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© Borgis - Nowa Stomatologia 1/2020, s. 15-25 | DOI: 10.25121/NS.2020.25.1.15
*Swietłana Kozaczuk
Deep penetration fluoridation for caries prevention and treatment: the use of Tiefenfluorid® junior in children. Case reports
Fluoryzacja dogłębna w profilaktyce i leczeniu próchnicy: stosowanie preparatu Tiefenfluorid® junior u dzieci. Opisy przypadków
Indywidualna Praktyka Lekarska, Kraków
Streszczenie
Profilaktyka fluorkowa wspólnie ze zdrową zbilansowaną dietą oraz nawykami higienicznymi jest filarem w walce z chorobą próchnicową. W czasach, gdy ruch antyfluorowy rośnie w siłę i budzi wątpliwości nawet wśród lekarzy i higienistek, środowisko stomatologiczne powinno korzystać w postępowaniu klinicznym z wiarygodnych dowodów naukowych dotyczących skuteczności i bezpieczeństwa terapii.
W artykule przedstawiono przypadki kliniczne stosowania preparatu do fluoryzacji dogłębnej Tiefenfluorid® junior (Humanchemie, Niemcy) w leczeniu i profilaktyce zmian próchnicowych u dzieci. W celu wykrycia zmian próchnicowych zastosowano metodę wizualno-dotykową. Do klasyfikacji zmian próchnicowych wykorzystano Międzynarodowy System Wykrywania i Oceny Próchnicy – ICDAS II. Dynamikę rozwoju zmian próchnicowych oceniano metodą wizualno-dotykową na wizytach kontrolnych co 3 miesiące w ciągu 12 miesięcy.
Fluor jest efektywny w leczeniu próchnicy początkowej w szkliwie, a preparat na bazie srebra i fluoru SDF skutecznie zatrzymuje próchnicę w zębinie. Wadą SDF jest zabarwienie zębów na czarny kolor. W przeciwieństwie do zwykłych fluorków, preparat do fluorowania Tiefenfluorid® junior (Humanchemie, Niemcy) dzięki działaniu preparatu utrwalającego staje się nietoksyczny, ponadto proces odbywa się w głębi szczelin labilnej warstwy szkliwa, a nie na powierzchni zębów.
Dogłębna fluoryzacja może być stosowana do zabiegów profilaktycznych, w tym mineralizacji bruzd, a także do leczenia próchnicy początkowej. W leczeniu próchnicy początkowej u małych dzieci stanowi alternatywę dla impregnacji i dla lakierów fluorowych.
Summary
The use of fluoride, a healthy diet and good dental care habits are the pillars of the fight against caries. At a time when the anti-fluoride movement is on the increase and raises doubts even amongst the dentists and dental hygienists, the dental environment should be based on the credible scientific evidence regarding the effectiveness and safety of therapy in their clinical management.
The article presents the clinical cases in which the agent for deep penetration fluoridation Tiefenfluorid® junior (Humanchemie, German) was used in the treatment and prevention of carious lesions in children. The visual-tactile method was used for detecting caries lesions. The International Caries Detection and Assessment System – ICDAS II was used for classifying dental caries. Carious lesions activity were assessed using visual-tactile method at control visits every 3 months within 12 months.
Fluoride is effective in the treatment of initial caries in enamel, and the agent based on silver and fluorine SDF (Silver Diamine Fluoride) effectively inhibits tooth decay in the dentin. The disadvantage of SDF is the black color of the teeth. In contrast to common fluoride compounds, the solution with fluoride Tiefenfluorid® junior (Humanchemie, German) becomes non-toxic due to the reaction with the second application solution with calcium hydroxide. Furthermore, the process takes place deep in the funnels of the dental enamel, not on the tooth surface.
The deep penetration fluoridation can be used for the caries prophylaxis, including the mineral fissure sealing, as well as for the treatment of initial caries lesions. In the treatment of initial caries in small children, it is an alternative to the silver nitrate impregnation and for the fluoride varnishes.
Słowa kluczowe: próchnica.
Introduction
Over 85% of 6-year-old and 95% of 18-year-old Polish children and teenagers have teeth affected by caries. Often dental problems arise from parents not knowing of the effective prevention of dental caries and oral diseases. The main preventive pillars are a healthy balanced diet, proper dental care hygiene habits and fluoride prophylaxis (1).
Almost 1/3 of Polish children aged 8 are overweight or obese according to WHO standards (2). About 10% of children aged 1-3 years are overweight/obese and 18.4% are at risk of becoming overweight (3). Over 60% of Polish children aged 3 and around 25% of children aged 5 have never been to a dentist before (4). Encouraging a child to brush their teeth often involves a lot of effort for parents. An additional problem is the anti-fluoride movement, which raises anxiety and doubts even among doctors and dental hygienists. Undoubtedly, all three preventive pillars are weakened.
The attitude of the Polish Academy of Pediatric Dentistry, National Consultant and FDI (World Dental Federation) is to limit the consumption of sugars, start to carry out dental hygiene procedures in the child’s oral mouth no later than when the first primary tooth has been erupted and implementation of the exogenous fluoride prophylaxis, which means the delivery of the fluoride compounds directly to the tooth surface. Daily use of a toothpaste containing 1000 ppm fluoride in children up to 3 years old and 1000-1450 ppm in children aged 3-6 years depending on the risk of tooth decay and the professional topical fluoride application 2-4 times a year, depending on the level of caries risk, is an effective prevention action in the fight against early childhood caries (1). Choosing a toothpaste for children, parents should pay attention not only to the appropriate fluoride content, but also to other ingredients such as SLS (sodium lauryl sulphate), parabens, PEG (polyethylene glycol) and RDA (relative dentin abrasivity). Doctors that broaden their knowledge about the agents for the professional topical fluoride application can better make a choice for their young patients.
The fluoride toxicity, that has been proven in the many scientific studies, depends on the dose and duration of exposure. The harmful effects of fluoride can be observed not only on teeth as a fluorosis, it also has harmful effects on the bones, the liver, the kidneys, the thyroid and the reproductive organs. It is neurotoxic and causes disorders in the mineral metabolism, including calcium, magnesium and phosphorus (5).
However, all of these side effects are related to the fluoride overdose under an endogenous supply, including the fluoride supplementation (tablets or drops). Studies that describe the toxic effects of fluoride on the thyroid, nervous and reproductive systems refer to areas with very high natural fluoride concentration in water ([above 30 mg/l] India and China) (6). The World Health Organization recommended the limit of fluoride in drinking water is 1.5 mg/l (7).
The water is not artificially fluoridated in Poland. The water around Tricity and Malbork is too rich in fluoride, which occurs naturally – from 1.6-2.0 mg/l in Gdańsk to 4.4 mg/l in the commune of Cedry Wielkie. Other regions in Poland have a concentration of fluoride in drinking water below WHO standards (e.g. Krakow, Poznan, Warsaw, Wroclaw 0.1-0.3 mg/l according to the data of the municipal water and sewer company). The food and drinks are a natural source of fluoride, especially black tea. Knowledge about the amount of fluoride in drinking water and food is crucial because of the ease of overdosing on this compound in young children, for example by using water rich in fluoride to prepare modified milk or food for babies.
The professional topical fluoride application limits the action of the cariogenic bacteria, inhibits the demineralization processes and supports the remineralization. Fluoride ions at low concentrations < 50 ppm provide the possibility of the mineral compounds repositioning that are lost during acid attacks, and the formation of crystals with a coat similar to fluorapatite. Fluoride ions with a higher concentration > 100 ppm provide the formation of a fluoride ion reservoir in the form of calcium fluoride (CaF2) released during the attack of bacterial acids on the tooth (1).
The professional topical fluoride application, including deep penetration fluoridation, is used for the preventive and therapeutic needs (8) (tab. 1). According to the Polish Academy of Pediatric Dentistry professional fluoridation for children is recommended 2-4 times a year depending on the risk of caries and child’s cooperation (1).
Tab. 1. Indications for the professional topical fluoride application (9, 10)
Preventive indications1. Prevention of the primary or secondary caries lesions.
2. Prevention of the caries on the root surface.
3. Prevention of the non-carious lesions, e.g. erosions.
4. Mineral fissure sealing.
Therapeutic indications1. Treatment of initial carious lesions when only tissue demineralization has taken place, not cavity formation, in order to stop the development of caries.
2. Treatment of the dentine hypersensitivity.
Clinical cases
The article presents the clinical cases in which the agent for deep penetration fluoridation Tiefenfluorid® junior (Humanchemie, German) was used in the treatment and prevention of carious lesions in children. The visual-tactile method was used for detecting caries lesions (examination using loupes at 3.5 x and CPI-TN probe). The International Caries Detection and Assessment System – ICDAS-II was used for classifying dental caries:
– 0 – sound,
– 1 – first visual change in enamel,
– 2 – distinct visual change in enamel,
– 3 – localized enamel breakdown (without clinical visual signs of dentinal involvement),
– 4 – underlying dark shadow from dentin,
– 5 – distinct cavity with visible dentin,
– 6 – extensive distinct cavity with visible dentin.
Written consent of the parents/legal guardians of the patients was obtained.
Clinical case 1
A child of age 3.5 years, generally healthy. First dental visit at the age of 18 months. From the interview: the mother was worried about the appearance of the upper incisors, suspecting a baby bottle tooth decay. The child is averse to using his front teeth and is averse to brushing his upper front teeth. The child is uncooperative. In the intraoral examination reveals: carious destruction of the clinical crowns of the anterior upper incisors, active caries lesions, sensitive on the probing. Caries lesions with code 3 ICDAS-II scale in teeth 52, 51, 61 and 62 on the labial surfaces and caries lesions with code 5 ICDAS-II scale in teeth 52, 51 and 62 are not bacterial plaque retention area, thorough cleaning at home with a toothbrush is possible. Extensive carious defect code 6 ICDAS-II scale in tooth 61 on the palatal surface is bacterial plaque retention area, thorough cleaning at home with a toothbrush is impossible. Preventive and therapeutic treatment plan:
1. Professional oral hygiene, oral hygiene instructions and dietary advice.
2. Cycle of deep penetration fluoridation: 3 times weekly (Tiefenfluorid® junior, Humanchemie), then after 1 month to inhibit caries and strengthen hard teeth tissues.
3. At home: use of the tooth care cream with with casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) complex (Tooth Mousse, GC) (11).
4. Check-up visits and the professional topical fluoride application every 3 months (high risk of caries).
5. Periodic evaluation (every 3 months) of the effectiveness of remineralisation activities. In the event of progression of the lesions, implement invasive treatment of lesions on the labial and palatal surfaces of the upper teeth 52, 51 and 62.
6. Conservative treatment of the caries lesion on the palatal surface of the tooth 61 – mechanical preparation of the carious defect, reconstruction with GIC material (Fuji IX, GC).
After a cycle of deep penetration fluoridation procedure at the age 18 months, the hypersensitivity completely disappeared and the carious lesions in the front teeth became hard. A deep penetration fluoridation procedure is painless and safe. The first stage is thorough cleaning of the teeth. Then apply to the dried tooth surfaces the first application solution with fluoride and the second application solution with calcium hydroxide (Tiefenfluorid® junior, Humanchemie) using a brush or microbrush applicator. After applying 2 solutions, the teeth should be washed with water or wiped with a wet gauze. The solution with fluoride becomes non-toxic due to the reaction with the second application solution with calcium hydroxide. Furthermore, the process takes place deep in the funnels of the dental enamel, not on the tooth surface. After the procedure, the patient can immediately drink and eat.

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Piśmiennictwo
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otrzymano: 2020-01-10
zaakceptowano do druku: 2020-01-31

Adres do korespondencji:
*Swietłana Kozaczuk
Indywidualna Praktyka Lekarska
ul. Poznańska 8/1U, 30-012 Kraków
tel.: +48 514-514-694
sv.kozaczuk@gmail.com

Nowa Stomatologia 1/2020
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