Fluoride uptake on the tooth enamel
according to application method
1
2
3
H ee-Jin Kim , C heon-H ee Lee , Ji-H yeon Park , Young-Bok C hung
1
1
Dr. Chung Young-Bok Dental Clinic, Seoul,
2
Department of Dental Hygiene, Andong Science College,
3
Department of Dental Hygiene, GangNeung YeongDong College, Korea
ABSTRACT
Objective: This study was conducted to grope the clinical use of a fluoride application method to prevent dental
caries.
Materials and method: 30 for healthy molar teeth and randomly divided into two groups on either side of each
tooth to form window size as 3 × 3 mm. The first experiment of left in the window was iontophoresis with
2% NaF for 4 minutes for 16 times, right in the window was fluoride varnish directly after iontophoresis
method for 4 times. Fluoride concentrations on the enamel surface were checked by EDS method and
compared them in each group. The second experiment was done in order to compare the fluoride uptake on
the tooth surface between the fluoride varnish method for 4 times and fluoride varnish directly after
iontophoresis method for 4 times, with the same procedure. PIGE was used for checking the fluoride uptake
on the tooth surface to prove the results certain, with surface samples in 2 teeth. The relative amounts of the
fluoride concentration by depth of the enamel were measured by EPMA with 4 sample surface of the others
2 molar teeth, in the same experiment conditions as above.
Results: The result of EDS which measures fluoride concentration of enamel that shows up in experiment 1,
compared with "iontophoresis only", "iontophoresis and varnish" shows a higher fluoride concentration(p<0.05).
In experiment 2, compared with "varnish only", "iontophoresis and varnish" has a higher fluoride
concentration(p<0.01). PIGE analyzes the fluoride concentration of the enamel surface. It was discovered that
compared to "iontophoresis only" and "varnish only", "iontophoresis and varnish" shows a higher fluoride
concentration. EPMA analyzes the fluoride concentration of the enamel surface for different depths. Experiment
1 shows that at the outermost, "iontophoresis and varnish" has fluoride concentration, however, when going
deeper, the fluoride concentration of "iontophoresis only" becomes higher. In experiment 2, "varnish only" and
"iontophoresis and varnish" have similar levels. However, as long as it goes deeper, the fluoride concentration
of "iontophoresis and varnish" becomes higher but that value of "varnish only" can hardly be observed.
Conclusion: When using fluoride topical application on the enamel surface, it was highly recommended that
fluoride varnish be used directly after fluoride iontphoresis rather than fluoride iontphoresis only or fluoride
varnish by itself. The new method is more effective and does not need repeated application.
Key Words: EDS, EPMA, fluoride iontophoresis, fluoride varnish, PIGE
Corresponding author's e-mail: [email protected] (Young-Bok Chung)
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International Journal of Clinical Preventive Dentistry. 2009, Volume 5, Number 1
1. Introduction
Dental caries is one of the most common chronic diseases
in the world, which are caused by complex actions of oral
such factors as the bacteria, food, tooth, saliva and other
factors. Although this is one of the typical oral diseases, we
can acquire a high prophylactic effect by use of proper
prophylactic measures and management. At the beginning of
the 1940s, fluorine was first introduced to prevent dental
caries which now is widely used(1).
Fluorine can inhibit bacterial generation(2), increase
microhardness of tooth enamel, and cause fluoroapatite of
limited solubility created on the enamel surface to inhibit its
demineralization(3). Moreover, since it can inhibit the
bacterial metabolic process, its anti-caries effect has been
recognized(4,5). Thus, its contribution to remineralization
process would also begin to be understood.
Constant degree fluorinated low concentration fluorine
combines absorbed apatite during or after the process of
teeth formation so as to generate fluoroapatite, which is
viewed as the best way of prevention. However, in most
areas that effectively decreased dental caries without taking
constant degree fluorine, the application method of fluoride
was said to be useful(6,7).
The fluorine application effects are varied from different
concentrations and categories of fluorine, and different
application method and frequency, etc.(8). There is great
debate on the best application method at the present. Dental
clinics use iontophoresis as the application method and use
it clinically. It uses APF (1.23%, Acidulated phosphate
fluoride, APF) and uses 2% NaF so as to encourage more
absorption of fluorine. Recently, fluoride varnish, which
uses admixture mucus of colophony resin into 5% NaF, and
a variety of forms that can be applied in the oral cavity are
still being continuously researched.
In order to make the fluoride combination more
effectively in the oral cavity, fluoride iontophoresis was
started to be used. This method sends small amounts of
electricity into the body and helps the ionized fluorine
infiltrate into teeth so as to prevent dental caries and
mitigate hypersensitivity. In all professional fluoride
application methods, iontophoresis has been used more and
more having the fluoride uptake effect. Chung(9) discovered
that compared with those who did not use the iontophoresis
device, the iontophoresis device users have relative more
uptake fluorine.
Fluoride varnish was exploited in 1960 and the beginning
of 1970, and it was widely used in European countries as a
professional fluoride application in 1980(10). The fluoride
varnish method uses colophony resin in 5% NaF and the
admixture is smeared on the teeth. This method cause
colophony resin to stick to teeth keeping the fluorine useful
for a longer period of time.
This study was conducted to grope the clinical use of a
fluoride application method to prevent dental caries. The
professional application method of fluoride iontophoresis and
fluoride varnish and fluoride iontophoresis directly after
fluoride varnish was conducted, and afterwards they
compared and analyzed the uptake fluoride concentration on
the enamel surface. Grope is an effective application method
in clinical use.
2. Materials and methods
2.1. Materials
In this test, the professional using iontophoresis device
Table 1. Classifications and conditions of test objective teeth
No of sample
surface
Test condition
iontophoresis only
n=15
Iontophoresis method with 2% NaF for 4 minutes
for 16 times
iontophoresis and
varnish
n=15
Iontophoresis directly after fluoride varnish method
for 4 times
varnish only
n=15
Fluoride varnish method
for 4 times
iontophoresis and
varnish
n=15
Iontophoresis directly after fluoride varnish method
for 4 times
Group
Experiment 1
Experiment 2
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Fluoride uptake on the tooth enamel according to application method
used the F-ion dcs(Dr-Prevent, South Korea) and put
fluoride solution into NaF solution. Fluoride varnish uses
Cavity Shield® (3M, USA). 30 permanent molar teeth were
selected without node and caries as the research objective.
Directly after the selection, a 15# blade was used to remove
the stoke parenchyma at the root of teeth. Before test,
prepare the physiological saline. Pick 4 teeth and divide
them with 2 for PIGE test and EPMA test.
In order to observe the fluorine uptake at the surface of
enamel, conduct Energy Dispersive X-ray Spectrometer
(EDS) and Proton Induced Gamma-ray Emission analysis
(PIGE) to measure and undertake the quantitative analysis.
In order to observe the fluorine uptake, according to enamel
depths, measure them with the Electron Probe
Micro-Analysis (EPMA).
2.2. Methods
2.2.1. Prepare the objective teeth
(1) Enamel prophylaxis
Use the pumice without fluorine and glycerine on
buccal of objective teeth every 30 seconds to
prophylaxis. Then clean and dry it.
(2) Nail varnish application
Make a 3 mm ×3 mm window at buccal surface
of molar teeth for 2 areas as right and left side.
Painted the nail varnish at the rest of windows on
the buccal surface of the teeth uniformly.
(3) Sample classification
Classify the objective teeth into 2 groups randomly,
with each group containing a total of 15 teeth. Sign
"iontophoresis only", "varnish only" in the left side
of windows and mark the right sides as
"iontophoresis and varnish". Test them following the
description herein in table 1.
2.2.2. Test method of research object
(1) Experiment 1 " iontophoresis only "
To allow the electricity to flow into selected teeth,
take the high speed handpiece and bur and cut off a
periapical of about 5 mm. Through the exposed pulp
canal, insert K file into there so that file can be
connected by the electricity. In experiment 1
"iontophoresis only" after drying the surface of teeth,
put 2% NaF solution into the window and put
cotton into it, then connect them with electricity
which is 4 min/500 mA iontophoresis. After this,
take the spilling water and brush the teeth every
280 sec. Since the time for brushing teeth is always
3 min, divide them into 8 parts and brush every
one of them for 20 seconds from then on.
Additionally, every day we brush teeth our teeth on
the average of twice daily, plus 4 times a week for
fluorine application. Record this every 7 days before
the next iontophoresis, thus, the brush time should
be 20(sec)×2(times)×7(days)= 280 sec. Dried the
window after doing for all procedures above and
repeated the same way for 16 times.
(2) Experiment 1 " iontophoresis and varnish "
After drying procession, deal with the window in
the same way as was done in experiment 1
"iontophoresis only". After the iontophoresis, directly
use micro brush to smear the fluoride varnish to the
window uniformly. Brush the teeth every 1,120 sec
after 30 min drying. This is just the number as 4
times repeated in 280 sec mentioned herein above.
After the washing, dried the window and repeated
this 4 times.
(3) Experiment 2 "varnish only"
Used micro brush to smear the fluoride varnish
uniformly after drying the window. 30 min later, do
the same way for experiment 1 and brushed them
every 1,120 sec.
(4) Experiment 2 "iontophoresis and varnish"
Use the same method as experiment 1 "
iontophoresis and varnish "
2.2.3 Measurement of fluorine content
(1) EDS Analysis
Take the proper teeth and test as object and
conduct an EDS to analyze and measure the fluoride
concentration of the enamel surface. The equipment
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International Journal of Clinical Preventive Dentistry. 2009, Volume 5, Number 1
to use were VEGA II LSU (TESCAN, Czech) SEM,
EDS2008 (IXRF SYSTEMS, USA).
(2) PIGE Observation
Based on the conditions in table 2, take proper
teeth as objects, and conduct PIGE to analyze and
measure the fluoride concentration of enamel surface.
The equipments being used during the experiment
are PIGE system, which KIGAM made itself, with
1.7 MV tandem VDG accelerator. The detector is
NaI gamma-ray detector. 2.5 MeV proton, the net
length is 1.5 mm.
(3) EPMA Observation
Follow the conditions in table 2 and select proper
teeth as object to conduct the EPMA to analyze and
measure the fluoride concentration of enamel surface
for different depths. Cut off the object teeth in a
horizontal direction through a cylinder with a 2 cm
diameter, and 2 cm in height. Take epoxy saucer
eyes to bury them and polish the observed surface
. The equipment used EPMA1610
until 1
accumulating
(Shimadzu, Japan). Net length is 1
voltage is 15 kv. Every 100
depth from the
surface was measured.
shows up in Experiment 1, the fluoride concentration in
fluoride varnish directly after fluoride iontophoresis was
more than that of fluoride iontophoresis. The statistical
difference is p<0.05. This suggests that fluoride varnish
directly after fluoride iontophoresis has more uptake effect
even with less iontophoresis times(table 3).
3.1.2. Experiment 2; Comparison of the fluoride
uptake between fluoride varnish only and
varnish with iontophoresis method.
In Experiment 2, compared with fluoride varnish only,
fluoride varnish directly after fluoride iontophoresis shows a
higher fluoride concentration on the enamel surface. The
statistical difference is p<0.01. This suggests that fluoride
varnish directly after fluoride iontophoresis has more uptake
effect with same iontophoresis times (table 4).
3.2. Fluoride concentration observed with PIGE
It shows a higher fluoride concentration in double
application with iontophoresis and varnish than in single
application only, both with iontophoresis application case and
varnish application sample(table 5).
3.3 Fluoride concentration observed with EPMA
2.2.4 Statistical management
Conducted Wilcoxon test to check statistical
significance of fluoride uptake extent between section
"iontophoresis only" and "iontophoresis and varnish"
in experiment 1 and section "varnish only" and
"iontophoresis and varnish" in experiment 2.
3. Results
3.1. Measured results on fluoride concentration of
enamel surface in EDS
3.1.1. Experiment 1; Comparison of the fluoride
uptake between fluoride iontophoresis only and
varnish with iontophoresis method.
The result of EDS which measures fluoride concentration
of enamel of fluoride application method separately that
- 42 -
Every 100 of the depth from the surface , the different
fluoride concentration results of experiment 1 shows that at
the outermost, 4 times fluoride varnish directly after fluoride
iontophoresis has fluoride concentration, however, as long as
it becomes deeper, the fluoride concentration of 16 times
fluoride iontophoresis becomes higher(table 6, figure 1).
In Experiment 2 shows that at the outermost, 4 times
fluoride varnish and 4 times fluoride varnish directly after
fluoride iontophoresis have similar levels. However, as long
as it becomes deeper, the fluoride concentration of fluoride
varnish directly after fluoride iontophoresis becomes higher
but the value of fluoride varnish can hardly be
observed(table 7, figure 2).
Fluoride uptake on the tooth enamel according to application method
Table 2. Classification and conditions of test objective teeth
No of sample
surface
Test condition
iontophoresis
only
n=1
Iontophoresis method with 2% NaF for 4 minutes
for 16 times
iontophoresis
and varnish
n=1
Iontophoresis directly after fluoride varnish method
for 4 times
varnish only
n=1
Fluoride varnish method
for 4 times
iontophoresis
and varnish
n=1
Iontophoresis directly after fluoride varnish method
for 4 times
Group
Experiment 1
Experiment 2
Table 3. Uptake fluorine content of enamel surface in experiment 1 measured with EDS (% concentration)
Group
"iontophoresis only"
"iontophoresis and varnish"
No of sample surface
n=15
n=15
Mean±SD
1.541±1.715
2.423±1.990
p value
0.027
Table 4. Uptake fluorine content of enamel surface in experiment 2 measured with EDS (% concentration)
Group
"varnish only"
"iontophoresis and varnish"
No of sample surface
n=15
n=15
Mean±SD
1.761±1.270
2.886±1.789
p value
0.003
Table 5. Fluoride concentration of enamel surface measured by PIGE
Single application
Double application with iontophoresis and varnish
±: standard error
No of sample
surface
n=1
n=1
Experiment 1
Iontophoresis
0.28±0.03 (%)
0.53±0.06 (%)
Experiment 2
Varnish
0.20±0.03 (%)
0.22±0.03 (%)
Table 6. Fluoride concentration according to the depth from enamel surface measured by EPMA
Experiment 1
"iontophoresis only"
"iontophoresis and varnish"
No of sample
n=1
n=1
0
0.199
0.449
100
0.103
0.177
200
0.091
0.199
300
0.435
0.051
400
0.25
0.127
Table 7. Fluoride concentration according to the depth from enamel surface measured by EPMA
Experiment 2
"varnish only"
"iontophoresis and varnish"
No of sample
n=1
n=1
0
0.172
0.178
100
0.1
0.042
200
0
0.13
300
0
0.106
400
0
0.317
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International Journal of Clinical Preventive Dentistry. 2009, Volume 5, Number 1
Experiment 1
0.5
0.4
0.3
0.2
0.1
0
i
i+v
0mk
100mk
200mk
300mk
400mk
Figure 1. The graph of fluoride concentration measurement by EPMA changing depths (Exp. 1)
Experiment 2
0.4
0.3
v
0.2
i+v
0.1
0
0mk
100mk
200mk
300mk
400mk
Figure 2. The graph of fluoride concentration measurement by EPMA changing depths (Exp. 2)
4. Discussion
In order to increase applied anti-caries effect, research on
category or application method has not stopped. Applying
fluorine onto the surface of teeth can help to connect the
enamel surface, and as the oral saliva melts the fluorine
begins to be useful which not only helps to prevent
demineralization but also can promote remineralization at the
same time(11).
Nelson(12) suggested that in the APF of enamel, there is
granular calcium fluoride and remained sediment stocking in
the cracked surface of enamel. Yu(13) also discovers that
when it comes to 450ppm APF, there is granular formatting
extent, which Yoon(14) also mentioned that when
in 0.5
applying a high concentrate fluoride solution, it will format
sized granule additionally.
1
However, calcium fluoride of solubility shows up and
- 44 -
disappeared quickly. Stockey(15) declares that if applying
fluorine onto enamel once, the stocking will reach to
3,700ppm. After brushing, most of them will disappear.
After 3 days brushing, the fluorine will decrease to 300ppm.
Thus, to keep the stocking fluorine from decreasing, it is
necessary to repeat the fluorine application.
Some research has suggested that although NaF is safe
chemically, if used it separately the connection effect will
more or less decline, so that fluoride iontophoresis is more
effective(16). Wilson(17) declares that the use of
iontophoresis can release more fluorine which increases the
content of fluorine. Huang GF and Guo MK(18) suggest
that if applying fluorine onto teeth every 5 min, and using
SEM to observe to discover that the infiltration of bad teeth
and the size of it is small while applying NaF
is 75
without iontophoresis. On the other side, the infiltration of
with a large size while applying
bad teeth is 250~830
NaF with iontophoresis. However, this iontophoresis process
Fluoride uptake on the tooth enamel according to application method
needs to be repeated several times and it is also trouble
some.
Most of these encouraged repeated application processes
many times lead to obtaining a high content fluorine
infiltrated into teeth. Thus, for kids and some patients who
do not want to wait a long time, the treatment effect
becomes low. Fluoride varnish is mostly a great method for
those patients without patience who want a one time
application with a long lasting effect.
Fluoride varnish uses a higher concentrate of fluorine
APF compared to NaF but with only 1/10 content of
fluorine applied. For its quick enrichment, there is no
danger to a large quantity of fluorine at a time. Hence, for
children and the disabled and those who feel less
comfortable to apply fluoride infiltrate, this method is more
convenient.
Regarding the fluoride varnish, Lee and Ocumpaugh(19)
discovered clinically the fluorine will remain in pit and
fissure for several mouths. Tveit(20) reported that 48 hours
after varnish application, the fluorine concentrate of enamel
surface was 1,500~4,500ppm, dentin was 7,000ppm, which
reached 25,000ppm on the surface of the root. Retief(21)
said that varnish with fluorine is much more effective that
1.23% APF.
In this test, to accumulate the concentration of uptake
fluorine at the surface of the enamel, it uses the Proton
Induced Gamma-ray Emission analysis (PIGE). This PIGE
was exploited to measure the atomic weight of chemical
elements such as nitrogen, oxygen and fluorine.
By using this analysis method, it can analyze the gamma
ray emanated from fluorine and analyze its atomic weight to
obtain the quantity(22). PIGE is a sensitive, precise and
nondestructive testing analyzing method. Some foreign
research centers use PIGE to measure the content of fluorine
in teeth and South Korea followed this accordingly(23-26).
For SEM-EDX and ESCA, they may have some problem
with ability and low intension. It detects the X-ray from
electric excitation, but the problem is that other elements
can also emanate X-ray. Thus, the outcomes are always low
precision. In the PIGE analysis, it measured the gamma ray
around 6 MeV which was a response of F(p,αγ), and since
it was not significant, this did not affect the precision
sufficently.
EPMA was assumed as a relative correct measure
method. Since the process is complex and it needs to polish
the surface, it is possible to cause errors here and, thus, we
need to be very careful. Moreover, when using EPMA to
measure elements based on depths like fluorine, it always
takes a long time for the line scanning process. On the
contrary, PIGE does not need special treatment and since it
is a nondestructive test, it can measure elements without
many conditions, and decrease errors so that it turns out to
be a precise test.
Further research needs to be done before infiltrating
fluorine on the surface of enamel. As mentioned herein
before, fluoride iontophoresis can make uptake fluorine on
the surface of enamel and fluoride varnish can keep fluorine
stuck to the teeth for a long period of time. In this study
these theories were used as a basis and the 1 time fluoride
application was used and kept uptake flourine remaining on
the surface of teeth which showed the effect of the fluoride
application method.
In this test, the fluoride application was used as fluoride
iontophoresis, fluoride varnish and fluoride iontophoresis
directly after fluoride varnish on healthy buccal teeth, and
the simple method of EDS was used to observe and
analyze the uptake fluorine on the surface of enamel. In
addition, PIGE was used to measure and analyze the uptake
fluoride concentration, and EPMA was also used to observe
and analyze the fluoride concentration of enamel surface for
of depth.
every 100
In the EDS analysis, as the teeth were from different
people and their qualities might be not equal. All samples
were divided into two parts as right window and left
window, and tests were conducted were conducted
independently. It took 16 times fluoride iontophoresis, 4
times fluoride varnish and 4 times fluoride varnish directly
after fluoride iontophoresis. The fluoride iontophoresis was
held 4 times a week, and fluoride varnish was held 1 time.
As the uptake fluorine content was little, the test was
repeated 4 times.
In experiment 1, the results of fluoride concentration, the
fluoride concentration in 16 times fluoride varnish directly
after fluoride iontophoresis is higher. The statistical
difference is p<0.05. This suggested that the fluoride varnish
directly after fluoride iontophoresis method can help to
uptake more fluorine with less application time. In
experiment 2, compared with 4 times fluoride varnish only,
4 times fluoride varnish directly after fluoride iontophoresis
takes higher fluoride concentration. The statistical difference
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International Journal of Clinical Preventive Dentistry. 2009, Volume 5, Number 1
is p<0.01. This shows that fluoride varnish directly after
fluoride iontophoresis method can accumulate more fluorine.
Until now, although it is still not known which method is
the most effective way to apply fluorine, it is recognized
that the fluoride iontophoresis method can accumulate more
and deeper depths of fluorine whereas the fluoride varnish
method enjoys a longer lasting effect and does not need to
be repeated many times. This method has become a new
clinical treatment to prevent dental caries.
This helps patients to reduce their treatment time and an
effective method to prevent dental caries can be applied.
5. Conclusion
This research presented a professional fluoride application
method as fluoride iontophoresis and fluoride varnish and
fluoride varnish directly after fluoride iontophoresis. After
this, it measured uptake the fluoride concentration of enamel
and were analyzed through EDS, PIGE and EPMA,
respectively, then compared the fluoride application method
differences separately and obtained the following conclusions:
1. Fluoride concentration in enamel surface measured by
EDS. The result of EDS which measures fluoride
concentration of enamel that shows up in experiment 1,
compared with 16 times fluoride iontophoresis only, 4 times
fluoride varnish directly after fluoride iontophoresis method
has a higher fluoride concentration(p<0.05). In experiment 2,
compared with 4 times fluoride varnish only, 4 times
fluoride varnish directly after fluoride iontophoresis method
has a higher fluoride concentration(p<0.01).
2. PIGE analyzes for fluoride concentration of enamel
surface and discovered that compared to 16 times fluoride
iontophoresis and 4 times fluoride varnish, 4 times fluoride
varnish directly after fluoride iontophoresis method was
revealed a higher fluoride concentration.
3. EPMA analyzes fluoride concentration of enamel
surface for different depths. Experiment 1 shows that at the
outermost, 4 times fluoride varnish directly after fluoride
iontophoresis method has fluoride concentration, however, as
long as it becomes deeper, the fluoride concentration of 16
times fluoride iontophoresis becomes higher. In experiment
2, 4 times fluoride varnish and 4 times fluoride varnish
- 46 -
directly after fluoride iontophoresis method have similar
levels. However, as long as according to the depth of the
enamel, the fluoride concentration of fluoride varnish directly
after fluoride iontophoresis method becomes higher but that
value of fluoride varnish can hardly be observed.
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