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ORIGINAL HYPOTHESIS
Year : 2018  |  Volume : 9  |  Issue : 3  |  Page : 68-71

Is Adding TiF4 in Supply Water a Viable Measure for the Control of Dental Erosion?


Department of Restorative Dentistry, Faculty of Dentistry of Araraquara, State University of São Paulo, Araraquara, Brazil

Date of Web Publication31-Oct-2018

Correspondence Address:
Aryvelto M Silva
Department of Restorative Dentistry, Faculty of Dentistry of Araraquara, State University of São Paulo, Rua Humaitá, 1680, Centro, Araraquara CEP 14801-903, SP
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/denthyp.denthyp_31_18

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  Abstract 


Introduction: The prevention of tooth erosion, progressive and irreversible loss of hard dental tissue due to the chemical process without bacterial involvement, can be mediated by the use of fluoride compounds with incorporation of titanium. The Hypothesis: The addition of titanium tetrafluoride (TiF4) to public water supply is an efficient and economical alternative for the management of dental erosion. Evaluation of the Hypothesis: Several studies show that TiF4, in gel or varnish forms, has a significant effect on the prevention of dental erosion, so that the increase of this compound in public water supply would contribute to a greater comprehensiveness of its protective effects on tooth erosion. The addition of TiF4 in public water supply is an effective and economical alternative for the prevention of dental erosion, contributing to a greater comprehensiveness of the protective effects of this compound.

Keywords: Fluorides, titanium, tooth erosion, water supply


How to cite this article:
Silva AM, Castro CL, Manso RW, Zaniboni JF, Andrade MF, Campos EA. Is Adding TiF4 in Supply Water a Viable Measure for the Control of Dental Erosion?. Dent Hypotheses 2018;9:68-71

How to cite this URL:
Silva AM, Castro CL, Manso RW, Zaniboni JF, Andrade MF, Campos EA. Is Adding TiF4 in Supply Water a Viable Measure for the Control of Dental Erosion?. Dent Hypotheses [serial online] 2018 [cited 2018 Dec 16];9:68-71. Available from: http://www.dentalhypotheses.com/text.asp?2018/9/3/68/244701




  Introduction Top


The decline in the prevalence of dental caries in developed and developing countries combined with the increase in the life expectancy of the population has allowed the appearance and detection of dental lesions with independent etiology of bacterial biofilms.[1],[2]

Dental erosion, one of the most prevalent noncarious lesions in the population, is mediated by the corrosive effect of acids on dental structure.[3],[4] Habits related to patients’ lifestyle, such as ingestion of drinks and foods with low pH, intrinsic factors such as gastroesophageal reflux disease, besides the use of medications and occupations that involve frequent exposure to acids are among some conditions that contribute to the occurrence erosion.[5],[6]

Enamel erosion leaves a softened partially demineralized surface that can remineralize by mineral deposition after topical application of fluoride. The protective action of topical fluoride is the precipitation of calcium fluoride (CaF2)-like material on the surface of the eroded tooth. However, one of the major drawbacks of such protective coatings is that they possibly dissolve readily in acid solution; therefore, the effectiveness of such fluoride in preventing erosion of the enamel is limited.[7]

Some studies have shown the efficacy of using titanium tetrafluoride (TiF4) in the form of gel and varnish, initially testing its effects on the management of dental caries. Several topical fluoride effects have been used, however, with limitations.[8] Systematic review of the effects of TiF4 on dental caries concluded that the studies reviewed did not confirm whether there is a benefit of using TiF4 in the management of dental caries.[9] After this study, other in vitro and in situ studies reached similar conclusions that when TiF4 is applied topically to the enamel surface as a varnish or solution, it promotes a reduction in the progression of caries lesions similar to NaF applications, even under severe conditions cariogenic challenges,[1],[4],[6],[10] and the first clinical study reported in the literature, although with only partially published results, suggests that the effects of NaF and TiF4 on caries related to dental caries are similar,[11] suggesting that in the management of caries lesions, supplementation with NaF has protective effects which is described in the literature.

However, in relation to dental erosion, the application of TiF4 in the form of varnish leads to a higher deposition of CaF2—an important compound for the resistance of the tooth against the erosive challenges, in relation to NaF varnish, observed in fact both in intact and demineralized enamel.[12] Hove et al.[4] compared the protective effects of TiF4, SnF2, and NaF on the development of erosion lesions in human enamel. NaF (2.1%) had no significant protective effect. TiF4 (1.5%) and SnF2 (3.9%) reduced the depth of attack by 100% and 91%, respectively, compared to the controls, and both treatments resulted in an amorphous surface layer, results that support the theory that TiF4-based compounds are significantly effective in the management of dental erosion.[3],[4],[12],[13],[14]


  The Hypothesis Top


TiF4 is an inorganic chemical compound formed from the attachment of four fluorine ions to one of titanium. Titanium is a nontoxic element, and its pure metallic form is biologically acceptable.[15] When the TiF4 compound is hydrolyzed, it results in a compound with low pH, with a strong tendency to couple with oxygen atoms of the phosphate group on the surface of the tooth, forming calcium phosphate, property that allows the formation of a resistant surface barrier to erosive challenges.[16]

In addition, TiF4 allows higher absorption and greater penetration of fluoride and lower solubility in acids of the tissues when compared to NaF.[17] In aqueous solution, TiF4 confers surface resistance of the dental surface to acidic challenges, both chemically, by reducing the solubility of the enamel by increasing the fluoride content, and physically, by providing a layer resistant to any penetration of acid.[18]

It is known that the adoption of new habits is a factor impeding the implementation of preventive measures in the long term, because it is proven the difficulty of individuals to include new practices in their routine. In this way, our hypothesis is that the addition of TiF4 in water of public supply would be an effective measure in the prevention of dental erosion, being of low cost and of wide access to the population, besides having adhesion facilitated by not consisting of the adoption of a new habit, because there would be only the inclusion of ion in water for consumption and preparation of food, which is part of the routine of all individuals.


  Evaluation of the Hypothesis Top


The first in vitro study that encouraged further studies on the effect of TiF4 on dental enamel as a preventive agent for tooth erosion was carried out in 1972 with enamel samples. The enamel dissolution, stimulated by acetic acid, was reduced by fluorine treatment, and among these, TiF4 was more effective than the other salts analyzed in relation to the protective effect against progressive enamel demineralization.[19]

Subsequent studies have shown that TiF4 has been able to reduce the solubility of the enamel by two mechanisms: chemically, the agent reduces the solubility of the enamel and increases the fluorine content; physically, it has the formation of a protective layer on the surface of the enamel formed by titanium oxide or titanium phosphate.[20],[21],[22]

It has already been established that TiF4 can reduce enamel demineralization[4],[13],[23] mainly due to its reaction with hydroxyapatite, producing an acid resistant layer. This layer is composed of hydrated titanium phosphate, titanium oxide, and CaF2 and behaves significantly better, conferring greater resistance to acids in the enamel protection than the layer of CaF2 produced by NaF.[4],[24] Even studies carried out with a microcosm biofilm model, which confers a greater aggressive potential than the abiotic model, have proved more effective results of TiF4 against enamel demineralization.[25]

The application of TiF4 in the form of varnish leads to a higher deposition of CaF2, an important compound for the resistance of the tooth against erosive challenges, in relation to NaF varnish, a fact observed in both intact and demineralized enamel[12] results that support the theory that TiF4-based compounds are effective in the management of dental erosion.

Aqueous solution of TiF4 has a highly acid pH—about 1.2, which is considered the main factor causing cytotoxic effects when the solution comes into contact with fibroblasts.[26] Although with a highly acidic pH, TiF4 applications promote low partial demineralization at the same pH of other fluoride compounds, and this is explained by the fact that the titanium ion has a very strong affinity for the oxygen atom when compared to the other commonly associated ions at the F, such as Na and Sn. Furthermore, this high affinity of the titanium ion for oxygen atoms confers a strong tendency toward the formation of titanium phosphate complexes, that is, the reaction of the titanium ions with the phosphate atoms present on the surface of the tooth, so that the binding of this compound is so strong that it is not easily dissolved even at acidic pH. Therefore, the highly acidic pH of TiF4 appears to be a disguised benefit due to the unique property of the titanium ion. And the slight demineralization that occurs is slightly repaired within a few weeks in the oral cavity.[19]

However, this possible cytotoxic effect requires more scientific support to be based on clinical studies, because it has been demonstrated that the cytotoxic effects of TiF4 compounds are not critical,[26] with similar cytotoxicity to NaF compounds, which are already added to the public supply of water in several cities,[24] with significant inhibitory effect on loss enamel mineral, results that support the use of TiF4 compounds in humans.[24],[26]

Salomão et al.,[24] Vieira et al.,[26] and Wang et al.[27] conducted studies to elucidate the ideal concentration of the TiF4 compound that promotes the beneficial effect of reducing mineral loss but also does not cause deleterious effects on health. It was elucidated that 0.1974 g of TiF4 dissolved in 20 ml of water does not produce critical cytotoxic effects and is capable of inhibiting the loss of mineralized dental structure[26]; in addition to that, the 2% concentration promotes a better remineralizing effect than the compound in other concentrations (1% or 4%)[27] and that 2.45% TiF4 has the same cytotoxicity as NaF in the same concentration.[24]

To the best of our knowledge, there are no reports in the literature of adverse effects associated with the use of TiF4 compounds. The literature suggests that a secondary effect associated with supplementation with TiF4 may involve dental fluorosis,[27] but due to its mechanism of action,[17],[18] it is suggested that the development of fluorosis from the use of this compound is minimal in relation to the other fluoride compounds already used.

In some countries, such as Brazil, there are laws that regulate the mandatory fluoridation of public water supply. Therefore, supplementing public drinking water with fluoridated compounds, such as TiF4, has a legal implication that it needs the approval of the respective political authorities. A study carried out in Brazil on the costs related to fluoridation of public water supply with NaF concluded that this value is approximately R $ 0.08 per capita/year, a cost that would be similar to the addition of TiF4, because fluoride compounds have similar costs.[28]

The addition of a chemical compound to public water supply also involves an example of ethical reflection needed in the field of public health. The ethical conflict over the adoption of a comprehensive practice such as public water supply supplementation involves several factors. The first is related to beneficence, so a practice can only be suggested to broad access by the population if it has a plausible justification as a public health measure. Second, it involves the autonomy of individuals that are related to the suggested practice. In this question, the crucial point of the ethical conflict is concentrated, because there is no way to guarantee the autonomy of all individuals who will be subject to a comprehensive measure, such as when it comes to supplementing public water supply, that it would not be necessary to violate the autonomy of individuals if this supplementation is available in other ways, such as in toothpastes, commercialized water, and food. On the other hand, restricting the supplementation of water for the entire population with a beneficial compound restricts the benefit to the most vulnerable groups, who have no regular access to other sources of fluoride compounds.[29]The ethical and moral dilemma of the impact of TiF4 supplementation in public water supply may be a contraposition of the precautionary principle to the principle of prevention. The first concerns the nonuse of a measure in which there is a lack of knowledge about risks or the nonuse of measures that have proven adverse effects.[30] Thus, the scarcity of clinical studies on the effects of TiF4 requires caution on the hypothesis presented. However, when considering the principle of prevention, where a knowledge of a measure with proven beneficial effects in the prevention of a public health problem should be used, the hypothesis is valid, as the reports in the literature are promising about the beneficial effects of TiF4 on the control of dental erosion.


  Conclusion Top


Fluoride compounds have their preventive effects on dental caries and erosion supported in the literature. However, in the handling of dental erosion, fluoride compounds incorporated with metals, such as TiF4, have presented more promising results. Our hypothesis is that the addition of TiF4 in the public water supply can be an effective and economical alternative for the prevention of dental erosion, contributing to a greater comprehensiveness of the protective effects of this compound.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Comar LP, Souza BM, Al-Ahj LP, Martins J, Grizzo LT, Piasentim IS et al. Mechanism of action of TiF 4 on dental enamel surface: SEM/EDX, KOH-Soluble F, and X-ray diffraction analysis. Caries Res 2017;51:554-67.  Back to cited text no. 1
    
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Cassiano LPS, Charone S, Souza JG, Leizico LC, Pessan JP, Magalhães AC et al. Protective effect of whole and fat-free fluoridated milk, applied before or after acid challenge, against tooth erosive loss. Caries Res 2016;50:111-6.  Back to cited text no. 2
    
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Hove L, Young A, Tveit AB. An in vitro study on the effect of TiF4 treatment against erosion by hydrocloric acid on pellicle-covered enamel. Caries Res 2007;41:80-4.  Back to cited text no. 3
    
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Buzalaf MAR, Magalhães AC, Rios D. Prevention of erosive tooth wear: Targeting nutritional and patient-related risks factors. Br Dent J 2018;224:371-8.  Back to cited text no. 5
    
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Ganss C, Schlueter N, Friedrich D, Klimek J. Retention of KOH-soluble fluoride on enamel and dentine under erosive conditions: A comparison of in vitro and in situ results. Arch Oral Biol 2007;52:9-14.  Back to cited text no. 7
    
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Wiegand A, Attin T. Influence of fluoride on the prevention of erosive lesions: A review. Oral Health Prev Dent 2003;1:245-53.  Back to cited text no. 8
    
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Souza BM, Santos DMS, Braga AS, Santos NMD, Rios D, Buzalaf MAR et al. Effect of a titanium tetrafluoride varnish in the prevention and treatment of carious lesions in the permanent teeth of children living in a fluoridated region: Protocol for a randomized controlled trial. JMIR Res Protoc 2018;7:e26.  Back to cited text no. 11
    
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Hove L, Holme B, Ogaard B, Willumsen T, Tveit AB. The protective effect of TiF4, SnF2 and NaF on erosion of enamel by hydrocloric acid in vitro measured with white light interferometry. Caries Res 2006;40:440-3.  Back to cited text no. 12
    
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Castilho ARF, Salomao PMA, Buzalaf MAR, Magalhães AC. Protective effect of experimental mouthrinses containing NaF and TiF4 on dentin erosive loss in vitro. J Appl Oral Sci 2015;23:486-90.  Back to cited text no. 13
    
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Levy FM, Rios D, Buzalaf MAR, Magalhães AC. Efficacy of TiF4 and NaF varnish and solution: A randomized in situ study on enamel erosive-abrasive wear. Clin Oral Investig 2014;18:1097-102.  Back to cited text no. 14
    
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Schlueter N, Ganss C, Mueller U, Klimek J. Effect of titanium tetrafluoride and sodium fluoride on erosion progression in enamel and dentine in vitro. Caries Res 2007;41:141-5.  Back to cited text no. 15
    
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Tveit AB, Hals E, Isrenn R, Totdal B. Highly acid SnF2 and TiF4 solutions. Effect on and chemical reaction with root dentin in vitro. Caries Res 1983;17:412-8.  Back to cited text no. 16
    
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Hals E, Tveit AB, Totdal B, Isrenn R. Effect of NaF, TiF4 and APF solutions on root surfaces in vitro with special reference to uptake of F. Caries Res 1981;15:468-76.  Back to cited text no. 17
    
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Wahengbam P, Tikku AP, Lee WB. Role of titanium tetrafluoride (TiF(4)) in conservative dentistry: A systematic review. J Conserv Dent 2011;14:98-102.  Back to cited text no. 18
[PUBMED]  [Full text]  
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Shrestha BM, Mundorff AS, Bibby BG. Enamel dissolution. I. Effects of various agents and titanium tetrafluoride. J Dent Res 1972;51:1561-6.  Back to cited text no. 19
    
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Souza BM, Fernandes Neto C, Salomão PMA, Vasconcelos LRSM, Andrade FB, Magalhães AC. Analysis of the antimicrobial and anticaries effects of TiF4 varnish under microcosm biofilm formed on enamel. J Appl Oral Sci 2018;26:e20170304.  Back to cited text no. 20
    
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Mantilla TF, Ramos-Oliveira TM, Silva CV, Cersosimo MCP, Turssi CP, Freitas PM. Effects of different concentrations and excipients of titanium tetrafluoride on dentin erosion prevention. Oral Health Prev Dent 2017;15:461-5.  Back to cited text no. 21
    
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Skartveit L, Spak CJ, Tveit AB, Selvig KA. Caries-inhibitory effect of titanium tetrafluoride in rats. Acta Odontol Scand 1991;49:85-8.  Back to cited text no. 22
    
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Moretto MJ, Magalhães AC, Sassaki KT, Delbem ACB, Martinhon CCR. Effect of different fluoride concentrations of experimental dentifrices on enamel erosion and abrasion. Caries Res 2010;44:135-40.  Back to cited text no. 23
    
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Salomão PMA, Oliveira FA, Rodrigues PD, Al-Ahj LP, Gasque KCDS, Jeggle P et al. The cytotoxic effect of TiF4 and NaF on fibroblasts is influenced by the experimental model, fluoride concentration and exposure time. PLoS ONE 2017;12:e0179471.  Back to cited text no. 24
    
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Sen BH, Kazemi RB, Spangberg LSW. Morphological effects on L929 fıbroblasts of titanium tetraflouride application. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:341-6.  Back to cited text no. 25
    
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Vieira TI, Câmara JVF, Cardoso JG, Alexandria AK, Pintor AVB, Villaça JC et al. Cytotoxicity of novel fluoride solutions and their influence on mineral loss from enamel exposed to a Streptococcus mutans biofilm. Arch Oral Biol 2018;91:57-62.  Back to cited text no. 26
    
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Wang P, Gao J, Wang D, Snead ML, Li J, Ruan J. Optimizing concentration of titanium tetrafluoride solution for human dentine remineralization. Arch Oral Biol 2017;83:7-12.  Back to cited text no. 27
    
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Frias AC, Narvai PC, Araújo ME, Zilbovicius C, Antunes JLF. Cost of fluoridating the public water supply: A study case in the city of São Paulo, Brazil, 1985–2003. Cad Saúde Pública 2006;22:1237-46.  Back to cited text no. 28
    
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Introduction
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