Role of the enamel organ in limiting fluoride uptake during the maturation phase of enamel development

Fluoride ingestion from toothpaste and diet in 1- to 3-year-old Brazilian children

OBJECTIVE

This study estimated the total daily fluoride intake of 1- to 3-year-old children from diet and dentifrice. The constituents of the diet were divided into solids, water, milk, and other beverages, which were analyzed separately. The correlation between fingernail fluoride concentrations and the total daily fluoride intake by children was also investigated.

METHODS

Thirty-three children, living in a fluoridated area, participated in the study. Fluoride intake from diet was monitored by the 'duplicate plate' method, investigating the different constituents of the diet. Fluoride ingested from dentifrice was determined by subtracting the amount of fluoride recovered after brushing from the amount originally placed onto the child's toothbrush. Fingernails were clipped and collected on three occasions. Fluoride was analyzed with the ion-specific electrode, after hexamethyldisiloxane-facilitated diffusion. Data were tested by anova and Tukey's post hoc tests, Student's t-tests and linear regression (P < 0.05).

RESULTS

Mean (+/-SD) fluoride intake from diet and dentifrice was 0.025 +/- 0.013 and 0.106 +/- 0.085 mg/kg body weight/day, respectively, totaling 0.130 mg/kg body weight/day. A strong positive correlation (r = 0.971, P < 0.0001) was seen between the amount of dentifrice loaded onto the brush (0.49 +/- 0.30 g) and the amount of fluoride ingested during each tooth brushing (0.59 +/- 0.45 mg). Among the constituents of the diet, water and milk had a significantly higher contribution to the fluoride intake (0.18 +/- 0.11 mg/day, P < 0.0001), when compared with solids (0.07 +/- 0.05 mg/day) and other beverages (0.07 +/- 0.04 mg/day). Mean (+/-SD) fingernail fluoride concentration on the three dates of collection was 3.11 +/- 1.14, 2.22 +/- 1.47 and 3.53 +/- 1.40 mug F/g. There was no significant correlation between fingernail fluoride concentration and the total fluoride intake.

CONCLUSIONS

Most of the children are exposed to a daily fluoride intake above the suggested threshold for dental fluorosis. The dentifrice alone is responsible for an average of 81.5% of the daily fluoride intake, while among the constituents of the diet, water and milk are the most important contributors. In addition, small variations in daily fluoride intake cannot be detected in fingernails.

Dental fluorosis: chemistry and biology

This review aims at discussing the pathogenesis of enamel fluorosis in relation to a putative linkage among ameloblastic activities, secreted enamel matrix proteins and multiple proteases, growing enamel crystals, and fluid composition, including calcium and fluoride ions. Fluoride is the most important caries-preventive agent in dentistry. In the last two decades, increasing fluoride exposure in various forms and vehicles is most likely the explanation for an increase in the prevalence of mild-to-moderate forms of dental fluorosis in many communities, not the least in those in which controlled water fluoridation has been established. The effects of fluoride on enamel formation causing dental fluorosis in man are cumulative, rather than requiring a specific threshold dose, depending on the total fluoride intake from all sources and the duration of fluoride exposure. Enamel mineralization is highly sensitive to free fluoride ions, which uniquely promote the hydrolysis of acidic precursors such as octacalcium phosphate and precipitation of fluoridated apatite crystals. Once fluoride is incorporated into enamel crystals, the ion likely affects the subsequent mineralization process by reducing the solubility of the mineral and thereby modulating the ionic composition in the fluid surrounding the mineral. In the light of evidence obtained in human and animal studies, it is now most likely that enamel hypomineralization in fluorotic teeth is due predominantly to the aberrant effects of excess fluoride on the rates at which matrix proteins break down and/or the rates at which the by-products from this degradation are withdrawn from the maturing enamel. Any interference with enamel matrix removal could yield retarding effects on the accompanying crystal growth through the maturation stages, resulting in different magnitudes of enamel porosity at the time of tooth eruption. Currently, there is no direct proof that fluoride at micromolar levels affects proliferation and differentiation of enamel organ cells. Fluoride does not seem to affect the production and secretion of enamel matrix proteins and proteases within the dose range causing dental fluorosis in man. Most likely, the fluoride uptake interferes, indirectly, with the protease activities by decreasing free Ca(2+) concentration in the mineralizing milieu. The Ca(2+)-mediated regulation of protease activities is consistent with the in situ observations that (a) enzymatic cleavages of the amelogenins take place only at slow rates through the secretory phase with the limited calcium transport and that, (b) under normal amelogenesis, the amelogenin degradation appears to be accelerated during the transitional and early maturation stages with the increased calcium transport. Since the predominant cariostatic effect of fluoride is not due to its uptake by the enamel during tooth development, it is possible to obtain extensive caries reduction without a concomitant risk of dental fluorosis. Further efforts and research are needed to settle the currently uncertain issues, e.g., the incidence, prevalence, and causes of dental or skeletal fluorosis in relation to all sources of fluoride and the appropriate dose levels and timing of fluoride exposure for prevention and control of dental fluorosis and caries.

Mechanism and timing of fluoride effects on developing enamel

Fluoride appears to specifically interact with mineralizing tissues, causing an alteration of the mineralization process. In enamel, fluorosis results in a subsurface hypomineralization. This hypomineralized enamel appears to be directly related to a delay in the removal of amelogenins at the early-maturation stage of enamel formation. The specific cause for this delay is not known, although existing evidence points to reduced proteolytic activity of proteinases that hydrolyze amelogenin. This delay in hydrolysis of amelogenins could be due to a direct effect of fluoride on proteinase secretion or proteolytic activity, or to a reduced effectiveness of the proteinase due to other changes in the protein or mineral of the fluorosed enamel matrix. The formation of dental fluorosis is highly dependent on the dose, duration, and timing of fluoride exposure. The early-maturation stage of enamel formation appears to be particularly sensitive to the effects of fluoride on enamel formation. Although the risk of enamel fluorosis is minimal with exposure only during the secretory stage, this risk is greatest when exposure occurs in both secretory and maturation stages of enamel formation. The risk of fluorosis appears to be best related to the total cumulative fluoride exposure to the developing dentition.

Biological mechanisms of dental fluorosis relevant to the use of fluoride supplements

Fluorosis occurs when fluoride interacts with mineralizing tissues, causing alterations in the mineralization process. In dental enamel, fluorosis causes subsurface hypomineralizations or porosity, which extend toward the dentinal-enamel junction as severity increases. This subsurface porosity is most likely caused by a delay in the hydrolysis and removal of enamel proteins, particularly amelogenins, as the enamel matures. This delay could be due to the direct effect of fluoride on the ameloblasts or to an interaction of fluoride with the proteins or proteinases in the mineralizing matrix. The specific mechanisms by which fluoride causes the changes leading to enamel fluorosis are not well defined; though the early-maturation stage of enamel formation appears to be particularly sensitive to fluoride exposure. The development of fluorosis is highly dependent on the dose, duration, and timing of fluoride exposure. The risk of enamel fluorosis is lowest when exposure takes place only during the secretory stage, but highest when exposure occurs in both secretory and maturation stages. The incidence of dental fluorosis is best correlated with the total cumulative fluoride exposure to the developing dentition. Fluoride supplements can contribute to the total fluoride exposure of children, and if the total fluoride exposure to the developing teeth is excessive, fluorosis will result.

Enamel mineral composition of normal and cystic fibrosis transgenic mice

The ability of ameloblasts and the enamel organ to control the influx of ions into the developing enamel is of considerable interest. The development of transgenic mice lacking a cAMP-regulated chloride channel, the cystic fibrosis transmembrane conductance regulator (CFTR), provides a model that may prove valuable for the study of ion regulation in developing teeth. The purpose of this investigation was to characterize the mineral content of normal and CF mice. Five homozygous and five heterozygous adult mice having the CFTR knockout transgene were evaluated. The mice were killed with CO2 and their mandibular incisors removed, embedded in methacrylate, and sectioned, and enamel particles from the incisal region were then dissected for analysis. Each particle was analyzed for its calcium, phosphorus, and magnesium content. The normal mice had a mean mineral content of 80.5%, in contrast to the CF mice, that had markedly hypomineralized enamel (mean = 51.5%). The calcium/phosphorus ratios were similar for both groups of mice and were compatible with the enamel consisting primarily of hydroxyapatite mineral. The enamel magnesium content was significantly elevated in the CF mice (mean = 3560 ppm) compared with the normal mice (mean = 2280 ppm). Normal mouse enamel was highly mineralized, while the CF mouse enamel mineral content was significantly reduced and had an elevated level of magnesium. The altered mineral content of CF mouse enamel indicates that CFTR could play an important role in ion regulation and consequently mineralization of mouse enamel.

Strategies for improving the assessment of dental fluorosis: focus on chemical and biochemical aspects

In order to assess fluoride accumulation and effects in developing dental tissues, one must determine the concentration profile of fluoride in the tissue and to assess separately the labile (i.e., free ions in fluid and ions associated with organic matter) and stable (i.e., incorporated into apatite lattice) pools of fluoride. Free fluoride ions in the mineralizing milieu markedly affect the driving force for precipitation and, as a result, the nature of precipitating crystals. The fluoride incorporated into the crystalline lattice increases the stability of the formed mineral. Improvement in the understanding of the mechanism of dental fluorosis requires more comprehensive information about the effects of fluoride on the ionic composition of the fluid phase, the nature of the initially precipitating mineral(s), the interactions between crystals and matrix proteins, and the enzymatic degradation of the proteins. Recent observations relevant to the role of fluoride in enamel formation include: (1) that there are threshold concentrations of fluoride below which the precipitation and hydrolysis of thin-platy octacalcium phosphate is facilitated but beyond which de novo apatite precipitation prevails; (2) that the presence of fluoride in the mineralizing milieu most likely affects the steady-state concentrations of mineral lattice ions; (3) that incorporation of fluoride into the stable pool is retarded by the presence of matrix proteins, particularly amelogenins, which inhibit the growth of apatite crystals; (4) that increasing the degree of fluoridation of apatite crystals enhances the adsorption of amelogenins onto the crystal surface, and (5) that amelogenins pre-adsorbed onto apatite crystals are more resistant to enzymatic cleavages by trypsin (used as a prototype of amelogeninases).

Tubule formation and elemental detection in developing opossum enamel

Most marsupials and some placental mammals possess enamel characterized by the presence of tubules, and the cellular origin of these structures has been the subject of a number of previous studies (See, for example, Lester, 1970; Azevedo and Goldberg, 1987). In the present report, tooth germs of the American opossum were examined to determine the structure and composition of enamel tubules during development and to analyze the enamel matrix relative to that of placental mammals with atubular enamel. For this purpose, tissues prepared by aqueous (decalcified and undecalcified) and anhydrous (undecalcified) methods were investigated by conventional transmission (TEM) and high voltage electron microscopy (HVEM), as well as by electron probe x-ray microanalysis (EPMA), selected-area electron diffraction (SAED), and electron spectroscopic imaging (ESI). Results indicate that most enamel tubules in the opossum begin as cytoplasmic remnants of Tomes' processes of ameloblasts. During development of the matrix, some of the tubules do not appear to be continuous throughout the prismatic layer. Sulfur is detectable around the lumen of the tubule in decalcified sections by EPMA and in and around the tubule by ESI. Calcium/phosphorus (Ca/P) molar ratios of the mineralizing matrix are generally higher than those found in enamel of other mammals and appear to decrease rather than increase with enamel maturation. The summary of data indicates the presence of sulfated glycoproteins or proteoglycans in this tissue, specifically around enamel tubules. Calcium and phosphorus are also present within the tubules, with the sulfated groups possibly binding calcium to prevent mineralization of the enamel tubules themselves.

The effect of fluoride on the developing mineralized tissues

The work described considers the effects on calcified tissues of those concentrations of fluoride which are not overtly cyto-toxic, i.e., in the general region of up to 1-2 mumol/L. Plasma fluoride concentrations or those of the cellular environment are considered rather than dietary levels. The effect of fluoride ion on specific stages of tooth and bone development is discussed. Little effect has been observed on the modulation of gene expression as far as odontogenesis is concerned, although there is evidence that fluoride could be osteogenic in both embryonic and adult tissues. Expression of extracellular matrix protein genes seems not to be impaired, but subtle changes detected in the enamel matrix could be due to selective alterations in amino-acid uptake or interference with subsequent protein processing. This could also be due to an extension of the secretory period without concomitant changes in post-secretory matrix processing. Removal of matrix is apparently impaired, with concomitant incomplete maturation. While existing mineral phases can be affected, it is more likely that matrix and or mineral-matrix interaction is the site of action. Explant studies suggest that the effect may be reversible. Inhibition of proteolysis during enamel maturation may account for the reported inhibition of enamel crystal growth. This is supported by the finding that the normally incomplete maturation of porcine enamel is associated with a somewhat greater residual protein content. The use of animal models in the investigation of enamel dysplasia (fluoride-induced or otherwise) should therefore be viewed with caution.

Effect of prenatal and postnatal fluoride on the human deciduous dentition. A literature review

Fluoride passes from the mother to fetal teeth. Much of the fluoride is taken up in secretory enamel, probably by the forming mineral apatite crystals. Some is retained with residual proteins. The low concentration of fluoride in the inner enamel is incorporated mainly during the secretory stage, while the enhanced concentration in the surface enamel is produced during the much longer maturation stage. Mature, hard enamel is generally absent during fetal life. The clinical question is whether prenatal fluoride imparts an additional benefit to the universally accepted effect of postnatal fluoride. In general, surface enamel fluoride levels of deciduous teeth increase with increasing pre- and postnatal fluoride administration. A consistent level of caries protection has been reported with pre- and postnatal administration of fluoride unrelated to the acquisition of fluoride in the surface enamel. Many children develop enamel opacities in their deciduous dentition related by various factors to enamel mineralization disturbances in drinking water areas even low in fluoride. Accumulation of fluoride due to an increased fluoride intake is a feature of fluorosed enamel in the deciduous as well as permanent dentition. The resulting mature fluorosed enamel retains a relatively high proportion of immature matrix proteins onto the crystal surface. The degree of fluorosis of the deciduous dentition is less compared with that of the permanent dentition, due probably to a partial protection afforded by the maternal loss of fluoride, formerly known as the "placental barrier".

Possible function of matrix proteins in fluoride incorporation into enamel mineral during porcine amelogenesis

The present study was undertaken to elucidate the mechanism of fluoride incorporation into secretory enamel mineral, with porcine enamel used as a model. Although the fluoride content in the enamel varied greatly among the animals, we observed that the fluoride-to-calcium ratio in the enamel tissue was maximal at the beginning of the secretory stage; the F/Ca ratio decreased (and leveled off) with the advancement of mineralization. In vitro work showed that some of the fluoride in the secretory enamel tissue was removed with the extraction of organic matter, mostly amelogenins. Furthermore, coating hydroxyapatite crystals with enamel matrix proteins resulted in a retardation of fluoride incorporation into the crystals when exposed to fluoride solutions, as a result of an inhibition of apatite reprecipitation. We also confirmed that the growth kinetics of fluoridated apatite onto HA seeds decreased with increasing coverage of the seed surface with the enamel proteins. All the results of the present study strongly suggest that the fluoride incorporation into enamel mineral during the secretory stage may be regulated by the kinetics of mineralization, which is highly dependent on the driving force for precipitation and the presence of proteinaceous inhibitors, mainly amelogenins.

Localization of lead and fluoride in cultured tooth germs by laser microprobe mass analysis

Trace elements can influence dental health, possibly by altering tooth resistance during preeruptive development. Therefore, it was investigated whether lead and fluoride would be incorporated into the calcifying matrices or the cellular parts of tooth germs in vitro. Using laser microprobe mass analysis, the localization of lead and fluoride was studied in the different layers or tooth germs that had been cultured in a medium to which PbCl2 of NaF had been added in different concentrations. Both elements could only be detected in the dentine layer. Hence, the enamel organ in the secretory stage of tooth development excludes lead and fluoride from the enamel, even when enamel formation by the ameloblasts is visibly disturbed. Furthermore, there seemed to be a process of saturation in the accumulation of lead and fluoride in the dentine.

Diffusion of fluoride through the rat enamel organ in vitro

This study investigated the diffusion of fluoride through the enamel organ in vitro. The rat molar explants used were entirely in the secretory stage or predominantly in the maturation stage of enamel formation. The removal of the enamel organ or metabolic inhibition with iodoacetate caused significant increases in enamel fluoride uptake at both stages of enamel formation. Inhibition with dinitrophenol caused a significant increase only in the maturation phase. Uptake of fluoride in enamel was related to the fluoride concentration in the medium, except in the maturation stage explants, where increasing the medium fluoride concentration from 0.05 ppm to 0.08 ppm did not significantly increase fluoride uptake at any of the three observation times. The findings indicate that the enamel organ exists as a diffusion-limiting membrane to the movement of fluoride from the extracellular fluid compartment to the developing enamel.

Fluoride concentrations of the surface enamel of children living in an optimally fluoridated community

The present study was undertaken in a community, where the tap water has been optimally fluoridated since 1959 (1.0-1.2 ppm). The material consisted of 92 children and adolescents including 30 sibling-couples. The mean age of the participants was 11.8 +/- 2.45 (SD) yr. 56 children had consumed fluoridated water all their life, the others only a part of the developmental period of their permanent dentition. Enamel biopsies were taken from 212 permanent teeth and 33 primary teeth by etching the tooth surface for 6 or 30 s. The etch depth was calculated from the mean of dissolved enamel calcium and phosporus. The fluoride concentration in the outermost enamel was almost similar in the teeth of the lifelong residents and the rest of the children. Towards the deeper layers the amount of fluoride decreases depending on its availability during the development of the enamel. There was no striking similarity neither in the fluoride concentration nor in the amount of dissolved enamel between the siblings when compared with the other children. The posteruptive incorporation of fluoride takes place only on the outermost surface of the enamel. The results suggest that in subsurface layers the fluoride exposure during tooth formation is the dominating determinant of enamel fluoride concentration.

Fluoride uptake and retention at various stages of rat molar enamel development

Suckling rat pups were given intraperitoneal fluoride injections at selected ages so that we could study fluoride uptake in the enamel of the maxillary first molar at various stages of enamel development. Plasma fluoride levels in six-day-old and 11-day-old pups were monitored following the intraperitoneal injection of fluoride. The findings indicate that: (1) fluoride was more easily taken up and retained during the early stages of enamel formation, but fluoride uptake can occur during all stages of enamel formation; (2) when injections were started early in enamel formation, more fluoride was contained in the enamel of the maxillary first molar at 13 days of age; and (3) the same dose of fluoride per gram body weight resulted in greater exposure to elevated plasma fluoride levels in six-day-old pups than in 11-day-old pups.

Effect of inhibition of net calcium uptake on net fluoride uptake in developing rat molars

Two methods were used to reduce net calcium uptake by the secretory stage enamel of developing rat molar explants. Neither method had a significant effect on fluoride uptake by the explants. These findings indicate that the mechanisms for uptake in the developing enamel are independent for calcium and fluoride.