthodontics,2005,8-12.
9. Cehreli ZC et al, Effect of 1.23 percent APF gel on fluoridereleasing restorative

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