Fluorides

Dental Caries

Prevent or reduce the incidence of dental caries; slow or reverse the progression of existing dental lesions.107 109 b d e i j s t v

Effect of fluoride is predominantly posteruptive; maintain consistent small amounts of fluoride in saliva and dental plaque.109 113 (See Actions.)

As a dietary supplement for the prevention of dental caries in children in areas where the concentration of fluoride ion in drinking water is less than optimal.109

American Dental Association (ADA) recommends that all patients, including those without dental caries and with no apparent increased risk of dental caries, receive adequate water fluoridation or oral fluoride supplementation, combined with daily use of fluoridated dentifrice and twice-yearly topical application of fluoride.128

In addition, ADA and others state that patients at low or slightly increased risk for dental caries (e.g., low socioeconomic status, low levels of parental education, no regular dental care, or without dental insurance or access to dental services) may require sodium fluoride 0.05% mouth rinse or 0.4% stannous fluoride gel.109 128

ADA and others recommend that patients at moderate-to-high risk for dental caries (e.g., active dental caries, history of high incidence of caries in older siblings or caregivers, root surfaces exposed by gingival recession, impaired ability to maintain oral hygiene, malformed enamel or dentin, low salivary buffering capacity, wearing of orthodontic appliances, or reduced salivary flow from medications, radiation treatment, or disease) receive additional exposure to fluorides (e.g., home or professionally applied products).109 128

CDC supports fluoridation of the public water supply as the most cost-effective means of providing optimal levels of fluoride to large segments of the population.109

Optimal concentration of fluoride ion in drinking water is approximately 1 ppm (range 0.7–1.2 ppm), depending on the annual mean maximum daily temperature of the area.106 109 b w In warm climates where more water is likely to be ingested, concentrations should be at the lower end of the range.106 109

In communities where the concentration of fluoride in the water supply is >2 ppm, use an alternative source of drinking water for children ≤8 years of age.109

Because consumption of commercially available beverages (including bottled water) in the US and Canada is displacing the consumption of tap or well water, the relative importance of fluoridation of local community water on fluoride intake may be affected.107 However, current recommendations in children continue to be based on the fluoride concentrations in local drinking water.106 107

ADA and others recommend that in areas where oral fluoride supplements are necessary, children 6 months to 16 years of age receive daily fluoride supplements to provide maximum benefit to both deciduous and permanent teeth.a

Efficacy of topically applied fluoride varies according to the concentration of fluoride ion in the preparation, method and frequency of application, and the duration of use.a

Acidulated phosphate fluoride gels (alone or in combination with a saliva substitute) have been used to control dental decay after xerostomia-producing radiation therapy of tumors of the head and neck.a

Stannous fluoride gels have been used to prevent decalcification in orthodontic patients.a

Stannous fluoride gels have been used to protect against postirradiation caries.a

Desensitizing Dentin

Topically to desensitize exposed root surfaces of teeth.f h

Bone Diseases

Has been used to increase bone density and relieve bone pain in the treatment of various metabolic and neoplastic bone diseases†.a

Has been used in conjunction with calcium and vitamin D or calcium and estrogen to reduce skeletal fracture rates in osteoporosis†; further study is needed.a

Has been used alone or in conjunction with calcium carbonate as an adjunct in the management of bone lesions in multiple myeloma†.a

Has been used to reduce bone pain in metastatic prostatic carcinoma†.a

Has been reported to stabilize the progression of hearing loss in a limited number of patients with otosclerosis†.a

Has been used to increase spinal (but not femoral neck) bone mineral density (BMD) in corticosteroid-induced osteoporosis†;108 however, further studies are needed and other therapies are preferred.108

Specific Drugs

• Mechanism of action in reducing tooth decay not fully understood;a however, research now indicates predominant effect is posteruptive, not preeruptive as previously hypothesized.109 113

• Increases tooth resistance to acid dissolution, promotes remineralization, and inhibits the cariogenic microbial process.109 a b e i j m o s w v

• Prior to tooth eruption, fluoride is incorporated into tooth enamel during formation.a

• Cariostatic effects on teeth after eruption result from combined effects of bacterial metabolism in plaque and on the dynamics of enamel demineralization and remineralization during an acidogenic challenge.107

• Obturates dentin tubule orifices; reduces patency of the tooth pulp and decreases hypersensitivity.f h

• Increases skeletal density and bone mass; however, large doses can cause skeletal fluorosis and osteomalacia.a

• Advise patients receiving fluoride powders or concentrated rinsing solutions that the preparation must be reconstituted and/or diluted as directed prior to use.103 i

• Advise patients receiving fluoride treatment gels or rinsing solutions for self-administration that these preparations are to be used as directed and not as dentifrices or mouthwashes or gargles, respectively.103 i

• Advise individuals receiving stannous fluoride-containing preparations of the importance of good oral hygiene (e.g., adequate brushing) to minimize the risk of staining.103 i Inform patients that such staining is not harmful or permanent and can be removed by a dentist or dental hygienist.103 i

• Instruct and/or supervise children <12 years of age during use of topical fluoride preparations (e.g., rinsing solutions, gels, dentifrices) to minimize the risk of fluorosis and the amount of fluoride swallowed and absorbed systemically.100 101 103 i Instruct children, especially those 2–6 years of age, not to swallow topical fluoride products.100 101 109 Inform individuals with children that ingestion of higher than recommended levels of fluoride by children has been associated with an increase in mild dental fluorosis in developing, unerupted teeth.w

• Importance of long-term compliance on a daily basis in patients who require oral fluoride supplements.w

• Advise patients not to brush or eat hard foods for 2 hours after application of topical solution.h

• Advise patients to contact a poison control center or other qualified clinician immediately if they swallow more fluoride than the amount used for brushing or rinsing.l n

• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses.b c d e f i j l m n o p s t w v h

• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.b c d e f i j l m n o p s t w v h

• Importance of informing patients of other important precautionary information.b c d e f i j l m n o p s t w v h (See Cautions.)

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Sodium fluoride is also commercially available in multivitamin and multivitamin/iron preparations for oral use and in dentifrices.

Sodium monofluorophosphate is commercially available only in dentifrices.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Stannous fluoride is also commercially available in dentifrices.