Fluoride and Oral Health

The discovery during the first half of the 20th century of the link between natural fluoride, adjusted fluoride levels in drinking water and reduced dental caries prevalence proved to be a stimulus for worldwide on-going research into the role of fluoride in improving oral health. Epidemiological studies of fluoridation programmes have confirmed their safety and their effectiveness in controlling dental caries. Major advances in our knowledge of how fluoride impacts the caries process have led to the development, assessment of effectiveness and promotion of other fluoride vehicles including salt, milk, tablets, toothpaste, gels and varnishes. In 1993, the World Health Organization convened an Expert Committee to provide authoritative information on the role of fluorides in the promotion of oral health throughout the world (WHO TRS 846, 1994). This present publication is a revision of the original 1994 document, again using the expertise of researchers from the extensive fields of knowledge required to successfully implement complex interventions such as the use of fluorides to improve dental and oral health. Financial support for research into the development of these new fluoride strategies has come from many sources including government health departments as well as international and national grant agencies. In addition, the unique role which industry has played in the development, formulation, assessment of effectiveness and promotion of the various fluoride vehicles and strategies is noteworthy. This updated version of 'Fluoride and Oral Health' has adopted an evidence-based approach to its commentary on the different fluoride vehicles and strategies and also to its recommendations. In this regard, full account is taken of the many recent systematic reviews published in peer reviewed literature.

Validation of fingernail fluoride concentration as a predictor of risk for dental fluorosis

The aim of this study was to validate the use of fingernail fluoride concentrations at ages 2-7 years as predictors of the risk for developing dental fluorosis in the permanent dentition. Fifty-six children of both genders (10-15 years of age) had their incisors and premolars examined for dental fluorosis using the Thylstrup-Fejerskov index. Fingernail fluoride concentrations were obtained from previous studies when children were 2-7 years of age. Data were analyzed by unpaired t test, ANOVA, and Fisher's exact test when the fingernail fluoride concentrations were dichotomized (≤ 2 or >2 µg/g). Children with dental fluorosis had significantly higher fingernail fluoride concentrations than those without the condition, and the concentrations tended to increase with the severity of fluorosis (r(2) = 0.47, p < 0.0001). Using a fingernail fluoride concentration of 2 µg/g at ages 2-7 years as a threshold, this biomarker had high sensitivity (0.84) and moderate specificity (0.53) as a predictor for dental fluorosis. The high positive predictive value indicates that fingernail fluoride concentrations should be useful in public health research, since it has the potential to identify around 80% of children at risk of developing dental fluorosis.

Skeletal fluorosis due to excessive tea and toothpaste consumption

We describe the case of a 53-year-old woman who presented with a metatarsal fracture and was found to have a bone mineral density (BMD) T-score of +11 in the lumbar spine and +7.6 in the hip. Subsequent investigation revealed very high serum, urine and tissue fluoride levels, associated with excessive tea and toothpaste consumption. The case emphasises the need to exclude fluorosis in individuals with unexpectedly high BMD levels.

An assessment of bone fluoride and osteosarcoma

The association between fluoride and risk for osteosarcoma is controversial. The purpose of this study was to determine if bone fluoride levels are higher in individuals with osteosarcoma. Incident cases of osteosarcoma (N = 137) and tumor controls (N = 51) were identified by orthopedic physicians, and segments of tumor-adjacent bone and iliac crest bone were analyzed for fluoride content. Logistic regression adjusted for age and sex and potential confounders of osteosarcoma was used to estimate odds ratios (OR) and 95% confidence intervals (CI). There was no significant difference in bone fluoride levels between cases and controls. The OR adjusted for age, gender, and a history of broken bones was 1.33 (95% CI: 0.56-3.15). No significant association between bone fluoride levels and osteosarcoma risk was detected in our case-control study, based on controls with other tumor diagnoses.

Assessment of dental fluorosis in Mmp20 +/- mice

The molecular mechanisms that underlie dental fluorosis are poorly understood. The retention of enamel proteins hallmarking fluorotic enamel may result from impaired hydrolysis and/or removal of enamel proteins. Previous studies have suggested that partial inhibition of Mmp20 expression is involved in the etiology of dental fluorosis. Here we ask if mice expressing only one functional Mmp20 allele are more susceptible to fluorosis. We demonstrate that Mmp20 (+/-) mice express approximately half the amount of MMP20 as do wild-type mice. The Mmp20 heterozygous mice have normal-appearing enamel, with Vickers microhardness values similar to those of wild-type control enamel. Therefore, reduced MMP20 expression is not solely responsible for dental fluorosis. With 50-ppm-fluoride (F(-)) treatment ad libitum, the Mmp20 (+/-) mice had F(-) tissue levels similar to those of Mmp20 (+/+) mice. No significant difference in enamel hardness was observed between the F(-)-treated heterozygous and wild-type mice. Interestingly, we did find a small but significant difference in quantitative fluorescence between these two groups, which may be attributable to slightly higher protein content in the Mmp20 (+/-) mouse enamel. We conclude that MMP20 plays a nominal role in dental enamel fluorosis.

Development of gold standard ion-selective electrode-based methods for fluoride analysis

BACKGROUND/AIMS

Currently available techniques for fluoride analysis are not standardized. Therefore, this study was designed to develop standardized methods for analyzing fluoride in biological and nonbiological samples used for dental research.

METHODS

A group of nine laboratories analyzed a set of standardized samples for fluoride concentration using their own methods. The group then reviewed existing analytical techniques for fluoride analysis, identified inconsistencies in the use of these techniques and conducted testing to resolve differences. Based on the results of the testing undertaken to define the best approaches for the analysis, the group developed recommendations for direct and microdiffusion methods using the fluoride ion-selective electrode.

RESULTS

Initial results demonstrated that there was no consensus regarding the choice of analytical techniques for different types of samples. Although for several types of samples, the results of the fluoride analyses were similar among some laboratories, greater differences were observed for saliva, food and beverage samples. In spite of these initial differences, precise and true values of fluoride concentration, as well as smaller differences between laboratories, were obtained once the standardized methodologies were used. Intraclass correlation coefficients ranged from 0.90 to 0.93, for the analysis of a certified reference material, using the standardized methodologies.

CONCLUSION

The results of this study demonstrate that the development and use of standardized protocols for F analysis significantly decreased differences among laboratories and resulted in more precise and true values.

Influence of genetic background on fluoride metabolism in mice

A/J and 129P3/J mouse strains have different susceptibilities to dental fluorosis, due to their genetic backgrounds. This study tested whether these differences are due to variations in water intake and/or F metabolism. A/J (susceptible to dental fluorosis) and 129P3/J mice (resistant) received drinking water containing 0, 10, or 50 ppm F. Weekly F intake, excretion and retention, and terminal plasma and femur F levels were determined. Dental fluorosis was evaluated clinically and by quantitative fluorescence (QF). Data were tested by two-way ANOVA. Although F intakes by the strains were similar, excretion by A/J mice was significantly higher due to greater urinary F excretion, which resulted in lower plasma and femur F levels. Compared with 129P3/J mice given 50 ppm F, significantly higher QF scores were recorded for A/J mice. In conclusion, these strains differ with respect to several features of F metabolism, and amelogenesis in the 129P3/J strain seems to be unaffected by high F exposure.

Fluoride uptake by plaque from water and from dentifrice

It has been suggested that fluoride retention in plaque is limited by available binding sites. We determined the effects of fluoridated or placebo dentifrices on plaque and salivary fluoride concentrations [F]s in communities with different water fluoride concentrations (0.04, 0.85, 3.5 ppm). After one week of dentifrice use, samples were collected 1.0 and 12 hrs after the last use of dentifrices. After the use of fluoridated dentifrice, plaque fluoride concentrations were higher at both times, except at 12 hrs in the 3.5-ppm community. Plaque concentrations at 1.0 hr after the use of fluoridated dentifrice increased almost constantly (6.5 mmol/kg), but then decreased approximately 50% at 12 hrs in each community. Unlike previous studies, the present findings suggest that the use of fluoridated dentifrice is likely to increase plaque fluoride concentrations significantly for up to 12 hrs in areas where the water contains fluoride close to 1.0 ppm. As previously reported, plaque fluoride concentrations were directly related to calcium concentrations.

Pharmacokinetics of ingested fluoride: lack of effect of chemical compound

Fluoride in drinking water may be present from natural sources or added as sodium fluoride (NaF), sodium silicofluoride (Na(2)SiF(6)) or fluorosilicic acid (H(2)SiF(6)). Results from an early study with rats suggested that, when ingested as Na(2)SiF(6), the absorption and excretion of fluoride were greater than when ingested as NaF.

OBJECTIVE

The present single-blind, crossover study with 10 adults was done to determine three key pharmacokinetic parameters: the maximum plasma fluoride concentrations (C(max)), the elapsed time to reach the maximum concentrations (T(max)) and the 6-h areas under the time-plasma concentration curves (AUCs) after ingestion of 500 mL of water containing 0.67 or 5.45 mg F/L present naturally or added as NaF or H(2)SiF(6).

DESIGN

Blood was collected prior to and at nine time points during 6h after ingestion of the test solutions. Plasma was analysed by electrode after HMDS-facilitated diffusion and the data were analysed for statistically significant differences using repeated measures ANOVA.

RESULTS

The C(max), T(max) and AUC values after ingestion of the solutions containing natural fluoride, NaF or H(2)SiF(6) did not differ significantly at either dose level. Further, the T(max) values associated with the 0.67 and 5.45 mg/L solutions did not differ significantly indicating that the absorption, distribution and elimination rates were not affected by the dose size.

CONCLUSIONS

Considered together with published reports, the present findings support the conclusion that the major features of fluoride metabolism are not affected differently by the chemical compounds commonly used to fluoridate water nor are they affected by whether the fluoride is present naturally or added artificially.

Relating nickel-induced tissue inflammation to nickel release in vivo

Nickel has a number of adverse biological effects that have made the use of nickel in biomedical implants controversial. Yet information about the distribution of nickel in tissues around nickel-containing implants is scarce. The purpose of the current study was to use a laser ablation technique, combined with inductively coupled mass spectroscopy, to assess the spatial distribution of nickel around nickel-containing implants in vivo. Polyethylene, pure nickel wire, or a nickel-containing alloy (Ni-Cr) were implanted subcutaneously into rats for 7 days. The tissues were analyzed for Ni content and inflammation at 1-mm intervals up to 5 mm away from the implants. The sham surgery sites and the polyethylene caused mild to moderate inflammation 1-2 mm from the implant site with no detectable nickel in the tissue. The nickel wire caused severe inflammation up to 5 mm away from the implant site with necrosis for 1 mm around the implant. Nickel concentrations reached 48 microg/g near the implants, falling exponentially to undetectable levels at 3-4 mm from the implants. The Ni-Cr wire caused inflammation equivalent to polyethylene, with less than 4 microg/g of nickel present in the tissue for 1-2 mm around the implants. The current study showed that the laser-ablation technique was well suited for the analysis of soft tissues for metal-ion content, and that the nickel distribution in tissues correlated well with overt tissue inflammation.

Fluoride metabolism and excretion in children

This paper compares fluoride pharmacokinetics (plasma, renal, and extrarenal clearances) and metabolic balances in healthy infants or children with those in young or middle-aged adults. Regardless of age, the removal of fluoride from the intra- and extracellular body fluids occurs almost exclusively by uptake in calcified tissues and excretion in the urine. While there can be considerable differences among individuals, the rates at which fluoride is cleared from plasma by calcified tissues and the kidneys in adults are approximately equal. The calcified tissue clearance of fluoride from plasma in children is substantially higher than that by the kidneys. This is due to the greater surface area of the loosely organized crystallites in the developing calcified tissues during growth. Thus, the balance of fluoride (total intake minus total excretion) is typically higher in children than in adults, but it can be positive or negative at any age. Positive balance occurs when chronic fluoride intake is sufficient to prevent plasma concentrations from declining. When positive, the fluoride content of the calcified tissues, which contain more than 99 percent of the body's fluoride, tends to gradually increase. Negative balance, which indicates net mobilization of fluoride from calcified tissues, can occur when plasma concentrations decline due to a reduction in the level of fluoride intake.

Fingernail fluoride: a method for monitoring fluoride exposure

This work was based on the hypothesis that fingernail clippings can be used as a biomarker for the subchronic exposure to fluoride. The results provide data on factors that may affect the concentration of fluoride in fingernail clippings as determined with the electrode following HMDS-facilitated diffusion. The following variables had only minor or no effects on the concentrations: (1) the surface area of the clippings (intact, minced or filed into powder) that were placed into the diffusion dishes; (2) soaking in deionized water for up to 6 h; (3) soaking in fluoridated water (1.0 ppm) for 2 h, and (4) removal of the organic material of nails by dry ashing. Fingernail fluoride concentrations were approximately 50% higher than those in toenails. A 1-month period of increased fluoride intake by one of the authors resulted in significant increases in fingernail fluoride concentrations after a lag time of approximately 3.5 months. The fluoride concentrations in fingernail clippings obtained from three groups of Brazilian children were directly related to the concentrations in the drinking water (0.1, 1.6 or 2.3 ppm). The results indicate that: (1) HMDS-facilitated diffusion completely separates fluoride from intact nail clippings, so the need for ashing or other preparative methods is obviated; (2) fingernail fluoride is derived mainly from the systemic circulation, and (3) fluoride intake is reflected by the concentrations in fingernails.

Fluoride in whole saliva, parotid ductal saliva and plasma in children

The purpose was to investigate the relation between fluoride concentrations in whole saliva, parotid ductal saliva, and plasma in 5- to 10-year-old children (n = 17). Two stimulated whole-saliva samples were obtained from each child. Before the second sample was obtained, each child rinsed several times with a total of 100 ml of deionized water. Parotid saliva samples were obtained by use of a Lashley cup. Fluoride concentrations were determined by fluoride ion-specific electrode after diffusion with hexamethyldisiloxane. Rinsing with deionized water did not significantly reduce the fluoride concentration in whole saliva. The whole-saliva fluoride concentrations were not significantly related to those in plasma or parotid ductal saliva. Parotid fluoride concentrations, however, were significantly related to plasma fluoride concentrations (p < 0.0001) by a proportionality constant of 0.80. It was concluded that parotid salivary fluoride concentrations can be used to estimate plasma fluoride concentrations in 5- to 10-year-old children.

Chronic fluoride ingestion decreases 45Ca uptake by rat kidney membranes

High exposures to fluoride (F-) may occur in environments rich in F- from natural or industrial sources and from misuse of F--containing dental care products, particularly by children. Both acute and chronic exposures to elevated levels of F- have negative effects on several calcium-dependent processes, including kidney glomerular and tubular function. We examined the effect of chronic F- ingestion on ATP-dependent 45Ca uptake by rat kidney membrane vesicles to characterize the mechanism by which high F- alters Ca++ transport in the kidney. Twenty weanling female Sprague-Dawley rats were raised on low-F- (0.9 mg/L), semi-purified diet with a Ca++ concentration of 400 mg/100g diet. Rats were divided into four groups and were fed ad libitum deionized water containing F- at 0, 10, 50, or 150 mg/L added as NaF for 6 wk. This consumption produced plasma F- levels of <0.4, 2, 7, or 35 micromol/L, respectively. ATP-dependent 45Ca uptake was significantly lower in the 150 mg F-/L exposure group than in the 0 mg F-/L controls (P < 0.05). Studies with thapsigargin, a specific inhibitor of the endoplasmic reticulum Ca++-pump, showed that the lower uptake was associated with significantly lower activities of both the plasma membrane Ca++-pump (P < 0.05, 150 mg F-/L group versus control) and endoplasmic reticulum Ca++-pump (P < 0.05 for both the 50 and 150 mg F-/L groups versus control). Slot blot analysis of kidney homogenates with specific Ca++-pump antibodies showed less (P < 0.05) endoplasmic reticulum Ca++-pump protein and plasma membrane Ca++-pump protein in all treatment groups than controls. Both Ca++-pumps are transport molecules of great importance in the regulation of Ca++ homeostasis. Our study suggests that chronic, high F- ingestion producing high plasma F- levels may occur in humans and may affect Ca++ homeostasis by increasing the turnover or breakdown or decreasing the expression of plasma membrane and endoplasmic reticulum Ca++-pump proteins.

Effect of resin cure mode and fluoride content on bracket debonding

Enamel decalcification around brackets is sometimes observed during and after orthodontic treatment. Reports in the literature suggest that the preventive advantage of fluoride-releasing adhesive resins may be compromised by an increased incidence of bond failure. The purpose of this study was to determine the effects on shear debonding of incorporating fluoride into the bracket bonding system. Another purpose was to determine the effect of polymerization mode on debonding. Orthodontic brackets were bonded to bovine enamel using one of three types of adhesive resin--no-mix, chemically cured, or light-cured--each formulated with and without fluoride. The teeth were stored in artificial saliva for 24 hours or 30 days and then debonded in shear. Data analysis was performed using ANOVA followed by post-hoc multiple comparison between group pairs. It was found that: (1) fluoride had either no effect or it increased the bond value; (2) the no-mix adhesive demonstrated the lowest bond value; (3) the duration of storage in artificial saliva had no effect on the bond value of the chemically cured and light-cured adhesives but did affect the no-mix adhesive; and (4) the no-mix adhesive released significantly less fluoride than the two other products. Thus, the presence of fluoride in the bonding adhesive does not reduce the force required to debond in shear, and chemically or light-cured adhesives provide consistently higher bond values over extended immersion times than the no-mix product.

Dental caries and fluorosis among children in a rural Georgia area

PURPOSE

This IRB-approved study compared the caries experience, fluorosis prevalence, and plaque and salivary fluoride concentrations ([F]) in middle school (MS; N = 51) and elementary school (ES; N = 144) children residing in nonfluoridated and fluoridated communities in rural Georgia. All participants were exposed to fluoridated water at school (0.5-1.2 ppm), some received that level at home, and others received home water with < 0.1 ppm F.

METHODS

Subjects' parents completed a questionnaire regarding fluoride exposure. Children were examined at school by two calibrated dentists.

RESULTS

No significant differences were seen in DMFS+dfs between children with or without fluoridated home water, nor for those with or without fluorosis. MS children with non-fluoridated home water had lower mean salivary [F] values than MS children with fluoridated home water. No differences were found among MS and ES children in mean plaque [F] for those with or without fluorosis.

CONCLUSIONS

Home water fluoridation had little effect on the variables measured. These findings appear to be due to fluoride exposure from fluoridated dentifrices, fluoridated drinking water at school, and the fluoride "halo" effect.

Effects of caffeine on fluoride, calcium and phosphorus metabolism and calcified tissues in the rat

This 6-week study was designed to determine the effects of graded doses of caffeine intake (3, 25 or 100 mg/kg per day) on the metabolic balance and tissue concentrations of fluoride, calcium and phosphorus in Sprague-Dawley rats. Caffeine intake did not affect the absorption, urinary excretion or balance of fluoride, the plasma, bone or enamel concentrations of fluoride, nor the occurrence of incisor enamel fluorosis. Neither did it affect the metabolism of calcium or phosphorus except that the urinary excretion of calcium was increased. This effect, however, was not sufficient to influence significantly calcium balance. The ash content of the femur epiphysis and bone mineral content of the tibia were significantly reduced only in the group exposed to the highest dose of caffeine. These effects on bone were not significantly related to the balance of calcium or phosphorus. It was concluded that caffeine, even at an extremely high level of intake, has no detectable effect on the balance or tissue concentrations of fluoride, calcium or phosphorus in the rat.

pH-dependent fluoride transport in intestinal brush border membrane vesicles

Fluoride (F) absorption from the rat stomach and urinary bladder, hamster cheek pouch, and the renal tubules of several species are pH gradient-dependent. These observations led to the hypothesis that F crosses these epithelia in the form of the undissociated acid, HF. Several recent reports, however, have provided evidence that F absorption from the rat small intestine is insensitive to the lumenal pH. We report here our evidence that F uptake by rabbit intestinal brush border membrane vesicles (BBMV) occurred rapidly and with an overshoot only in the presence of an inward-directed proton gradient. In the absence of a proton gradient or in the presence of an outward-directed gradient, F uptake was slow and without an overshoot. In the presence of an inward-directed proton gradient, F uptake was partially inhibited by DIDS and DEP but not by diBAC. PCMBS inhibited F uptake by up to 83% in a dose-response manner. DiBAC appeared to reduce intravesicular pH slightly but the other reagents had no effect. When the uptake buffer contained chloride or nitrate, F uptake was partially inhibited compared to the mannitol or gluconate controls. It was concluded that F transport across the rabbit intestinal BBMV occurs via a carrier-mediated process which may involve cotransport of F with H+ or exchange of F with OH-. The inhibitory effects of DIDS, DEP and PCMBS may occur by affecting this carrier-mediated transport.

Effects of fluoride on structure and function of canine gastric mucosa

These studies were done to determine the effects of fluoride (F) on the structure and function of the canine gastric mucosa and the possible protective effects of 16,16-dimethyl-prostaglandin E2 (dmPGE2). A portion of the stomach with its vascular supply intact was mounted in a two-compartment chamber, one side of which contained a control solution. Minor effects were caused by exposure to 1 mmol/liter F. Both 5 and 10 mmol/liter F caused marked increases in the fluxes of water and Na, K, and H ions; mucus secretion; and tissue swelling and redness. The extent of these changes did not increase appreciably upon exposure to 50 or 100 mmol/liter F. Histological findings included marked thinning of the surface cell layer, reduced uptake of PAS stain, localized exfoliation and necrosis of surface cells, acute gastritis, and edema. It was concluded that: (1) the threshold F concentration for effects on the structure and function of the gastric mucosa was approximately 1 mmol/liter; (2) the maximum or near-maximum effects were caused by 10 mmol/liter F; (3) the effects persisted for at least 6 hr after the exposure; and (4) dmPGE2 (0.5 microg/ml) did not attenuate the effects induced by F.

Determinants and mechanisms of enamel fluorosis

Enamel fluorosis occurs when fluoride concentrations in or in the vicinity of the forming enamel are excessive during its pre-eruptive development. Fluoride concentrations in plasma, enamel and other tissues reflect the difference between intake and excretion, i.e. fluoride balance. In addition to the diet, modern sources of ingested fluoride include a variety of dental products, some of which have been identified as risk factors for fluorosis. Fluoride absorption is inversely related to dietary calcium which, at high concentrations, may cause net fluoride secretion into the gastrointestinal tract. The excretion of absorbed fluoride occurs almost exclusively via the kidneys, a process which is directly related to urinary pH. Thus, fluoride balance and tissue concentrations and the risk of fluorosis are increased by factors such as high protein diets, residence at high altitude, and certain metabolic and respiratory disorders that decrease pH. Factors that increase urinary pH and decrease the balance of fluoride include vegetarian diets, certain drugs and some other medical conditions. Although several other fluoride-induced effects might be involved in the aetiology of fluorosis, it now appears that inhibition of enzymatic degradation of amelogenins, which may delay their removal from the developing enamel and impair crystal growth, may be of critical importance. In addition to the effects of fluoride, disturbances in enamel formation that can be confused with fluorosis are caused by chronic acidosis and hypoxia independently of the level of fluoride exposure.

A physiologically based pharmacokinetic model for fluoride uptake by bone

A sex-specific, physiologically based pharmacokinetic (pbpk) model has been developed to describe the absorption, distribution, and elimination of fluorides in rats and humans. Growth curves generated by plotting mean body weights (kg) against age (weeks or years) are included in the simulation model to allow the integration of chronic fluoride exposure from birth to old age. The model incorporates age and body weight dependence of the physiological processes that control the uptake of fluoride by bone and the elimination of fluoride by the kidneys. Six compartments make up the model. These are lung, liver, kidney, bone, and slowly and rapidly perfused compartments. The model also includes two bone subcompartments: a small, flow-limited, rapidly exchangeable surface bone compartment and a bulk virtually nonexchangeable inner bone compartment. The inner bone compartment contains nearly all of the whole body content of fluoride, which, in the longer time frame, may be mobilized through the process of bone modeling and remodeling. The model has been validated by comparing the model predictions with experimental data gathered in rats and humans after drinking water and dietary ingestion of fluoride. This physiological model description of absorption, distribution, and elimination of fluoride from the body permits the analysis of the combined effect of ingesting and inhaling fluorides on the target organ, bone. Estimates of fluoride concentrations in bone are calculated and related to chronic fluoride toxicity. The model is thus useful for predicting some of the long-term metabolic features and tissue concentrations of fluoride that may be of value in understanding positive or negative effects of fluoride on human health. In addition, the pbpk model provides a basis for across-species extrapolation of the effective fluoride dose at the target tissue, bone, in the assessment of risk from different exposure conditions.

Enamel uptake and patient exposure to fluoride: comparison of APF gel and foam

This crossover study with 46 child dental patients compared two topical APF products, a gel and a foam, with respect to the amounts of product and fluoride (F) applied, salivary F concentrations, and enamel F uptake. Half the subjects were treated for 4 min with the gel first and the other half with the foam. After approximately 16 days, each patient received a second treatment using the other product. An acid-etch enamel biopsy was performed and whole saliva samples were collected before and after each treatment. Significantly less F was applied to the teeth and retained by the subjects when the APF foam was used. Salivary F concentrations after treatment with the gel were higher than after treatment with the foam. The differences in enamel F uptake at both 15 min and 16 days after the APF applications, however, were not significant. We concluded that: 1) the two products are equivalent with respect to enamel F uptake; 2) only about one-fifth as much of the foam product is required for adequate coverage of the teeth, which significantly reduces F exposure and retention by the patient.

Fluorosis-like effects of acidosis, but not NH+4, on rat incisor enamel

Previous studies have shown that chronic acidosis induced by NH4Cl is associated with disturbances in enamel mineralization that resemble severe fluorosis and increased fluoride concentrations in both soft and hard tissues. It has not been shown whether these effects are due to acidosis per se or exposure to high levels of NH+4. This 42-day study with rats fed a low-fluoride diet was done to identify the etiological factor. Two control groups received deionized water or water containing NaCl. Two groups received NH+4-containing compounds that did not produce acidosis (NH4HCO3 or HN4 acetate). Two other groups were rendered acidotic by exposure to NH4Cl in the drinking water (metabolic acidosis) or to an atmosphere containing 10% CO2 (respiratory acidosis). The femur epiphysial fluoride concentrations were elevated in the NH4Cl and NH4 acetate groups, and the magnesium concentrations were elevated in the groups exposed to NH+4 compounds and in the 10% CO2 group. Microradiographic analysis revealed severe disturbances in the mineralization pattern of incisor enamel in both acidotic groups, but normal enamel in the other groups. Enamel fluoride and magnesium concentrations were highest in the acidotic groups. The enamel fluoride concentrations were low (8-14 ppm) and not regarded as the cause of the defective mineralization. It was concluded that the effects on structure and composition of enamel were due to acidosis and not to exposure to high levels of NH+4.

In vitro effect of human saliva on the output of fluoride from controlled-release devices

This study was designed to determine the in vitro fluoride output from controlled-release devices in stimulated, whole human saliva, and to assess changes in the salivary calcium concentration following immersion of the devices. Twenty fluoride (F) controlled-release devices of the hydroxyethyl methacrylate (HEMA)/methyl methacrylate (MMA)-type were employed. Each was designed to release 1-2 mg F per day. All devices were placed individually in 10.0 ml of deionized water for 3 days to assess baseline F output. Seven devices with markedly high or low output were discarded. During days 4-13, three of the remaining 13 devices were placed individually in 10.0 ml of stimulated, whole saliva donated by three volunteers. All devices were returned to deionized water during days 14-17. All solutions were replaced daily with fresh solutions, and each test tube was inverted once every 24 hr. The study was conducted at 19-21 degrees C. Fluoride concentration of the deionized water and human saliva was assessed by ion-specific electrode; calcium concentration of the saliva was assessed pre- and postimmersion by flame atomic absorption spectrometry. The fluoride output of the devices placed in saliva decreased to 36% of their baseline rates (P < 0.001). The calcium concentration of the human saliva decreased from a mean preimmersion value of 3.58 mg/100 ml (+/- 0.63 SD) to a postimmersion value of 2.64 (+/- 1.12 SD; P < 0.001). These results suggest an interaction between the fluoride released by the devices and calcium in the saliva.(ABSTRACT TRUNCATED AT 250 WORDS)

Intake and metabolism of fluoride

The purpose of this paper is to discuss the major factors that determine the body burden of inorganic fluoride. Fluoride intake 25 or more years ago was determined mainly by measurement of the concentration of the ion in the drinking water supply. This is not necessarily true today because of ingestion from fluoride-containing dental products, the "halo effect", the consumption of bottled water, and the use of water purification systems in the home. Therefore, the concentration of fluoride in drinking water may not be a reliable indicator of previous intake. Under most conditions, fluoride is rapidly and extensively absorbed from the gastrointestinal tract. The rate of gastric absorption is inversely related to the pH of the gastric contents. Overall absorption is reduced by calcium and certain other cations and by elevated plasma fluoride levels. Fluoride removal from plasma occurs by calcified tissue uptake and urinary excretion. About 99% of the body burden of fluoride is associated with calcified tissues, and most of it is not exchangeable. In general, the clearance of fluoride from plasma by the skeleton is inversely related to the stage of skeletal development. Skeletal uptake, however, can be positive or negative, depending on the level of fluoride intake, hormonal status, and other factors. Dentin fluoride concentrations tend to increase throughout life and appear to be similar to those in bone. Research to determine whether dentin is a reliable biomarker for the body burden of fluoride is recommended. The renal clearance of fluoride is high compared with other halogens. It is directly related to urinary pH. Factors that acidify the urine increase the retention of fluoride and vice versa. The renal clearance of fluoride decreases and tissue levels increase when the glomerular filtration rate is depressed on a chronic basis.

Lack of significant effect of coffee and caffeine on fluoride metabolism in rats

It has been reported that rat plasma fluoride (F) concentrations are higher by up to 100% when F is administered ig in coffee or a caffeine solution compared with when it is administered in water. It was hypothesized that the consumption of caffeinated beverages has contributed to the prevalence of dental fluorosis. The present studies were done to determine the physiological mechanisms for these effects. For approximately 2 h after F was administered in coffee, plasma F concentrations were higher than when administered in water, decaffeinated coffee, or a caffeine solution (3 mg/kg), but the intergroup differences were small and generally not statistically significant. The 4-hour plasma AUC values did not differ with statistical significance. There were no differences among the groups in the renal or extrarenal (skeletal) clearances of F, which suggested that the higher plasma F concentrations in the coffee groups may have been due to a slight and transient increase in absorption rate. The possibility that caffeine per se might elevate endogenous plasma F and calcium concentrations was excluded after caffeine (25 mg/kg) ig without F was given. In addition, the renal excretion, clearance, and fractional renal clearance of calcium did not differ among the groups. The results indicated that decaffeinated coffee and caffeine had no effect on F metabolism, whereas caffeinated coffee appeared to increase the initial absorption rate but not the 4-hour bio-availability.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of plasma fluoride and dietary calcium concentrations on GI absorption and secretion of fluoride in the rat

This 30-day balance study with weanling rats was designed to determine the effects of plasma fluoride and dietary calcium concentration and their interaction on the absorption, balance, and tissue concentrations of fluoride. The three major groups differed according to the total exposure and plasma concentrations of fluoride. One group received fluoride only in the diet and the other two received additional fluoride by continuous infusion from miniosmotic pumps implanted S.C. Each group was divided into two subgroups with dietary calcium concentrations of 0.4% or 1.4%. Fluoride intake with the diet did not differ among the groups. Fecal fluoride excretion was directly related to plasma fluoride concentration. The absorption and balance of dietary fluoride were inversely related to plasma fluoride concentration. These effects were greatest in the groups fed the 1.4% calcium diet. The interactions of plasma fluoride and dietary calcium on these variables were highly significant (P < 0.0001). The balance of dietary fluoride was negative in the four groups that received additional fluoride by infusion. In the two groups that received fluoride only in the diet, the plasma and bone fluoride concentrations were 41% and 59% lower, respectively, in the 1.4% dietary calcium group. The findings indicate that net fluoride secretion into the GI tract can occur when plasma fluoride concentrations and calcium intake are elevated. They suggest that elevated plasma fluoride levels and calcium intake are factors that may diminish the effect of oral fluoride treatment in osteoporotic patients.

Acute fluoride poisoning from a public water system

BACKGROUND

Acute fluoride poisoning produces a clinical syndrome characterized by nausea, vomiting, diarrhea, abdominal pain, and paresthesias. In May 1992, excess fluoride in one of two public water systems serving a village in Alaska caused an outbreak of acute fluoride poisoning.

METHODS

We surveyed residents, measured their urinary fluoride concentrations, and analyzed their serum-chemistry profiles. A case of fluoride poisoning was defined as an illness consisting of nausea, vomiting, diarrhea, abdominal pain, or numbness or tingling of the face or extremities that began between May 21 and 23.

RESULTS

Among 47 residents studied who drank water obtained on May 21, 22, or 23 from the implicated well, 43 (91 percent) had an illness that met the case definition, as compared with only 6 of 21 residents (29 percent) who drank water obtained from the implicated well at other times and 2 of 94 residents (2 percent) served by the other water system. We estimated that 296 people were poisoned; 1 person died. Four to five days after the outbreak, 10 of the 25 case patients who were tested, but none of the 15 control subjects, had elevated urinary fluoride concentrations. The case patients had elevated serum fluoride concentrations and other abnormalities consistent with fluoride poisoning, such as elevated serum lactate dehydrogenase and aspartate aminotransferase concentrations. The fluoride concentration of a water sample from the implicated well was 150 mg per liter, and that of a sample from the other system was 1.1 mg per liter. Failure to monitor and respond appropriately to elevated fluoride concentrations, an unreliable control system, and a mechanism that allowed fluoride concentrate to enter the well led to this outbreak.

CONCLUSIONS

Inspection of public water systems and monitoring of fluoride concentrations are needed to prevent outbreaks of fluoride poisoning.

Effect of artificial saliva and calcium on fluoride output of controlled-release devices

The purpose of this in vitro study was to assess the effect of graded concentrations of calcium in artificial saliva on the output of fluoride from HEMA/MMA controlled-release devices. After the initial release rates were determined in deionized water, the devices were assigned to five groups. The devices of one group remained in deionized water throughout the 19-day study while those of the other groups were placed in artificial saliva containing 0, 4.5, 8.0, or 12.0 mg% calcium on days 4-13. Ten devices of each group were placed in deionized water again on days 14-17 and then in 0.1 mol/l HCl on days 18-19. The five devices of each group that were not placed in deoinized water on day 14 were inspected for surface crystals and then placed in 1 mol/l KOH for 2 days. The fluoride release rates in artificial saliva were reduced by 71-90% and in proportion to the calcium concentration. The release rates in deionized water (days 14-17) approached the baseline values; they exceeded baseline rates by 13-49% while in HCl. The fluoride release rates did not differ among the groups while in KOH, but calcium output was directly related to the calcium concentration of the artificial saliva. The results indicate that fluoride release from HEMA/MMA devices is markedly reduced in artificial saliva and that the reduction is proportional to the concentration of calcium.

Acute and chronic fluoride toxicity

Compared with the latter half of the 19th century and the first half of the 20th century, the frequency of fatalities stemming from the ingestion of fluoride compounds has declined dramatically. Since 1978, there have been four fatalities caused by the ingestion of fluoride, all in dental products. The numbers of exposures to fluoride doses that cause concern, however, has increased, as judged by the annual reports of the American Association of Poison Control Centers. The number of reports made to poison control centers has increased from approximately 7700 in 1984 to 10,700 in 1989. Over 3700 persons have been treated in health care facilities for exposure to fluoride during this period, and there have been 133 cases for which the medical outcomes were classified as moderate or major. The sources of fluoride have been limited almost exclusively to fluoride-containing vitamins and dental products. Based on a review of the doses involved in the four fatalities, three of which involved young children, the "probably toxic dose" of fluoride has been set at 5 mg F/kg body weight. For children who are 6 years of age or less, the PTD can be found in single containers of several kinds of dental products. Recommendations that should reduce the frequency of over-exposures to fluoride are described.

Regarding adverse effects due to the chronic intake of fluoride (excluding dental fluorosis), there is no evidence for risk in the US up to the level of intake that is associated with drinking water containing 4 ppm. This statement is based on 1990 or 1991 reports by the NY State Department of Health, the USPHS, and the National Cancer Institute. Two new reports, however, have implicated chronic fluoride intake at relatively low levels in a higher incidence of bone fractures. This relationship requires further study.

Fluoride flux in the rabbit CCD: a pH-dependent event

We measured fluoride flux (JF; pmol.min-1.mm-1) in the isolated rabbit cortical collecting duct (CCD) to investigate the determining factors of JF. The perfusate contained 100 microM fluoride and the bath was fluoride-free. Osmotically-induced lumen-to-bath water flux did not affect JF. When perfusate pH was reduced from 7.4 to 6.1 and from 6.1 to 5.0, JF increased from 0.008 +/- 0.002 to 0.027 +/- 0.007 (P less than 0.01) and from 0.018 +/- 0.003 to 0.040 +/- 0.005 (P less than 0.01), respectively. Acetazolamide at 10(-4) M in the bath reduced JF slightly though not statistically. The anion-transport inhibitor, 4,4'-diisothiocyanato-stilbene-2,2'-disulfonic acid (DIDS), at 10(-4) M in the perfusate did not affect JF. Substitution of luminal chloride with gluconate failed to affect JF in tubules from normal rabbits or from rabbits treated with deoxycorticosterone which stimulates chloride-bicarbonate exchange in the CCD. JF showed no correlation with transepithelial voltage which ranged from +4 to -104 mV. We conclude that the luminal pH represents the primary determining factor influencing JF in the rabbit CCD, and fluoride does not use a chloride-mediated or a DIDS-inhibitory transport pathway.

The effects of protein deficiency and fluoride on bone mineral content of rat tibia

This study examined the effects of chronic protein deficiency and fluoride administration (10 mg/kg/day), separately or in combination, on rat tibia properties. Protein deficiency increased the bone fluoride concentration and reduced the bone mineral content (BMC) especially at the proximal or growing end which contains mainly cancellous bone. Fluoride administration also reduced BMC, but to a lesser extent, and it resulted in proximal tibia fluoride concentrations that were nearly twice those of the distal tibia. The interaction between fluoride administration and the protein content of the diet on BMC was nonsignificant, suggesting that the effects were additive, not multiplicative or synergistic. Fluoride administration, but not protein deficiency, increased bone magnesium levels. It is hypothesized that the reduction in BMC in the areas where the fluoride concentrations were the highest was due to a localized toxic effect of fluoride.

Fluoride release from three glass ionomer materials and the effects of varnishing with or without finishing

The release rates of fluoride from discs made from three glass ionomer products, Miracle Mix (MM), Ketac-Silver (KS) and Ketac-Bond (KB), into artificial saliva for 3 weeks were determined. The discs were either not varnished, varnished or varnished and finished. The release rates were not proportional to the fluoride concentrations of the products and were ordered: MM > KB > KS. The rates declined sharply as a function of time regardless of the product or treatment. Varnishing the discs caused a reduction of 61-76% depending on the product. Finishing the varnished discs produced a significant increase in the fluoride release from MM but had no effect on the release from KS or KB. In a separate study with MM, it was determined that the release rate of fluoride was inversely proportional to the powder: liquid ratio used to prepare the discs.

A comparative study of fluoride pharmacokinetics in five species

This study was designed to quantitate and compare the major features of the short-term pharmacokinetics of fluoride--i.e., the plasma (Cp), renal (Cr), and extra-renal (Cer) clearances--in young adult dogs, cats, rabbits, rats, and hamsters. Plasma and urine samples were collected for seven h after the iv administration of fluoride (0.5 mg F/kg). Cp ranged from 3.5 to 8.6 mL/min/kg in the dog and hamster, respectively. Cr ranged from less than 1.5 mL/min/kg in the dog and rabbit to about 3.5 mL/min/kg in the rat and hamster. Cer ranged from 2.1 mL/min/kg in the dog to over 4.5 mL/min/kg in the cat, rabbit, and hamster. It was concluded that (1) there are major quantitative differences in the metabolic handling of fluoride among the five species, and that (2) Cp, Cr, and Cer values of the young adult dog, when factored for body weight, resemble those of the young adult human most closely.

Fluoride reabsorption by nonionic diffusion in the distal nephron of the dog

This study was done to test the hypothesis that fluoride reabsorption is extensive from the distal nephron, the major site for tubular fluid acidification, and to compare the distal nephron handling of fluoride and chloride. Ten stop-flow studies were done in five dogs anesthetized with pentobarbital. Urinary alkalinization was achieved by the intravenous infusion of sodium bicarbonate and acetazolamide or lithium chloride. Acidification was achieved by the infusion of sodium nitrate or sodium sulfate. The results indicate that the extent of fluoride reabsorption from the distal nephron is inversely correlated with urinary pH (P less than 0.001). When the urine was strongly acidified by the infusion of sodium sulfate, urine to plasma fluoride concentration ratios were less than 1.0, a finding not previously reported from studies of the renal handling of fluoride. The reabsorption of fluoride from the distal nephron was not correlated consistently with that of chloride. The results indicate that the distal nephron is an important site for the reabsorption of fluoride and they provide additional evidence that HF is the permeating moiety.

Fluoride, calcium and phosphorus metabolism in the rat: comparison of 'natural ingredient' with semipurified diets

Three groups of weanling female rats were fed different, commercially available, 'natural ingredient' diets containing 12, 28 or 45 parts/10(6) F, mainly as bone meal, for six weeks. Two other groups were fed a low-fluoride (0.76 parts/10(6)) semipurified diet. They received fluoride doses, either in the drinking water or by daily intraperitoneal injection, which were approximately equal to the average dose of the other three groups. Rats on the 'natural ingredient' diets ingested more food and water and excreted more faeces and urine, effects which were attributed to the higher amounts of dietary fibre, Na, K and Cl. Thus, at any given concentration of fluoride in the food or water, the level of fluoride ingestion and the ensuing effects would be influenced by the type of diet used. The values for fractional fluoride absorption (45-49%) and retention (38-47%) were similar among the groups given 'natural ingredient' diets. In the groups given semipurified diet, the corresponding values were about twice as high with the exception that fractional absorption was negative (-41%) in the injected group, which indicated net intestinal secretion of fluoride. Fluoride balances and tissue concentrations were highest in the groups fed the semipurified diet, even though the level of intake was not always higher. The fractional values for calcium and phosphorus absorption (41-51%) and retention (33-43%) were also similar among the groups given 'natural ingredient' diets. The corresponding values were about twice as high in the groups fed the semipurified diet. In terms of supporting maximum bone calcification, phosphorus absorption was marginal in two of the groups on the 'natural ingredient' diets.(ABSTRACT TRUNCATED AT 250 WORDS)

Calcium-induced inhibition of taurine transport in brush-border membrane vesicles from rabbit small intestine

The influence of Ca2+ on the activity of the taurine transport system was investigated in rabbit small intestinal brush-border membrane vesicles. Preincubation of the brush-border membrane vesicles with Ca2+ prepared by the Mg2(+)-aggregation method markedly decreased the NaCl gradient-dependent uptake of taurine in these vesicles. Uptake of glucose and alanine, both dependent on a Na+ gradient, were also decreased by Ca2(+)-treatment, but their reduction was very small compared with that of taurine uptake. The inhibitory effect of Ca2+ was dose- and time-dependent. The inhibition was reduced by the presence of ethylene glycol-bis(beta-amino ethyl ether)-N,N,N'-N'-tetraacetic acid during treatment of the membrane vesicles with Ca2+. Neomycin partially protected the taurine transporter activity from the Ca2(+)-induced inhibition, but indomethacin did not. 5-Nitro-2-(3-phenylpropylamino)benzoate, a Cl(-)-channel blocker, did not increase taurine uptake in the Ca2(+)-treated membrane vesicles. It is concluded that the Ca2(+)-induced inhibition of taurine uptake in rabbit intestinal brush-border membrane vesicles is not due to accelerated dissipation of the ion gradient driving forces across the membrane but rather to a direct effect on the transporter, most likely mediated by the activation of the membrane-bound phospholipase C.

Influence of coffee on fluoride metabolism in rats

Concomitant intragastric administration of sodium fluoride and coffee resulted in a significantly higher (P less than 0.01) plasma fluoride level than intake of the same amount of fluoride with water. The same result was obtained when coffee was substituted with an equivalent amount of caffeine. Comparison of plasma fluoride levels by total area under the curve of plasma fluoride concentration versus time indicated an almost 2-fold difference. Although the mechanism(s) is not known, it appears that caffeine is responsible for the present observation. This finding could help explain the variations in the incidence of dental fluorosis among people living in optimally fluoridated communities.

Environmental and physiological factors affecting dental fluorosis

In addition to differences in fluoride intake and possibly to calcium deficiency or malnutrition, there are several factors which may account for individual differences in the occurrence of dental fluorosis. Disorders in acid-base balance affect the renal handling of fluoride such that, in acidosis, the excretion rate is diminished and, in alkalosis, the excretion rate is enhanced. Thus, any factor that can decrease urinary pH would be expected to increase the likelihood of dental fluorosis and vice versa. Results from studies with both rats and dogs have shown that acid-base disturbances per se, especially acidosis, adversely affect the mineralization of enamel in a manner that resembles fluorosis. It has been found that the retention and tissue levels of fluoride are increased by residence at high altitude. It has also been found that, in the absence of fluoride exposure, residence at high altitude per se can have a profound disruptive effect on amelogenesis which could be confused with fluorosis. The effects of diseases which lead to increases in urinary flow rate and water intake on the likelihood of the occurrence of dental fluorosis are also discussed.

The physiological and toxicological characteristics of fluoride

The metabolism and toxicity of fluoride are discussed with emphasis on new scientific findings. The gastric absorption, tissue distribution, and renal excretion of the ion are all influenced by the magnitude and direction of the pH gradient between adjacent body fluid compartments. This mechanism explains the asymmetric distribution of fluoride across cell membranes, and the manipulation of transmembrane pH gradients has proven efficacious in acute fluoride toxicity. The comparative metabolism and relative toxicities of ionic fluoride and monofluorophosphate are discussed. It is no longer certain that there is a difference between the acute toxic potentials of sodium fluoride and those of MFP. It is concluded that the "probably toxic dose" or PTD of fluoride--the dose which should trigger therapeutic intervention and hospitalization--is 5 mg/kg of body weight. As currently packaged, many dental products contain sufficient fluoride to exceed the PTD for young children. There is a need for additional research into the sources, effects, and fate of strongly bound or organic fluoride compounds. Attention is drawn to the fact that, while the metabolic characteristics and effects of fluoride in young and middle-aged adults have received considerable research attention, there is a paucity of such information for young children and the elderly. The increasing prevalence of dental fluorosis is addressed. It is concluded that nondietary sources of fluoride, mainly fluoride-containing dental products, are a major source of ingested fluoride. The article concludes with 12 recommendations for future research.

Hydrolysis and transport of proline-containing peptides in renal brush-border membrane vesicles from dipeptidyl peptidase IV-positive and dipeptidyl peptidase IV-negative rat strains

In this investigation, we have demonstrated that the renal brush-border membrane of Fischer 344 rats from the Japanese Charles River Inc. specifically lacks dipeptidyl peptidase IV (DPP IV) activity, whereas the renal brush-border membrane of Fischer 344 rats from three different sources within the United States possesses normal levels of DPP IV activity. Comparison of the brush-border proteins between Charles River (U.S.A.) Fischer 344 rats (DPP IV positive) and Japanese Charles River Fischer 344 rats (DPP IV negative) revealed that a protein band (Mr = 100,000), apparently identical with DPP IV, was absent in the membranes from Japanese Charles River Fischer 344 rats. We examined the handling of radiolabeled beta-casomorphin fragment 1-5 (Tyr-Pro-[3H]Phe-Pro-Gly), a specific substrate for DPP IV, in renal brush-border membrane vesicles isolated from DPP IV-positive and DPP IV-negative rats. Although the membrane vesicles from DPP IV-positive rats were able to hydrolyze the pentapeptide to di- and tripeptides with the subsequent active transport of these products via the H+ gradient-dependent peptide transport system, the membrane vesicles from DPP IV-negative rats failed to hydrolyze the pentapeptide and hence lacked the ability to transport the radiolabel actively from the parent peptide. The H+ gradient-dependent glycyl-sarcosine uptake and the Na+ gradient-dependent proline uptake, however, were normal in DPP IV-negative rats. Urine analysis revealed that the DPP IV-negative rats excreted proline- and hydroxyproline-containing peptides in significantly increased amounts in their urine compared with control rats. Furthermore, following intravenous administration of Tyr-Pro-Phe-Pro-NH2, a peptide that is exclusively hydrolyzed by DPP IV, urinary excretion of the peptide in the intact form was many-fold greater in DPP IV-negative rats than in control rats. These data provide conclusive evidence for the obligatory role of DPP IV in the renal handling of proline (and hydroxyproline)-containing peptides.

Enamel and dentin fluoride levels and fluorosis following single fluoride doses: a nuclear microprobe study

Female rats were given single intraperitoneal doses of fluoride (F) (0, 4, 7, or 14 mg F/kg body weight). Plasma F levels returned to predose values within 24 h. Incisors from animals killed 35 or 70 days after the F doses had been given were analyzed for mineralization defects by microradiography, and for F and P concentrations by nuclear microprobe. At 35 days, all F-injected rats had enamel fluorosis. At 70 days, by which time the incisors would have been renewed nearly twice, fluorosis was still evident in the 14 mg/kg body weight group. The enamel and dentin F concentrations at each time point were proportional to the administered F doses that had been given weeks earlier. The F concentrations at 35 days were similar to those found at 70 days. The results support the hypothesis that, following pulse loading, F can be mobilized from the bone adjacent to the enamel organ and result in local F concentrations sufficiently large to adversely affect amelogenesis.

Acute oral toxicity of sodium fluoride and monofluorophosphate separately or in combination in rats

Fasted Sprague-Dawley male rats were used in three experiments to determine the acute LD50 values of fluoride when it was administered intragastrically as NaF, disodium monofluorophosphate (Na2PO3F, MFP) or NaF and MFP. Another study was done to examine the relationship between the likelihood of a fatal outcome and peak plasma fluoride concentrations as well as 6-hour AUC values. It was concluded that fatalities due to the acute toxic effects of fluoride were: (1) independent of the chemical form in which it was given; (2) independent of the vehicle (dentifrice or water), and (3) not predictable in terms of a well-defined threshold range of peak plasma fluoride concentrations or AUC values.

The distribution of fluoride of prenatal origin in the rat--a pilot study

Sixteen female, Sprague-Dawley rats were divided into four equal groups. Two groups served as controls receiving low or regular concentrations of fluoride (F); animals in the other two groups were given drinking water, containing 100 parts/10(6) F, for 3 weeks either during or immediately before pregnancy. Thirteen days after delivery, the pups and dams were killed and various tissues analysed for F content. Prenatal F supplementation increased F concentrations in plasma, mandibular incisors and femoral epiphyses of pups by 25, 36 and 38% respectively, when given during pregnancy. Only a slight increase of 9 and 11% in the respective F concentrations of incisors and epiphyses occurred when the supplement was given before pregnancy. The fluoride level of milk was consistently higher than that of the maternal plasma. These results suggest the need for further study of prenatal F supplementation.

Effects of acid-base status and fluoride on the composition of the mineral in developing enamel and dentine in the dog

Developing molar teeth of the dog were sectioned, embedded in copper containing polymethyl methacrylate, polished and their Ca/P and Ca/Na molar ratios investigated with the electron microprobe. The teeth were obtained at 30 days from 9 pups fed regimes of different acid-base status with or without fluoride supplementation from birth to sacrifice at 30 days. No clear trends in their Ca/P or Ca/Na ratios with variation in the diet were observed. However, evaluation of the Ca/P ratio of the enamel as a function of depth revealed that this ratio was 0.80 +/- 0.15 at the mineralization front. This suggests that in enamel brushite rather than octacalcium phosphate is the precursor phase of the mineral.

Fluoride in dental products: safety considerations

This review summarizes the nature of acute fluoride toxicity, its time-course, and the fluoride doses that are involved. The generally accepted "certainly lethal dose" range for 70 kg adults, i.e., from 5 to 10 g of sodium fluoride or from 32 to 64 mg fluoride/kg, is discussed. Based on recent case reports of fluoride-induced fatalities, it is concluded that this dose range has little utility in cases involving young children. The concept of a "probably toxic dose" (PTD) is advanced. The PTD, 5.0 mg F/kg, is defined as the dose of ingested fluoride that should trigger immediate therapeutic intervention and hospitalization because of the likelihood of serious toxic consequences. The concentrations and quantities of fluoride in selected dental products are discussed in relation to the PTD. It is concluded that, as these products are currently packaged, most of them contain quantities of fluoride sufficient to exceed the PTD for young children. Recommendations are made to reduce the risk of toxicity associated with their use.

Topical fluorides: effects on physiologic and biochemical processes

The ingestion of fluoride from dentifrices or mouthrinses can contribute substantially to the total daily intake of the ion, even in communities that provide optimally fluoridated drinking water. It is concluded that the frequent and unsupervised use of these products by children six years of age or younger, especially those living in areas with water fluoridation, places them at risk of dental fluorosis. Recommendations to reduce the risk are presented. The use of 1.23% (12,300 ppm) APF gels, particularly in the absence of suctioning during the application and expectoration after the application, is associated with the swallowing of relatively large quantities of fluoride. The resulting increases in plasma fluoride levels may be sufficient to cause dental fluorosis, as judged by studies with laboratory animals, and a reduction in the kidney's ability to concentrate the urine, as judged by studies with both laboratory animals and humans. The epigastric distress experienced by some patients during or after APF gel applications appears to be due, at least in part, to a direct toxic effect of fluoride on the gastric mucosa. Data from studies with humans and laboratory animals indicate that there may also be associated changes in plasma and tissue cAMP levels, glucose metabolism, and salivary amylase secretion. There is an immediate need for the dissemination to the dental profession of standardized methods for gel application that will minimize the quantities of fluoride available for ingestion and systemic absorption.

Fluoride absorption: independence from plasma fluoride levels

The concept that there are physiologic mechanisms to homeostatically regulate plasma fluoride concentrations has been supported by results in the literature suggesting an inverse relationship between plasma fluoride levels and the absorption of the ion from the gastrointestinal tract of the rat. The validity of the relationship was questioned because of possible problems in the experimental design. The present work used four different methods to evaluate the effect of plasma fluoride levels on the absorption of the ion in rats: (i) the percentage of the daily fluoride intake that was excreted in the urine; (ii) the concentration of fluoride in femur epiphyses; (iii) the net areas under the time-plasma fluoride concentration curves after intragastric fluoride doses; and (iv) the residual amounts of fluoride in the gastrointestinal tracts after the intragastric fluoride doses. None of these methods indicated that plasma fluoride levels influence the rate or the degree of fluoride absorption. It was concluded that, unless extremely high plasma fluoride levels are involved (pharmacologic or toxic doses), the absorption of the ion is independent of plasma levels. The results provide further evidence that plasma fluoride concentrations are not homeostatically regulated.