ORAL CARE

Zenaida B. Soriano, MS

Senior ASEAN Expert

Cosmetics

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The Mechanism of CariesCaries results from the acid dissolution of tooth enamel. Several factors influence this process and the relationships among these factors are shown in the diagram below:

Diet Plaque Bacteria

Carbohydrates Enzymes

Acid Tooth Enamel

Demineralisation

CARIES

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A typical “white spot” or incipient caries lesion on the surface of a tooth.

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A longitudinal section through a white spot illuminated by polarized light.The white spot is characterized by an unbroken, intact enamel surface with an underlying area of demineralised enamel.

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A scanning electron micrograph (500x) of a slice taken through a white spot formed artificially in the laboratory. This shows the highly porous nature of a white spot caused by the demineralization of the enamel crystals.

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Routes to Caries Prevention

HS P

CI

Increase Host Resistance_______________Water fluoridationInternal fluoride (i.e., tablets)Fluoride dentifricesFluoride mouthwashesProfessional fluoride treatmentsOcclusal sealantsProfessional careVaccine (future?)

Plaque removal and control_______________Oral hygience

•Toothbrushing•Flossing

Chemical agents•Destroy/inhibit bacteria•Disrupt plaque structure

Dental prophylaxesPatient motivation

Diet Control

Reduce carbohydrate intakeSubstitute noncariogenic sweetenersControl patterns of food consumption

HS = host susceptibility; P = plaque; CI = carbohydrate intake

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Mechanism of Fluoride Action

Fluoride action can be considered a dual-phase phenomenon, i.e., pre and post-eruption of the teeth Tooth formation – fluoride incorporated in the

enamel as fluorapatite. Pre-eruption maturation – incorporation of

fluoride on enamel surface leading to more perfect apatite and well-structured enamel.

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Fluoride can interfere with the carious process at 3 levels:

At the level of plaque bacteria At the surface of the tooth before and

during initial acid attack and During and subsequent to acid attack with

lesion formation

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Fluoride and Oral Bacteria The inhibitory effect of fluoride on plaque

microorganisms has been cited by many investigators.

Fluoride uptake by plaque is shown in Table 2:

0 1 10 50 1003.9 7.6 18.1 41.9 91.00.8 1.5 10.1 35.8 119.84.9 5.1 1.8 1.2 0.84.6 6.1 17.9 53.3 85.01.9 2.1 12.9 48.4 83.42.4 2.8 1.4 1.1 1.0

Fluorine (parts /106) in bacteria

Fluoride (parts / 106) added to medium

1. Total

Total ionizable

Medium contained 0.2 parts / 106 fluorine initially. Ionizable by cold 0.5M perchloric acid.

Initially ionizable Total ionizable2. Total Initially ionizable

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Demineralization Studies In-Vitro

Extracted human teeth were exposed to 0.1M lactate solution, pH 4.3 and containing 0.004, 0.009, 0.024, 0.054, 0.504, or 1.004 ppm fluoride.

Demineralization was followed by scanning electron microscope and polarized light microscopy.

Rapid (within 72 hours) demineralization occurred in the absence of fluoride, and cavitation was observed.

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In-Vivo

The above results support in-vivo data of

Pearce and co-workers who demonstrated that:

1. The deposition of sufficient amounts of fluoridated apatite can markedly inhibit intraoral demineralization of oral enamel blocks.

2. That those amount of fluoride can promote the remineralization of previously demineralized enamel.

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In-Vivo

“Under the dynamic conditions present within the oral cavity, fluoride will reduce the rate of enamel demineralization… as well as increase the resistance of the surface enamel to subsequent acid attack through the incorporation of fluoride”

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Conclusions

Fluoride has multiple mechanisms of action:

1. In the plaque above the tooth surface

2. At the plaque and tooth enamel interface

3. Below the tooth surface

The frequency of application of fluoride or presence of fluoride during acid challenge, is more important to the efficacy of fluoride than the concentration of fluoride.

DENTAL FLUOROSIS

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Estimated Intake of Fluoride Relative to Drinking Water

Source Infanta Childb Adultc

Drinking water consumption (1mg/liter) d 0.051 0.034

Air (0.05 µg / m3) 0.00002 0.00002 0.00002Food 0.24 0.002-0.02 0.0043-0.011

Daily dose (mg/kg)

cThe child is assumed to weigh 70 kg, drink 2 liters of tap water, inhale 23 m3 a day.

dNo value is listed since the infant's intake of water is by formula and is counted as food.

aThe infant is assumed to weigh 3.5 kg, consume solely 0.85 liter of formula reconstituted

with tap water, and inhale 3.4 m3 a day.

bThe child is assumed to weigh 33 kg, drink 1.4 liters of tap water, inhale 15 m3 a day.

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The EPA assessed the prevalence of dental fluorosis in relation to fluoride intake using results of dental fluorosis studies conducted over 48 years (1937-1984)

No moderate or severe fluorosis was observed at levels of 0.6 mg/L or less

Moderate fluorosis was observed intermittently at levels of 0.7 to 1.8 mg/L

At levels around 1 mg/L up to 2.2 mg/L, moderate fluorosis was observed in 0.15% of the children examined.

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Safely Tolerated Dose of Fluoride with Age

Age (years) Weight (lbs.a)STD

(mg F)

2 22 804 29 1066 37 1358 45 164

10 53 19312 64 233

Adult 154b540

STD = Safely Tolerated DoseaThird percentile of the normal age-specific weight distribution.

bStandard 70-kg adult

SUMMARY

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Aspects that impact on the formulation and usage of products for self-applied fluoride prophylaxis:Fluoride incorporated into properly

formulated products for self-application is safe and effective.

The mechanism by which fluoride acts to prevent and even reverse carious lesions are now supported by sound experimental evidence.

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Aspects that impact on the formulation and usage of products for self-applied fluoride prophylaxis (contd.):Fluorides can present hazards to health,

but only when its use is abused.There is support for the concept that

fluoride can exert its effects at lower levels in individual products possibly because of the multiple routes of administration now being employed and cumulative effects thereof.

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Aspects that impact on the formulation and usage of products for self-applied fluoride prophylaxis (contd.):The dental profession fully recognizes the

importance and safety of fluoride in combating dental caries.

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PERIODONTAL DISEASE

Gingivitis:Inflammation of the gingiva caused by accumulation of plaque and tartar below the gum line.

Associated with presence of specific bacteria Bacterial toxins released Host immune response Host susceptibility varies Bone loss does not occur

Periodontitis:Advanced stage of periodontal disease. Inflammation and destruction of the supporting tissues.

Tissue destruction due to bacterial toxins and release of enzymes from host’s immune system

Gumline recedes / roots exposed Bone and tooth loss can occur Treatment includes surgery

PRODUCT SAFETY

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Evaluation of the following aspects of safety should be considered for all cosmetics subject to ingestion, whether drugs or not:

Oral toxicity Mucous membrane irritation Primary skin irritation Potential for contact sensitization Photosensitization Percutaneous toxicity

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Efficacy of Fluoride Dentifrices in Clinical Trials

Fluoride Source Characteristics of Trials Results

Sodium flouride

Various abrasives in dentifrices. Over 25 reported trials. Subjects ranged in age from 4 years to young adults. Trials generally <2-3 years' duration, mostly with 1000 ppm fluoride.

Up to 50% reduction in caries increment. Usually 20-30% reduction. Negative results with abrasives able to bind fluoride, e.g., calcium carbonate.

Sodium monofluorophosphate

Various abrasives in dentifrices. Over 30 reported trials. Subjects ranged in aged from 5 years to young adults. Trials mostly 2 years or longer, mostly with 1000 ppm fluorine.

Up to 59% reduction in caries. Two-thirds or more of trials indicated reductions of over 20%. Active regardless of abrasive used.

Stannous fluoride

Only "compatible" abrasive used. At least 35 reported studies. Subjects ranged from 5 to 36 years of age. Trials of different duration, <1 year to 3 years, mostly with 1000 ppm fluorine.

Up to 59% reduction in caries. About half of trials showed 20-39% reduction.

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Safety of Fluoride DentifricesThe question of the safety of fluoride in dentifrices has been addressed on several levels:

1. Inherent chronic and acute toxicity2. Age of user3. Potential to cause fluorosis4. Risk vs benefit

The dental community, regulatory agencies, and the majority of the public have concluded that fluoride dentifrices pose no safety hazard under defined condition of use.

MOUTHWASHES or ORAL RINSES

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Clinical Investigations Conducted with Mouth Rinses Containing Fluorides

INVESTIGATORS MATERIAL UTILIZED* CONCLUSIONS

McCormick and Koulourides, 1965

NaF (3-40 ppm F-) plus

calcium and phosphate

Daily rinsing for one year produced significantly less interproximal caries in Grade 1 and 2 children

Torell and Ericsson, 1965A NaF (226 ppm F-)Daily rinsing for two years produced a 50% DMFS caries reduction in 10-year-old children

NaF (904 ppm F-)

Rinsing every two weeks for two years produced a 21% DMFS caries reduction in 10-year-old children

Kasakura, 1966 NaF (452 ppm F-)Daily rinsing for two years produced a 60% DMFS caries reduction in Grade 4 children

Koch, 1967 NaF (2260 ppm F-)

Rinsing every two weeks for three years produced a 23% DMFS caries reduction in 10-year-old children

Torell, 1969

NaF (904 ppm F-) plus CaCO3/0.8% sodium monofluorophosphate dentifrice used daily at home

Rinsing every two weeks for 2 1/2 years in conjunction with daily use of the fluoride dentifrice produced significantly less caries than use of the fluoride rinse alone

Gerdin and Torell, 1969 0.2% KF + Mn Cl20.2% NaF + Mn Cl2

0.2% NaF

Weekly rinsing for four years indicated that the KF + Mn Cl2 rinse produced significantly less caries than the other two rinses in 9- to 13-year-old children

*All rinses are essentially neutral, unless otherwise indicated.

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Clinical Investigations Conducted with Mouth Rinses Containing Fluorides

*All rinses are essentially neutral, unless otherwise indicated.

INVESTIGATORS MATERIAL UTILIZED* CONCLUSIONS

Swerdloff and Shannon, 1967 0.1% SnF2 (250 ppm F-)

Daily rinsing for five months established the feasibility of using this rinse and produced a non-significant DMFT caries reduction in school children

Horowitz, Creighton, and McClendon, 1971 NaF (904 ppm F-)

Weekly rinsing for 20 months produced a 44% DMFS caries reduction in Grade 5 children and a 16% reduction in Grade 1 children

Frankl, Fleisch, and Diodati, 1972 NaF (200 ppm F-) pH 4.0Daily rinsing for two years produced a 25% DMFS caries reduction in 14-year-old children

Aasenden, DePaola, and Brudevold, 1972 NaF (200 ppm F-)

NaF (200 ppm F-) pH 4.0

Brandt, Slack and Waller, 1972 NaF (904 ppm F-)

Twice weekly rinsing for two years produced a 35% DMFS caries reduction and three times weekly rinsing produced a 36% reduction in 7-year-old children

Moreira and Tumang, 1972 NaF (452 ppm F-)

Weekly rinsing for two years produced a 35% DMFS caries reduction and three times weekly rinsing produced a 36% reduction in 7-year-old children

Daily rinsing for three years produced a 27% DMFS caries reduction (neutral rinse) and a 30% reduction (acidulated rinse) in 8- to 10-year-old children

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Clinical Investigations Conducted with Mouth Rinses Containing Fluorides

*All rinses are essentially neutral, unless otherwise indicated.

INVESTIGATORS MATERIAL UTILIZED* CONCLUSIONS

Radike, Gish, Peterson, King and Segreto, 1973

0.1% SnF2 (250 ppm F-) Fluoridated Water

Daily rinsing for two years produced a 33-43% DMFS caries reduction in 8-to 13-year-old children

Rugg-Gunn, Holloway, and Davies, 1973 NaF (226 ppm F-)

Daily rinsing for three years produced a 35% DMFS caries reduction in 11-to 12-year-old children

Gallagher, Glassgow, and Caldwell, 1973 NaF (1808 ppm F-)

Weekly rinsing for two years produced a 27% DMFT caries reduction in 11-to 13-year-old children

Heifetz, Driscoll, and Creighton, 1973 NaF (0.3% ppm F-)

NaF (0.3% ppm F-) pH 4.0

Forsman, 1974 NaF (113 ppm F-)

NaF (904 ppm F-)

Weekly rinsing for two years produced a 38% DMFS caries reduction (neutral rinse) and a 27% reduction (acidulated rinse) in Grade 7 and 9 children

Weekly rinsing for two years produced a significant caries reduction for both rinse groups, with the lower level of fluoride providing a somewhat better effect

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Clinical Investigations Conducted with a Mouth Rinse Containing 0.01 Per Cent of a Macrolide Antibiotic (CC 10232)

INVESTIGATORS PARAMETER EVALUATED RESULTS

Volpe, Kupczak, Brant, King, Kestenbaum, and Schlissel, 1969 Supragingival plaque and calculus Approximately 70-77% reduction in plaque

Approximately 75% reduction in calculus

Stallard, Volpe, Orban, and King, 1969Supragingival plaque, calculus, and gingivitis 11-23% reduction in plaque

70-91% reduction in calculus55-72% reduction in gingivitis

Volpe, Schulman, Goldman, King and Kupczak, 1970 Supragingival calculus 38% reduction at 3 months

50% reduction at 6 months33% reduction at 9 months

Kovaleski and Ash, 1970Supragingival plaque, calculus, and gingivitis Beneficial effect on plaque up to 60 days

Rokita, Hazen, Millen, and Volpe, 1975 Supragingival plaque and calculusLess deposit, less mineralization and fewer spirochetes

Thank You