Saturday, November 9, 2019
The oral effect of fluorides and acids The WritePass Journal
The oral effect of fluorides and acids Introduction The oral effect of fluorides and acids IntroductionOverview Fluorides: Acids: Evaluation: BibliographyRelated Introduction Overview Fluorides and acids are synonymous with dental hygiene. They are marketed across the world as being beneficial or detrimental. In this report, I shall explore the many views concerning the effects of fluorides and acids in the mouth. This includes their effects on teeth and gums as well as other relevant areas that concern human oral anatomy. Below is a brief outline of the topics that shall be discussed within this report:  Fluorides: What are fluorides? Why are fluorides important for oral hygiene? The chemical action of fluorides on teeth. How do fluorides bind with enamel to strengthen and protect it? What are the ways in which fluorides can be administered? Is â€Å"Fluoridation†good or bad?  Acids: What are acids? Why are acids important? Why are they bad? The chemistry of acids what makes them acidic? The genetic and lifestyle factors that could alter oral acidity. What is the chemical action and effect of acids on teeth? What is the effect of acids on gums for tooth support?  Evaluation: Are the relationships between fluorides and cavities reliable and/or valid? What issues of safety concerning the use of fluorides arise as a result of this project? Are the sources used in this project reliable and/or valid?  Fluorides  Topics that shall be covered in this section: What are Fluorides? Why are fluorides important for oral hygiene? The chemical action of fluorides on teeth. How do fluorides bind with enamel to strengthen and protect it? What other chemicals are needed to strengthen teeth? What are the ways in which fluorides can be administered? Is â€Å"Fluoridation†good or bad?  What are Fluorides? Fluorides are formed from the reduction of the element fluorine the 17th most abundant element in the earth’s crust.[1][2] Fluorine is highly reactive, and only exists as a combination of other elements in a fluoride compound. Fluoride compounds can be found in rocks and soil. Fluoride ions are generally produced when water passes over rocks that contains the fluoride minerals.[2] Why are Fluorides Important for Oral Hygiene? Fluorides are widely used in toothpaste, mouthwash and supplementary products to help reduce the risk of dental cavities.[6] In the UK, fluorides are mainly administered topically to the teeth through the process of brushing. However, only around five million people in cities across the West Midlands and North East England fluoridate (see fluoridation section) their water, so the fluorides have both topical and systemic administrations.[5] According to the British Dental Health Foundation, â€Å"Children who have fluoride when their teeth are developing tend to have shallower grooves in their teeth, so plaque can be more easily removed†.[3] Moreover, the U.S. Centre for Disease Control lists water fluoridation as one of the ten greatest public health achievements of the 20th century.[4] These methods of exposing the teeth to fluoride also increase the concentration of fluoride in the saliva. The fluoride ions interact with molecules of broken down (demineralised) enamel due to acid erosion.[7] This produces a similar enamel-like compound that can then remineralise the tooth enamel. When the rate of demineralisation is greater than the rate of remineralisation, dental caries begin to form. From this, the administration of fluorides work to increase the rate of remineralisation of tooth enamel, thus offsetting the rate of demineralisation reducing the risk of dental decay.[7][8] It is through the promotion of enamel remineralisation in the remineralisation/demineralisation cycle that fluorides have such an important role in maintaining healthy tooth enamel for good oral hygiene.[8][9]  The Chemical Action of Fluorides on Teeth Tooth decay is an infectious disease, involving an increase in the plaque formation of oral bacteria such as Streptococcus mutans and Lactobacillus.[10] These facultative bacteria respire anaerobically. Therefore, organic acids are produced when carbohydrates, such as sugar, are used up.[11] As more acid is produced the pH of the saliva decreases.[14] The pH scale generally ranges from pH 1 (the most acidic) to pH 14 (the most alkaline). The recommended saliva pH is said to around 7.2 to 7.4.[13] Therefore, saliva is just slightly alkaline. According to the ‘Manual of Dietetic Practice’ (2002), at a pH below 5.5, acid reacts with and breaks down the crystalline calcium hydrogen phosphate (hydroxyapatite) the main component of tooth enamel in a process known as demineralisation.[12] However, when the food source is depleted, the tooth enamel can be remineralised, where the saliva can provide the mineral ions lost for remineralisation. When the oral pH is greater than 4.5, available fluoride ions in the fluid surrounding teeth react with the dissolved crystalline calcium hydrogen phosphate ions forming a fluorapatite layer. This layer binds itself to the enamel surface. Moreover, the fluoride ions can react with the non-dissolved hydroxyapatite enamel, to substitute the hydroxyl group of the hydroxyapatite compound for fluoride ions. This process eventually forms a fluorapatite coating on the outside layer of the teeth.[8][16] The process to produce this remineralised veneer is much quicker than that to produce the normal hydroxyapatite coating.[8][40] Moreover, it is much harder to demineralise the fluorapatite coating by acid than it is for its hydroxyapatite counterpart.[40] This is because the fluoride group, which was substituted for the hydroxyapatite hydro xyl group, inhibits biological systems in the bacteria, so they cannot produce acids as effectively.[40] All of these factors concerning the formed fluorapatite, make this newly formed tooth enamel less likely to undergo acid erosion.[8] In this way, fluorides can function to reduce the risk of cavities forming in the teeth by its topical effects.[17] However, some fluorides function within the body by interacting with the teeth. In these cases, the fluorides can become incorporated into the blood plasma and impregnated into the developing teeth by its blood supply.[17] This in-built fluoride makes the concerning teeth much more resistant to decay.[19][40]  The Chemical Equation for the Production of Fluorapatite: Crystalline calcium hydrogen phosphate (hydroxyapatite) reacts with fluoride sources, such as calcium fluoride CaF2 to produce a fluorapatite compound (calcium halophosphate).[20] Ca10(PO4)6(OH)2             +           CaF2               ⇒ Ca10(PO4)6(F)2     + Ca2+ hydroxyapatite            + calcium fluoride ⇒ fluorapatite      + calcium  Studies Supporting the Use of Fluorides The â€Å"Centres for Disease Control†(CDC) published the graph shown by figure 4 above.[37] From figure 4 above, it can be seen that as the percentage of people drinking fluoridated water increases, the mean number of permanent teeth lost, filled or decayed due to cavities decreases. It has also been shown that the fluoridation of water has reduced the risk of caries by 40-60%.[3] This, therefore, supports the evidence behind the mechanisms of fluorides to reduce the risk of developing cavities. However, it should be noted that these links do not signify a causal relationship between fluoride administration and the risk of developing cavities. This is because many other factors can also reduce the risk of cavities, and so one is not fully certain whether the fluorides are the reason for increased enamel strength.  Other Chemicals Needed Naturally Stronger and Whiter Teeth As the surface of the tooth enamel begins to breakdown, the tooth itself begins to discolour. This is mainly due to years of chewing and general use, where staining agents become adsorbed to the teeth and the yellower dentine underneath becomes more exposed. Stains can be caused by smoking, eating, drinking and over grinding of teeth. The stronger one’s teeth, the lesser the likelihood that it would become stained by these methods. When tooth enamel has a strong structure, it is more easy to maintain its naturally white appearance. Strong tooth structure results from eating foods high in certain minerals and vitamins. In this way, stronger tooth enamel is less likely to undergo erosion by acid or undergo tooth decay.[21] The list below states and briefly describes some of the recommended nutritional supplements to take for stronger and whiter teeth:[29]  Phosphorus:  Phosphorus is involved in strengthening the teeth and the bones in the body.  Vitamin C and Vitamin D :  Vitamin C and vitamin D aids calcium absorption in the body.  Magnesium:  Magnesium aids the formation of tooth enamel  Calcium:  Calcium is needed for the body to develop durable bones and teeth. The more calcium absorbed, the greater the rate of calcification of the bones and teeth to a point. In this way, the teeth are stronger and less susceptible to acid-erosion. As calcium is naturally white, calcified teeth are thus whiter in appearance. Interestingly, the calcium deposited in the bones and teeth can be utilised by the blood to help provide the necessary minerals for the body. These minerals and vitamins have a greater systemic function in the body than fluorides for the prevention of cavities. It is, therefore, through the greater mineralisation of the teeth that these dietary supplements have the greatest effect on increasing tooth density to lower its permeability to acid absorption and breakdown.[22] In this way, both the systemic and topical methods of cavity-prevention are together vital to ensure good oral hygiene.[17]  Safe Fluoride Levels Fluoride Dietary Reference Intakes Recommended by the Institute of Medicine:[29]      0.01 mg per day for those aged up to 6 months.      4 mg per day for men aged 19 years upwards. The Tolerable Upper Intake Level:      0.10 mg per day for those aged up to 8 years.      10 mg per day for those aged 8 years and upwards. Background Information:  The effects of consuming fluorides depend on the total daily intake of fluoride.[24] According to a publication by Fawell, J.K., et al. (2006), an adult living with unfluoridated water in a temperate climate would have a total daily fluoride intake of 0.6 mg/day, compared to one with fluoridated water, who would intake 2 mg/day of fluoride.[23] However, these intakes are different for different regions in the world, due to differing water compositions, cultures and climates. Requirements:  All personnel should report, inspect and monitor all processes involved in fluoridation to help prevent cases of overfeed of fluorides into drinking water. Organisations should also train staff to adhere to safety and good practice regulations. They should also produce audits and reports pertaining to the technical requirements for the safe and efficient usage each major compound used fluoridation.[25] These requirement have been set by the â€Å"The Centres for Disease Control and Prevention†. What are the Ways in which Fluorides can be Administered? Diet Fluorides are naturally found in many of the foods that we eat today. It can be found in fruits, vegetables and even in other organisms. Some of the most common sources containing particularly large fluoride concentrations are listed below:[23  Barley Cassava Rice Yams Potato Raisins Fish Shellfish Taro  Fluoride Therapy Fluoride therapy encompasses the use of toothpastes, mouthwashes, fluoridated water, dietary supplements and other means to deliver fluoride ions systemically or topically. Some of these methods shall be discussed below: Fluoridation What is it?  Water fluoridation is a technique used to administer fluorides via the public water supply. Although fluorides can be naturally occurring in our water, fluoridation specifically concerns the issue of adding more fluorides, so as to be of specific medical benefit to the public. Fluoride compounds are used to fluoridate water supplies. Sodium fluoride is the most common compound to use, due to its greater convenience, lower costs and greater associated safety.[27]  Sodium fluoride (NaF):  A white crystal or powder with no distinct scent that was the first chemical to be used in fluoridation.[27] Generally, the crystallised form is preferred when the compound is being handled, as there is less potentially toxic dust formed.[28] Because of this, NaF is generally used by smaller water companies. Further Information:  Fluoridated drinking water has the greatest contribution to one’s daily fluoride intake.[23] In the United States of America, a census was carried out in 1992. The census found that found that fluorosilicic acid (63%) had the greatest population reach out of all those that received water fluoridation, followed by sodium fluorosilicate (28%) and sodium fluoride (9%) respectively.[31]  Some Facts about Water Fluoridation Facts are from the source, â€Å"Fluorides†, produced by the ‘World Health Organisation’.[41] Out of all fluorides ingested, 70% to 90% of it is absorbed. When ingested, it can then form the acid HF (hydrogen fluoride), which makes up 40% of the total absorption. When the carried by the blood, the fluorides can then travel around the body. For those of 0 – 1 years of age, 80% to 90% of the fluorides that are absorbed remain. The rest is then removed by excretion (e.g. urine and faeces) 60% of the fluorides absorbed in adults remain in their body. The large majority (99%) of fluorides that remain are stored in bones and teeth. Excessive amounts of fluoride deposits in these regions can cause fluorosis. Notes:  In the United States of America, the optimal level of fluoride range from 0.7ppm to 1.2ppm[32], although the ‘WHO’ states that the absolute upper bound for fluorine in water should be 1ppm.[23] In the UK, the recommended and optimal concentrations of fluoride in water are 1ppm and 1.5ppm respectively.[33] However, the fluoride concentration in water depends on the mean maximum atmospheric temperature in that area. This is because, in hotter regions, inhabitants would consume more of the fluoridated water, and thus less fluorides should be present in it.[32]  Toothpaste Method of Administration:  Toothpaste is applied topically to teeth through brushing. Notes:  On average, toothpaste contains 1000-1500ppm of fluoride, usually in the form of NaF. Further Information:  Parents should supervise their children’s tooth brushing to ensure that they do not swallow any toothpaste, which is a major cause of dental fluorosis in children under 7.[3][39]  Mouthwash Method of Administration:  Mouthwashes are rinsed in the mouth for generally 30-40 seconds before being spat out. Further Information:  Typically, mouthwashes contain fluorides by the addition of NaF (sodium fluoride). One can easily buy mouthwashes with 225 ppm of fluoride at local supermarkets without prescription. Notes:  Alcohol mouthwashes should not be given to children, due to their increased risk of them swallowing it. This is due to children having greater difficulty in overcoming the swallowing reflex.[3] Moreover, allowing children to swallow fluoride mouthwashes may increase their risk of dental fluorosis.[35]  Fluoridation: The Big Debate The issue of fluoridation has always raised big questions regarding its effectiveness, safety and usage. Some of the main pros and cons of fluoridation shall therefore be explored.                                                                                                Pros:  Large Reach:  All members of the community would have access to regular fluorides doses, regardless of income, education or dental access. It many be particularly beneficial to children, as studies have shown that they do not brush as regularly as they should. Therefore, the omission of this administration fluoride can be compensated through water fluoridation, which all children should and would drink.  Advantageous for the Elderly:  As you get older, one’s saliva flow would generally decrease. This would mean that the elderly have less salivary fluorides that could access, remineralise and strengthen tooth surfaces. Moreover, the elderly have decreased manual dexterity to brush effectively and reach all surfaces. Therefore, all of these issues increase the risk of root surface decay for the elderly, but fluorides would help prevent this from occurring.  Evidence:  Many studies have been carried out to show that fluoridation of water does have a positive impact on oral hygiene and helping to prevent dental decay.  Support:  The fluoridation of water is supported by large health bodies such as: The British Dental Association; The World Health Organisation; The British Medical Association; and the British Fluoridation Society.  Cost Effective:  The use of fluorides reduces the risk of dental caries, and so potentially saves money for a patient who otherwise would have had to have payed for fillings.  Reduces the Risk of Dental Caries:  A recent study has concluded that adding fluorides to drinking water supplies can lower the risk of dental caries by 40-60%.  Acid Resistance and Speed:  The compound formed when the broken down enamel reacts with fluoride is more acid resistant and forms more quickly than the original enamel coating.  Natural:  Fluorides, derived from the natural element, Fluorine, are non-artificial ions. They are regularly used by the body to carry out many other metabolic processes, so its addition into the body would not be unusual. In this way, we have a better understanding of the systemic interaction of fluorides in the body.                                                            Cons:  Dental Fluorosis:  Dental fluorosis is probably the biggest issue surrounding the fluoridation of water. It is a conditions where an excessive consumption of fluorides can potentially cause white spots or brown stains to appear on the tooth enamel.  Poison:  An excessive consumption of fluorides is toxic and potentially fatal. However, one would have to regularly consume a volume of water far greater than that recommended for fluorides to have such a harmful effect.  Concern:  This idea that we are always drinking something potentially toxic could lead to much media attention. For example, the media may frighten the public with just one case regarding a patient with dental fluorosis. In this way, public attention that such stories would attract could lead to exploitation of the water fluoridation topic.  Law:  A patient contracting a condition where fluoride consumption is a risk factor could sue the water-board/government for unwillingly supplying them with fluorides. Therefore, there could be a vast potential liability in nationalising fluoridated water, and its media coverage may encourage even more to sue.  Ethics:  Some people may not wish to have further chemicals added to their water, as they cannot choose to drink unfluoridated water in a fluoridated community unless they buy bottled (distilled) water, which may be prohibitive for certain social backgrounds.  Necessity:  It is not yet completely certain whether fluorides are necessary to ensure that one can live. Fluorides work to reduce the risk of the formation of dental caries by counteracting some of the detrimental effects of acids and the associated oral microbes brought about from the consumption of carbohydrates. Therefore, it could be argued that some people do not need fluorides, since they do not consume much carbohydrates.  Resources:  Many pieces of equipment and additional resources are needed to carry out the process of water fluoridation. This can be costly, as improper pipework may have to be replaced to avoid health risks regarding overexposure of fluorides, such as fluorosis. All sources for the pros and cons are listed in the bibliography Acids Topics that shall be covered in this section: What are acids? What are the different types of dental decay? Why are acids harmful? The chemistry of acids what makes them acidic? The genetic and lifestyle factors that could alter oral acidity. What is the chemical action and effect of acids on teeth? What are the different types of dental decay? What is the effect of acids on gums and for tooth support?  What are Acids? An acid is a substance that has a pH value lower than 7, with the lowest and therefore the most acidic pH value being 1.[14] An acid is conventionally described as a substance that donates protons (hydrogen ions). The greater the ability of an acid to donate these protons, the stronger the acid.[14] Why are Acids Harmful to the Teeth? Just hours after brushing, oral bacteria, such as streptococcus mutans, form a thin coating over your teeth called plaque.[10] When foods or beverages that contain carbohydrates (for sucrose, fructose and glucose) enter the mouth, the bacteria within the plaque rapidly convert these carbohydrates (sugars) into lactic acid through anaerobic respiration. It is the hydrogen ions contained within this produced compound that acts and reacts as the acid.[11] Moreover, the acid can be kept in contact with the tooth for up to 2 hours due to the plaque coating. This time frame allows the acid to breakdown the components of the enamel (hydroxyapatite) to eventually result in cavities.[40] The most common areas that can accumulate plaque are the molars and premolars, due to their deep depressions.[41] The outermost layer of the tooth is called the enamel. The enamel of the tooth is commonly known to be the hardest in the human body, due to its highly dense mineral structure. The main mineral in enamel is known as hydroxyapatite, which is a calcium phosphate lattice.[42][43] As the bacteria produce more acid, the conditions in the mouth become more acidic, reducing the pH. When the pH is lowered to 5.5, the rate at which the tooth is demineralised is greater than the rate for remineralisation. This results in an overall loss of phosphate and calcium ions from the enamel, which over time would lead to dental cavities.[12] The demineralisation reaction in enamel involving the constituent phosphate and calcium ions: Ca10(PO4)6(OH)2(s)                         + 8H+(aq)    ⇒ 10Ca2+(aq) + 6HPO42-(aq)               + 2H2O(l) hydroxyapatite                               + hydrogen ⇒ calcium     + hydrogen phosphate + water From the equation above, the hydroxyapatite (crystalline calcium phosphate) reacts with the hydrogen ions to dissociate into calcium and hydrogen phosphate ions plus water.[20][42] Therefore, this primary mineral of the enamel has broken down and become absorbed into the saliva. However, once the plaque acid has been diluted and neutralised (mostly due to the saliva) the tooth enamel can then be remineralised, recovering the ions dissolved in the salivary fluid.[44] Throughout the day, your mouth is trying to maintain this continuous balance of demineralisation and remineralisation. Eventually over time, an overall loss of ions from the enamel would lead to tooth decay. Since enamel goes clear in the presence of light, the acids can break it down further to expose the softer and yellower dentine tissue below. The dentine is much more susceptible to acid-erosion, as it is less mineralised – it contains fewer minerals. In this way, fewer reactions need to take place to remove these minerals, so the rate of demineralisation is quicker than that for enamel. Dentine has nerves running through it, whereas enamel does not. Therefore, caries extending to the dentine can cause painful sensations especially when consuming hot or cold substances.[45] 5 things required for remineralisation of tooth enamel[36] The correct minerals (containing Ca2+, PO43- and Fl ions) must be present in one’s saliva. Carbonic acid must then be produced (naturally produced from carbon dioxide and water) and close to the minerals, so it reacts with and dissociate them into their constituent ions. This process must take place near the tooth area affected. The affected demineralised area of hydroxyapatite must be clean and accessible. Complementary shaped ions formed from the minerals can then attract to oppositely charged ions within the hydroxyapatite lattice. Carbonic acid must then reform carbon dioxide and water, which precipitates the complementary ions that were dissolved in it into the area of demineralised enamel. In this way, remineralisation of the tooth enamel has occurred.  What are the Different Types of Dental Decay? Dental decay involves the breakdown and weakening of the tooth structure by oral bacteria. This is normally through acidic conditions in the mouth. However, patients with untreated caries would have a greater risk of cavities continuing to form regardless of acidic conditions. Pit and fissure caries are amongst the most common forms of dental decay.[47] Currently, â€Å"tooth decay is one of the most common disorders†in the world.[46] Pit and Fissure Cari Pits and fissures are typical characteristics of molar and premolar teeth, where the inwardly-folding enamel meet. Fissures are the result of undeveloped grooves, where the two folds of enamel have not fully joined. Therefore, it is in these areas where bacteria can most easily accumulate, increasing the risk of caries forming in these regions. Pits and fissures are also notoriously difficult to clean, so this only propagates the process of dental decay further. The deep grooves, called fissures, occur mainly on teeth at the far back of the mouth. These teeth are known are occlusal teeth, as they are involved in chewing. According to the website, DentalIQ, â€Å"Occlusal surfaces account for 12.5% of all tooth surfaces but will experience over 50% of all decay†.[49] They also state that, â€Å"Pit and fissure caries account for 88% of total caries in children†.[47][49] Pits are different to fissures, as they are only small holes naturally found in the teeth, usually at the points where the fissures themselves meet (in posterior teeth).[48] The reason why there are such a high cases of dental decay associated with these types of tooth surfaces is because the indents in the enamel mean that bacteria can accumulate in the sheltered conditions easily. In this way, if one does not properly clean these surfaces, the bacteria (e.g. streptococcus mutans) can thrive and destroy the nearby enamel. According to a study by the ‘Centres for Disease Control and Prevention’, â€Å"approximately 90% of caries in permanent teeth of children occur in tooth surfaces with pits and fissures†.[50][52] To reduce the risk of dental cavities forming in these pit and fissures regions of the teeth, dentists employ an innovative technique, known as ‘fissure sealing’. This involves filling the pits and fissures with a ‘sealant’, so that they form smooth surfaces that are much easier to remove plaque and food remains. According to the website, DentalIQ, Sealants are 100% effective in preventing pit and fissure caries if they are completely retained†.[49] Therefore, acids may not have as harmful effects on the posterior teeth if these preventative measures are taken. Over time, decay breaks down the enamel. The decay typically favours the breakdown of the enamel rods, which are highly ordered and mineralised basic unit of enamel structure. Therefore, x-rays of decayed teeth generally show a very distinct pattern, since the enamel rods are also of a very specific shape. This pattern can be seen by white markings from x-ray to the left.[63] When the enamel rods have fully decayed, the bacteria and acids then begin to break down the much softer dentine underneath, which would require more intensive dental treatment to be carried out, in the form of root canal surgery. Common Tooth Regions where Caries can Form: Definitions from the eNotes nursing encyclopaedia.[38] Facial:  Outside surface of anterior tooth, adjacent to the face. The term includes buccal (cheek) and labial (lips) areas. Lingual:  Inside surface of tooth, adjacent to the tongue. Occlusal:  Biting surface of posterior tooth. Incisal:  Biting edge of anterior tooth. Mesial:  Proximal surface of tooth closest to the midline. Distal:  Proximal surface of tooth farthest from the midline. What are the Genetic and Lifestyle Factors that could Alter Oral Acidity? Foods and Drinks pH Values[53] Gooseberries              2.8 3.1 Grapes                        3.4 4.5 Raspberries                3.2 3.7 Strawberries              3.0 3.5 Oysters                       4.8 6.3 Golden Delicious        3.6 Lemons                       2.2 2.4 Limes                          1.8 2.0 Sorrel                         3.7 Carrots                                   4.9 5.2 Rhubarb                     3.1 3 Pork                            5.3 6.9 Olives (Green)            3.6 3.8 Coca-Cola                   2.52  The following risk factors for increased oral acidity have been taken from the website, iloveindia.com.[56] Diseases:  Esophagitis or Gastro-Oesophageal Reflux Disease (GERD) can increase oral acidity as the conditions involve acidic juices from the stomach refluxing into the mouth. Salivary Glands:  Decreased secretion of saliva, so the rate of acid neutralisation too decreases. Thus, acids are retained in the mouth for longer periods of time. Foods:  Excess consumption of foods high in acid (e.g. fizzy drinks and sour sweets) can lead to acid reflux, increasing oral acidity. Diets:  Some studies promote following a high carbohydrate diet, which would encourage oral acidity due to its anaerobic breakdown. Eating Intervals:  Eating sweet foods over short intervals is far worse than eating the same amount in one sitting. This is because acidic conditions are continually returning to the mouth, due to the anaerobic metabolisation mechanism of bacteria. Eating Disorders:  Those suffering from bulimia nervosa reflux consumed food, creating extremely acidic conditions in the mouth  What is the Effect of Acids on the Gums and Bone?  Gingivitis: â€Å"Gingivitis is an inflammation of the gums surrounding the teeth†.[54] In its early stages, bacteria begins to accumulate in the plaque around the teeth and gums, usually due to a lack of oral hygiene. This causes an excess of acid to be produced, irritating the gums. Over time, the gums become increasingly irritated and broken down, leading to reddening, or inflammation. It is quite common in these circumstances that the gums would also bleed easily when irritated further, such as when brushing. However, in gingivitis, the damage is solely to the gums, and if treated soon enough, is wholly reversible.[54] when gingivitis is left untreated, it can advance to periodontitis: According to the Medical encyclopaedia of the University of Maryland, â€Å"Periodontitis is the inflammation and infection of the ligaments and bones that support the teeth†.[34] Gingivitis is usually a precursor to periodontitis, as the inflammations in the gums, form pockets between the gums and teeth. Plaque, containing the acid-producing bacteria, can then accumulate and become sealed in these formations due to the further swelling of the surrounding damaged gum line. The bacteria is now in closer proximity to the supporting tissues of the teeth. The acids released by these bacteria then begin to breakdown these tissues and ligaments, weakening the attachment of the tooth to the bone. Abscesses (swollen area containing pus) are also very common in patients with periodontitis, since the pockets of plaque contain bacteria that secrete toxic liquids. These abscesses also increase the rate of bone destruction.[34] Over time, the structure holding the tooth in place is broken down, and loss of the affected tooth is much more likely. In fact, periodontitis is the leading cause of tooth loss in adults.[18]  Evaluation of Project There have been various strengths and weaknesses of some of the conclusions made within this project. Like many scientific analyses, it is very difficult to try and state a causal relationship between certain variables. For example, from figure 4, which demonstrates a link between fluorides and cavities, it is only suggested that there may be a link between them. However, there are many other factors that could also lead to a reduced risk of cavities, so stating that these effects are solely due to fluorides would be considered an invalid conclusion. However, there are many studies that support these links between fluoride exposure and cavity development, so the inclusion of this relationship is not just a means of convenience. Moreover, fluorides have been used in many countries across the globe for many years, and their theoretical effects have been validated and corroborated, increasing the reliability of the administration methods. In turn, many large companies have utilised fluorides within their oral care products, such as toothpastes and mouthwashes. There are also various social and ethical issues surrounding the use of fluorides, especially when concerned with the fluoridation of water. Since fluorides are a derivative of the highly reactive and potentially toxic element, fluorine, there may be quandaries as to whether fluorides are safe for use. This public anxiety has extended to the point of anti-fluoridation societies being created to outlaw the addition of fluorides to the public water supply. This dilemma has been seen particularly in America, where a majority of the population receive fluoridated water. In turn, by producing this report that supports the use of fluorides, some people may protest against it. All these issues are weaknesses of the report that should be considered. However, fluorides have been extensively studied prior to their use in the water supply. When used correctly, they have been found to be of such beneficial to oral health that the BDA (British Dental Association) and the ADA (American Dental Association) both highly recommend them. Many high-powered governments have considered fluorides to be beneficial for oral health, and they even save their citizens money, as they typically have to pay for less dental work, as a result of a reduced risk of developing cavities. The sources used in this investigation can be considered sufficiently reliable and valid. The source, â€Å"Dental caries: a dynamic disease process†, can be considered reliable, as it has been cited by 17 other independent studies.[8] In this way, the information used in this source has been reviewed and accepted by professional scientists. Since, dental caries are relevant to my studies, the information regarding them can also be considered valid for inclusion within this report concerning the effects of fluorides on the risks of developing cavities. Moreover, ‘dentalhealth.org’ states that â€Å"Fluoride can greatly help dental health by strengthening the tooth enamel. The reliability of this information is increased, as it is supported by the source, ‘tips4dentalcare.com’, which states that, The main positive effect of fluoride is increasing durability of tooth enamel. However, some may consider that certain sources are biased, since they are published by organisations that have certain interests in favour of a particular conclusion. For example, the source detailing the advantages of fluorides on oral health by the â€Å"British Dental Health Foundation†, could be biased towards supporting council fluoridation initiatives. However, these organisations are highly respected, and work on behalf of the public, not private, sector. Therefore, issues of outside interests could be considered invalid, and so the information provided and used within this report can be considered valid for use.  Bibliography Greenwood, Norman N.; Earnshaw, A. (1997) Chemistry of the Elements, 2nd ed. Oxford: Butterworth-Heinemann, p. 804. Just Think It. (2008). Fluoride. 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