fluorides in periodontal therapy

8/10/2019 Fluorides in Periodontal Therapy

1/4|28|Smile Dental Journal | Volume 5, Issue 3 - 2010

Fluorides in Periodontal Therapy:

A Review

Dhruva Kumar GaniMDS

Lecturer, Department ofPeriodontology, LenoraInstitute of Dental Sciences,

Andhra Pradesh, India

[email protected]

AbstractIn general practice, the most common dental diseases in patients are caries and periodontaldisease. Dental visits would typically involve removal of supragingival plaque and calculus,identification of failed restorations and/or incipient carious lesions and the placing ofrestorations to restore tooth surfaces to health. Typically a patient would be delivered twoor more restorations at each dental visit. Although the association between fluoride anddental caries has been widely studied and clearly determined, the association betweenfluoride and periodontal health and disease is not clearly mentioned in literature. To ourincompatible studies in the literature either suggests regular usage of fluoride as an adjunctto conventional periodontal therapy or dispute against topical fluoride use on periodontally

involved teeth was found. This literature review concludes the aims and utility of fluorides inpatients with periodontal disease, and rational principle use of fluorides in the managementof periodontal diseases. Topical fluorides application of exposed root surfaces afterperiodontal therapy may be beneficial.

Keywords: Fluorides, Periodontal therapy, Stannous fluoride.

IntroductionDental care has always been based upon diagnosis whereas dental hygiene caretraditionally has been driven more by schedule, insurance coverage, and both patientand professional perceptions. This can lead to an increased number of root caries in

periodontal patients. It is important to understand the relationship of bacteria in the oralcavity and periodontal disease, and to be aware of the need to incorporate a strong cariesprevention program into periodontal protocols.1General dentistry for oral health consciouspeople of the previous generation meant visits to the dentist every six months.2A cleardistinction between pediatric and adult dental needs was not as apparent as it is today. Asthe population aged, teeth were lost due to caries and/or periodontal disease. Dental visitswould typically involve removal of supragingival plaque and calculus, identification of failedrestorations and/or incipient carious lesions and the placing of restorations to restore toothsurfaces to health. A patient typically would receive two or more new restorations at eachdental visit, and topical fluoride application would be included in preventive treatment. Themodern concept of dentistry is based on a number of various scientific discoveries. Basic andclinical sciences have identified the specific microbial etiologies of caries and periodontal

disease; subsequently, antiseptics, antibiotics and root canal medications have successfullybeen employed in dento-oral infections.3Ultrasonic scalers, now in widespread use, removesupra- and subgingival calculus as well as do hand instruments 3,4in significantly less time.Commonly used fluoride agents in dentistry are sodium fluoride, stannous fluoride andAcidulated phosphate fluoride. Other available fluoride agents include strontium acetate/sodium fluoride, potassium chloride/sodium monofluorophosphate, and sodium fluoride/sodium monofluorophosphate.5

Sodium FluorideSodium fluoride is the oldest of the fluoride solutions used to fight caries. The anticariesbenefits of sodium fluoride depend on use of an effective concentration and the frequency ofapplication of the fluoride solution.6Topical applications of neutral sodium fluoride solutionswith fluoride concentrations of 100 parts per million (ppm), or less result in the formation

of fluorapatite, while lowering the pH of the fluoride-containing solution or increasing thefluoride concentration to greater than 100 ppm favors the formation of calcium fluoride.7

Todays commercial sodium fluoride solutions are on the order of 9,000 ppm (2 % solutions)

Sreekanth Kumar MallineniBDS

Private Practitioner, Ganidental care and implantcentre, Nellore, (A.P), India

[email protected]


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argument against routine fluoride use. While conductingin vitro studies of the effects of fluoride on dentin anddentin fibroblast interactions, they found that fluorideconditioning of dentin inhibits fibroblast attachment and/or reattachment, and concluded that the use of fluoride

containing solutions should be avoided during and afterperiodontal surgery and scaling. Thus, the clinician ispresented with two opposing views that imply supportof two different treatment modalities, and endorsingan incorrect concept may lead the dentist to select atreatment that could damage the health of the dentalhard and soft tissues. The present article focuses on thepublished evidence available in support of the use offluoride as an aid to periodontal treatment. It explainsissues such as tooth sensitivity, tissue healing potentialand supportive periodontal therapy.

Fluorides Effect on Subgingival AreasThe aim of the fluoride treatment is to prevent dentinalsensitivity, it is less important to place the fluoridesolution in the periodontal pocket than it would be ifthere was clinical evidence of root caries. This is becauseexposed dentin within a periodontal pocket has the freegingiva to provide a barrier to the external environmentand is less likely to respond to the external stimuli thandentin completely exposed to the external environment.In a few words, a lack of penetration of solution belowthe gingival margin is the biggest impediment to totaland effective subgingival delivery of therapeutic agents.Rams and Slots14reviewed devices currently used to

deliver antimicrobial agents to periodontal pockets.The approaches described are similar, if not identical,to methods used to apply fluoride to subgingival areas.Even though primary root caries may never start ina periodontal pocket, a supragingival carious lesionmay develop subgingivally, and so complete pocketpenetration of fluoride would be the preferable anticariestherapy. The usual oral irrigators can achieve penetrationabout 50 % with the use of a soft cone shaped rubber tipand 80 % blunt tipped irrigating cannula connected toa handheld syringe.15However, Rosling et al.16reportedalmost 100 % pocket penetration may be achieved if

the solution is delivered in the cooling solution attachedto ultrasonic scalers in periodontal treated patientsafter 3 months and 12 months recalls. From the results

and result in the transformation of surface enamelhydroxyapatite to calcium fluoride with the liberation ofphosphate ions.8

Stannous FluorideAnother fluoride compound developed for topical useduring the1950s was stannous fluoride. The reactionof stannous fluoride differs significantly from that ofsodium fluoride in that both the cation and anionreact chemically with enamel hydroxyapatite, andthere is no loss of phosphate ions. Stannous fluorideapplied topically produces calcium fluoride, stannousfluorophosphates and a hydrated tinoxide.6

Acidulated Phosphate Fluoride (APF)A topical fluoride system developed in the 1960swas acidulated phosphate fluoride or APF. The use

of APF results in the formation of calcium fluoride,fluorhydroxyapatite and phosphate ions.6The lower thepH of these fluoride compounds, the more enhanced isthe rate of reaction between fluoride and hydroxyapatite.In APF solutions, the use of phosphoric acid to achievea low pH favors the formation of fluorhydroxyapatite.This is clinically desirable because less calcium fluorideis produced and, more importantly, the numberof phosphate Ions lost from the enamel surface isminimized.6The use of fluorides in periodontal patientsdepends on different oral conditions, recommendationof fluorides for different periodontal conditions are

showed inTable 1

. Many dentists would probablyidentify fluoride as the most significant change in thepractice of dentistry. The widely used fluoride has agreat impact on the prevention of dental problems ingeneral and particularly caries. Stannous fluoride hasshown antibacterial activity against microorganisms likePorphyromonas gingivalis, Porphyromonas intermedia,Actinomycetes,9,10but the few studies that haveaddressed the periodontal status of populations in areaswith high and low levels of fluoride in the water haveconcluded that fluoridated drinking water has little orno effect on gingival and periodontal health. However,there is an animal study,11and Goldman12that support

the capability of fluoride applications whenever dentinor cementum is exposed, including during surgicalprocedures. In disparity, De Jong et al.13published an

Periodontal Condition Recommendation of Fluorides

Ginigivitis/PeriodontitisStannous fluorideMedicated dental floss (Sn F2)

Exposed roots1.1 % Naf toothpasteSodium fluorideStannous fluoride

Dentinal hyper sensitivity

Fluoride varnish

Sodium fluorideStannous fluoridePotassium fluoride

(Table 1)


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tubules can be equated with the reduction in dentinalsensitivity as reported by patients.

Fluorides in PeriodontitisWhile the role of topical and systemic fluoride in the

inhibition of dental caries is well-established, the effect offluoride on the severity of periodontal disease in variouspopulations remains to be established. Axelsson, Lindheand Nystrm conducted a 15-year study of patients atdental recall visits ranging from two to 12 months afterthe initial appointment to assess the benefits of plaquecontrol and repeated applications of topical fluoride.20Fluoride was applied at each dental visit, and reportedthat this level of attention resulted in a significantlylower incidence of caries and essentially halted anyloss of periodontal tissue support. However, the resultof this latter study did not assign any benefit to the

periodontium or root surface from the specific fluoridetreatments; therefore, the researchers conclusionsabout the value of fluoride to the periodontium or rootsurface are general and perhaps misleading. A completestudy would assess the benefits of fluoride use alonewithout additional oral hygiene procedures. Boyd et al.15indicated that self administered 0.02 % stannous fluorideirrigation on a daily basis may improve periodontalattachment levels without any additional treatment.Based on the results of this study, some dentists mayrecommend patients with destructive periodontaldisease a stannous fluoride home irrigation regimen asan alternative to invasive periodontal therapy. Home

and professionally administered stannous fluoridetreatments may offer both antiplaque and antigingivitisresponses.9However, antiplaque and antigingivitisresponses are not apparent with sodium or amine basedfluoride treatments.21Without any additional treatment,a professionally administered application of 1.64 %stannous fluoride gel to sites of periodontitis reduces thenumbers of subgingival motile organisms and gingivalinflammation over a 6 to 10 week period.22However,some studies have shown that subgingival irrigation with1.64 % stannous fluoride decreases motile bacteria,spirochetes and black pigmented anaerobic rods for

several weeks in patients with advanced periodontaldisease,17and a single subgingival application ofstannous fluoride reduced numbers of subgingivalblack pigmented anaerobic rods but had little effect atreducing the total anaerobic bacterial count. Despite thereported positive results, there are no conclusive datademonstrating an adjunctive clinical benefit of the use ofstannous fluoride in periodontitis.

Fluorides Effect After Scaling & RootPlaningRoot surfaces adjacent to pathologic periodontal

pockets are liable to undergo histological changesand modifications of cementum characteristics. Toxicsubstances from the inflammatory process and from thesubgingival microflora may be adsorbed to the outer

of a study by Boyd et al.15showing that daily homeirrigation with a 0.02 % stannous fluoride solution canreduce probing depths and gingival bleeding, it maybe assumed that home delivery of fluoride solutionscan also benefit periodontal patients in reducing

tooth sensitivity and preventing root caries. Similarbenefits may be assumed for other fluoride solutionsor pastes.17However, many patients are unable toachieve the maximum benefits of subgingival deliverybecause topical pocket application may be restricted toprofessional applications during dental visits.

Fluorides Effect on Cementum & ExposedDentinThe most accepted mechanism of dental stimulusactivity associated with tooth hypersensitivity is ahydrodynamic representation. This may be related to

a communication between dental tubules and dentalnervous tissues and suggests that fluid gradients andtemperature and pressure changes on the tooths exteriorcan be experienced within the tooth as communicatedby the pulpal nerve plexus.4Different patients willexperience different levels of tooth hypersensitivity, andin time the tooth will respond by generating additionalsecondary dentin. Traditionally, toothpaste and gelswith high fluoride content have been used to fight toothhypersensitivity. Dentists frequently suggest the use of atoothpaste that contains sodium fluoride and potassiumnitrate. Potassium nitrate may be more effective thanfluoride in reducing dentin sensitivity. After removal ofcalculus and cementum during scaling and root planingprocedures dentinal hypersensitivity may arise. However,immediately after therapy, some patients may experienceuncomfortable levels of dentinal hypersensitivity thatcan compromise their oral hygiene efforts, and the useof professionally applied fluoride may be consideredfor a patient with a high degree of dentinal sensitivity.Such a condition will be diagnosed after the effectof any anesthetic agent has ceased while dentaltreatment. Hansen18studied dentinal hypersensitivityin vivo and found that a fluoride- containing varnish(Duraphat, Woelm Pharma Co., Germany) and a light

cured glassionomer liner (Vitrabond, 3M)demonstratedbetter clinical success than achieved with a non-fluoridetreatment. Knight et al.19used an in vitro model toaddress the issue of dentinal hypersensitivity and fluorideusage and the assumption was that closure of the hollowdentinal tubules after treatment could decrease dentinalsensitivity. These authors found that the use of sharpcurettes caused an obliteration of dentinal tubules, whilea light-cured resin application yielded less effectiveclosure of the tubules. The two opposing opinionsregarding methods to decrease dentinal sensitivity(application of Duraphat or Vitrabond vs. use of hand

instrumentation) are difficult to compare. The positivein vivo results of Hansen18would appear to lessen thevalue of the negative in vitro findings of Knight et al.19Also, there is no evidence that the obliteration of dentinal


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part of such root surfaces. These substances, includingendotoxins from gram-negative bacteria, are toxicto connective tissue and cause periodontal disease.Investigators have studied components of organic andinorganic matter on root surfaces immediately following

scaling and root planing.13,23,24

The use of EDTA led to a complete smear layer removalfrom the root surface. Remnants of dental calculus,contaminated root cementum and subgingival plaquemay be present after scaling. Fibroblasts can migrateand attach to root surfaces best when the root surface isfree. De Jong et al.13suggested reschedule of fluorideapplications until an epithelial attachment to the rootsurface has been established. If a patient has a history ofroot sensitivity, then the dentist might consider applying ahigh content fluoride product at the time of scaling and

root planing.12,24

Hamp and Nyman24stated that all forms of periodontalsurgery, including root resection, result in exposed rootdentin surfaces which may be susceptible to dentincaries. Fluoride solutions should routinely be applied tosuch surfaces after completion of surgery.

ConclusionThe improved supragingival plaque control could alsohave played a major role, although the impact of thesupragingival environment on subgingival recolonizationafter periodontal therapy is still controversial. Thefluoride treatment plan should be based upon a fluoriderisk assessment, and recommendation should be basedupon need rather than age or reimbursement method.As always when working with patients, education,motivation, and benefits must be reviewed continuouslyfor treatment success. Periodically, patients will gothrough periods of lapse, relapse and collapse withmany of recommendation treatment plans. One of themost challenging job responsibilities is to affect thebehaviour of patients in a positive way, which ultimatelyhas an impact on treatment outcomes. However, handinstrumentation alone may result in sufficient blockage of

the dentinal tubules which, in the opinion of at least onegroup of researchers, can be equated with a reductionin root sensitivity. From the literature the use of fluoridesolutions in periodontal patients is supported for one oftwo reasons, either to prevent root caries or to avoid rootor dentin sensitivity, both reasons are justified.

Clinical RelevanceTopical fluoride application is useful not only to preventdental caries but also may be useful to prevent dentinalhypersensitivity of periodontally involved teeth. Topicalfluorides application of exposed root surfaces afterperiodontal therapy may be beneficial to clinician andpatient as well.

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2. Anthonappa RP, King NMSix-month recall dental appointments,for all children, are (un) justifiable.J Clin Pediatr Dent.2008;33(1):1-8.

3. Paine ML, Slots J, Rich SKFluoride use in periodontal therapy: areview of the literature. J Am Dent Assoc. 1998;129(1):69-77.

4. Breininger DR, OLeary TJ, Blumenshine RV. Comparative

effectiveness of ultrasonic and hand scaling for the removal ofsubgingival plaque and calculus. J Periodontol. 1987;58:9-18.5. Gillam DG, Bulman JS, Jackson RJ,Newman HN. Comparison of

2 desensitizingdentifrices with a commercially available fluoridedentifrice in alleviating cervical dentine sensitivity. J Periodontol.1996;67:737-42.

6. Harris NO, Christen AG. Primary preventive dentistry. 4thed.Norwalk, Conn. Appleton Lange;1995.

7. Fisher RB, Muhler JC. The effect of sodium fluoride upon thesurface structure of powdered dental enamel. J Dent Res.1952;31:751-5.

8. Joost-Larsen M, Fejerskov O. Structural studies on calcium fluorideformation and uptake of fluoride in surface enamel in vitro. ScandJ Dent Res. 1978;86:337-45.

9. Weber DA, Howard-Nordan K, Buckner BA, et al.Microbiologicalassessment of animproved stannous fluoride dentifrice. J

ClinDent. 1995;6 (Spec. No.):97-104.10. Binney A, Addy M, Owens J, Faulkner J. A comparison of riclosan

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12. Goldman HM. Gingivectomy. Oral Med Oral Surg Oral Pathol.1951;4:1136-57.

13. De Jong HP, Schakenraad HP, Busscher HJ. Spreading of humanfibroblasts on pretreated human root dentine. J Biol Buccale.1988;16:31-4.

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17. Schmid E, Kornman K, Tinanoff N. Changes of subgingival colonyforming units and black pigmented Bacteriodes after a singleirrigation of periodontal pockets with 1.64 % SnF2. J Periodontol.1985;56:330-3.

18. Hansen EK. Dentine hypersensitivity treated with a fluoride-containing varnish or a light-cured glass-ionomer liner. ScandJDent Res. 1992;100:305-9.

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dentinal tubuli. J Periodontol. 1993;64:366-73.20. Axelsson P, Lindhe J, Nystrm B. On the prevention of caries and

periodontal disease. Results of a 15-year longitudinal study inadults. J Clin Periodontol. 1991;18:182-9.

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