耀慧 DDS, MDSc, FICD 台北醫學 學臨床助理教授 國防醫學院牙科公共衛 碩 國際牙醫學院台灣地區院 美國德州衛 科學院專科進修 1 1
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FLUORIDE THE MOST EFFECTIVE AND WIDELY USED APPROACHES FOR CARIES PREVENTION AND CONTROL in :Recommendations for using fluoride to prevent and control dental caries in the United State, MMWR CDC, Aug 17 2001/50(RR14):PP1-42 14 14
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GUIDELINE ON FLUORIDE THERAPY AAPD, 2014 Recommendations 1). There is confirmation from evidence-based reviews that fluoride use for the prevention and control of caries is both safe and highly effective in reducing dental caries prevalence From: American Academy of Pediatric Dentistry. Guideline on Fluoride Therapy. http:// www.aapd.org/media/policies_guidelines/g_fluoridetherapy.pdf, May 1 2016 16 16
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氟是帶負電最強的化學元素, 通 常以化合物形式存在 為 然界中第 17 常 的元素 體中以骨頭及牙齒含量最 18 18
食物 空氣 藥物空氣 藥物 食物 Data form: WHO, Fluorides and human health,1970 19 19
In Taiwan (US national Defense,1961) 0.1~1.1ppm, 公最 (1.1ppm) 台灣本島 ( 郭獻,1998) 中 南部 (0.08~0.09ppm) 於北部 (0.04ppm) 或東部 (0.03ppm) 臺北 來 事業處,2003 ( 市長信箱信件編號 : 20031016123) 臺北地區 :0.06~0.07ppm 20 20
資料來源 : WHO, Fluorides and human health. Ch.2 The supply of fluoride to man. p.17-74, 1970 21 21
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worldwide dentists are trying to convince the public that children are not getting enough fluoride,.. but the exact opposite is true: children and adults are exactly overdosing on fluoride 25 25
From: The Fluoride Education Project,Fluoride in food. http:// poisonfluoride.com/pfpc/html/f-_in_food.html From: The Fluoride Education Project,Fluoride in food. http:// poisonfluoride.com/pfpc/html/f-_in_food.html 26 26
Total fluoride intake 氟化物總攝取量 東京 科 學, 2004 嬰兒每 氟化物攝取量平均 : 0.023-0.029 mg/kg 建議標準值 : 0.05-0.07 mg/kg (Ophagu et al, 1985) 27 27
British Dental Journal 2013; 214: 587-593 28 28
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From: K. Bailey et al, Fluoride in Drinking-water, WHO, 2006 31 31
FLUORIDE CONCENTRATION OF TEA Authors Authors Authors Authors WHO,1970 NA NA 97(3.2-178.8) Ramsey,1975 England 28 1.2(0.48-3.20) Striibig,1981 Germany 37 1.4(0.56-2.73) Wei,1989 HK 26 1.52(0.73-3.46) Chen,1996 US 44 1.53(0.02-5.20) Beherndt,2002 Germany 44 1.10(0.03-3.35) 農委會 Taiwan (90-350) Data from: fluoride and human health,1970, Caries Res 2002:36:405 & http://www.coa.gov.tw/ external/teais/index.html, Modified by: Dr. Yao-Hui Huang 32 32
FACTORS ASSOCIATED WITH FLUORIDE CONCENTRATION OF TEA Tea leaves Type Soil Time picked (older contain more F) Infusion time (Chen, 1996) Majority within 30 Continue until 120 綠茶 ( 鐵觀 包種 龍井 ) 烏龍茶 33 33
品名氟濃度值 PH 值 XX 山烏龍茶 ( 無糖 ) 0.5ppm 6.66 XX 烏龍茶 ( 無糖 ) 0.8ppm 6.23 XX 天霧烏龍茶 ( 無糖 ) 0.4ppm 6.19 YY 烏龍茶 ( 無糖 ) 0.7ppm 6.50 XX 烏龍 ( 無糖 ) 0.8ppm 6.45 XX 青 烏龍茶 ( 無糖 ) 0.7ppm 6.33 XX 極品烏龍茶 ( 無糖 ) 1.15ppm 5.82 資料來源 : 國防醫學院牙科公衛研究室,2004-2-1 34 34
Q & A 哪些食物含有氟化物? 所有食物均含氟化物 含氟量較 的食物? 茶葉 資料來源 :WHO, Fluorides, Environmental health criteria 227, 2002 35 35
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Featherstone, 2004 37 37
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Re-mineralization De-mineralization 41 41
擾細菌酵素的活性 Enolase: formation of acid Phosphoglucomutase: formation of polysaccharide 氟離 抑制葡萄糖通過細胞壁 42 42
MESSAGE FROM NIH 2001, NIH Consensus Development Conference Statement The evidence for the benefit of applying fluoride varnish to permanent teeth is general positive Effective also to reverse or arrest early dental caries From: NIH, Diagnosis and management of dental caries throughout life. NIH Consensus Development Conference Statement, 2001. J Dent Educ 65:1162-8, 2001 43 43
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2009-8-6 2010-3-25 2009-12-5 2010-7-7 45 45
(Rugg-Gunn,2013, by delivery method) Community preventive measures 社區防齲 Personal effort is NOT required 不需個 努 Reduce inequalities in disease 降低疾病之不均勻勻分布 Community-bases self-administered Professionally administered From: Andrew Rugg-Gunn, Dental caries: Strategies to control this preventable disease. Acta Medica Academica 2013;42(2):117-130 46 46
資料來源 : WHO,1994 單位 : 百萬 圖表製作 : 耀慧醫師 47 47
在此輸入名 語錄 48 48
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1. 20-50 % 2. 3% 4. 3. 1-2% 20-35% 5. 1-2% 6. 1-2% 7. 51 TOOTHPASTE TOOTHPASTE
Typical Composition Binders 0.0 2% Flavor 0.5 2% Abrasive 18 50% Sweetener 0.2 1% Surfactant 0.5 2% 80-90% Water 0 50% Humectants 20 65% Fluoride 0.2 1.2% 52 TOOTHPASTE TOOTHPASTE
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TOOTHPASTE AS BATHROOM SNACK CROLL,1992 (QUINTESSENCE INT.23(2):77-78) 54 54
(X) (O) 55 55
Correct Amount of Toothpaste for Young Children 56 56
Pea size amount of toothpaste 0.25~0.5 g (Villena, 2000) 57 57
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建議之牙膏使用方法 橫擠式 From: Pediatr Dent, 22(4):312-317, 2000. lower SD==> easier to be standardised 59 59
2010, Walsh 535 studies found, 75 were included. 71 contributed data to meta-analysis Effectiveness: 23 % (DMFS) for 1000-1250 ppm 36 % for 2400-2800 ppm No statistically significant effect: <550 ppm 低於 550 ppm 無預防蛀 效果 Results on the deciduous dentition: equivocal 資料來源 :Walsh T et al, Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents..cochrane Database Syst Rev 2010; issue 1 60 60
2010, Walsh--- Conclusions confirms the benefits of using fluoride toothpaste..., but only statistically significantly at fluoride concentrations of 1000 ppm and above 有效預防蛀 需 >1000 ppm 資料來源 :Walsh T et al, Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents..cochrane Database Syst Rev 2010; issue 1 61 5 561
FROM: JADA, 145(2):190-191, 2014 The ADA currently advises caregivers to brush <2 y/o- with water 2-6 y/o- pea-size F toothpaste But, from 2014 ADA recommend 62 62
FROM: JADA, 145(2):190-191, 2014 63 63
From: B.H. de Oliveira et al, Children s Toothbrushing Practices Recommended on the Internet by Pediatric Dentistry Associations. Pediatr Dent 2016;38(7):484-8. 64 64
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should not produce unwanted effects on health, e.g. dental fluorosis No longer at risk of dental fluorosis From: Scottish Intercollegiate Guidelines Network (SIGN) Dental interventions to prevent caries in children. Edinburgh: SIGN; 2014. 66 66
From: Scottish Intercollegiate Guidelines Network (SIGN) Dental interventions to prevent caries in children. Edinburgh: SIGN; 2014. 67 67
From: Scottish Intercollegiate Guidelines Network (SIGN) Dental interventions to prevent caries in children. Edinburgh: SIGN; 2014. 68 68
From: Scottish Intercollegiate Guidelines Network (SIGN) Dental interventions to prevent caries in children. Edinburgh: SIGN; 2014. 69 69
2016 From: Marinho VCC, Chong LY, Worthington HV, Walsh T. Fluoride mouthrinses for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2016, Issue 7. Art.No.: CD002284. 70 70
From: Marinho VCC, Chong LY, Worthington HV, Walsh T. Fluoride mouthrinses for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2016, Issue 7. Art.No.: CD002284. 71 71
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British Dental Journal 2012; 212: 315-320 73 73
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Proposed Best Practices for Selfapplied Fluoride Administration From: Zero et al. Effective Use of Self-care Fluoride Administration in Asia. Adv Dent Res 24(1):16-21, 2012 75 75
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From: 1 Weyant RJ, et al. Topical Fluoride for Caries Prevention: Executive Summary of the Updated Clinical Recommendations and Supporting Systematic Review. JADA 2013;144(11):1279-1291. 80 80
From: 1 Weyant RJ, et al. Topical Fluoride for Caries Prevention: Executive Summary of the Updated Clinical Recommendations and Supporting Systematic Review. JADA 2013;144(11):1279-1291. 81 81
Ministry of Health, New Zealand 2009 Experience of caries (including pre-cavitated lesions) in the past 3 years and health professional assessment of individual and/or family risk of caries 82 82
total F intake 40% by stomach excretion from urine, 10-25% 75-90% absorbed absorbed F retain in Ca-rich areas (bone & teeth) 35-50% by intestine urine excretion, 10-20% (nfants); 40% (adults) infants, 80-90% retained adults, 60% retained From: K. Bailey et al, Fluoride in Drinking-water p29-30, WHO, 2006 83
Plasma fluoride levels after a small amount of fluoride ingested Reaches a peak within 20 60 min followed by a rapid decline as a result of both uptake in calcified tissues and urine excretion Return to baseline levels within 3 4 h From: Victor R Preedy, Fluorine Chemistry, Analysis, Function and Effects,p56, The Royal Society of Chemistry 2015. 84
微量 防蛀牙 (0.7 ppm) 過量 中毒 急性 (30-1000 ppm) 慢性 (dental >1.5 ppm; skeletal > 10 ppm) 85 85
Fluorosis=> 氟中毒?? fluorosis dental fluorosis skeletal fluorosis Ingestion of excess fluoride, most commonly in drinking-water, can cause fluorosis Moderate amounts lead to dental effects, but long-term ingestion of large amounts can lead to potentially severe skeletal problems. => => http://www.who.int/water_sanitation_health/diseases-risks/diseases/fluorosis/en/ 86 86
Fluorosis=> 氟中毒?? Enamel fluorosis is not a disease but rather affects the way that teeth look http://www.ada.org/en/member-center/oral-health-topics/fluorosis 87 87
. there are some undesirable side-effects of excessive fluoride exposure. Experience has shown that it may not be possible to achieve effective fluoride-based caries prevention without some degree of mild enamel fluorosis, regardless of which methods are chosen. (Perterson, 2016) From: Poul Erik Petersen and Hiroshi Ogawa, Prevention of dental caries through the use of fluoride the WHO approach, Community Dental Health 33: 66 68, 2016. 88 88
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氟化物產品急性中毒劑量簡表 ( 以 20 公 為例 ) 單次劑量 ( 毫克 ) 0.05% NaF 漱 (c.c.) 0.2% NaF 漱 (c.c.) 1000ppm 超氟牙膏 (200 克 / 條 ) 1mg 氟錠 1mg NaF 氟 錠 致死劑量 960 4170 990 5 條 1000 顆 2200 顆 可能中毒 100 434 104 0.5 條 100 顆 220 顆 致死劑量 :ADA,1994 可能中毒劑量 :Bayless and Tinanoff, 1985(5mg/kg) 圖表製作 : 耀慧醫師 90 90
GUIDELINE ON FLUORIDE THERAPY AAPD, 2014 From: American Academy of Pediatric Dentistry. Guideline on Fluoride Therapy. http://www.aapd.org/media/policies_guidelines/g_fluoridetherapy.pdf, May 1 2016 91 91
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