Chapter 5: Microelements: Part II: F, Al, Mo and Co.

Ultratrace element is a relatively new term, and is defined as those elements with an established, estimated, or suspected dietary requirement of minute amount, generally of the order of µg/day. This chapter focuses on fluorine (F), aluminium (Al), molybdenum (Mo), and cobalt (Co). Whilst diet is the principal source of Al, Mo, and Co found in the body, inadvertent ingestion of dental hygiene products accounts for a significant proportion of F intake. Apart from F, the influence of other ultratrace elements on oral health, and in particular dental caries, has not been fully established. The calcified tissues contain 99% of body F. During tooth development, ingested (systemic) F is incorporated into the apatite crystals of the developing tooth which helps in improving resistance to acid demineralisation. However, the presence of low but constant levels of topical F in the fluid phase at the tooth enamel surface are more important in controlling tooth decay in people of all ages. An adequate intake, from all dietary and non-dietary sources, is estimated as 0.05 mg/kg body weight/day for children older than 6 months and adults, based on estimated intakes that have been shown to reduce the incidence of dental caries while minimising adverse health effects such as dental fluorosis. An inverse relationship between incidence of dental caries and levels of Al in drinking water, food, and soils has been indicated by some epidemiological studies. Co and Mo, whilst occasionally showing potential beneficial oral health effects in laboratory experiments, do so at concentrations much higher than found in vivo.

Chapter 1: Nutrition and Diet.

Diet and nutrition are fundamental in maintaining the general and oral health of populations. Diet refers to the total amount of food consumed by individuals; whereas nutrition is the process of utilising food for growth, metabolism and repair of tissues. The relationship between diet and nutrition and health is 2-way; health status can be affected by nutrient deficiency and vice versa. Dietary guidelines have been developed to provide evidence-based food and beverage recommendations for populations; aiming to promote a diet that meets the nutrient requirement, and to prevent diet-related diseases such as dental caries and obesity. Based on the amount required by the human body for normal metabolism, growth and physical well-being, nutrients are divided into 2 categories: macronutrients consisting of proteins, carbohydrates and fat; and micronutrients consisting of vitamins and minerals. Fats are the most energy-dense macronutrient; whereas carbohydrates are quantitatively the most important dietary energy source for most populations. Proteins are vital structural and functional components within every cell of the body and are essential for growth and repair and maintenance of health. Vitamins and minerals, which are found in small amounts in most foods, are essential for normal metabolic function. This chapter provides an overview of the impact of nutrients on general and oral health, with an emphasis on macronutrients.

A Comparison of Simple Analytical Methods for Determination of Fluoride in Microlitre-Volume Plasma Samples.

The aim was to compare potential methods for fluoride analysis in microlitre-volume plasma samples containing nano-gram amounts of fluoride. Methods: A group of 4 laboratories analysed a set of standardised biological samples as well as plasma to determine fluoride concentration using 3 methods. In Phase-1, fluoride analysis was carried out using the established hexamethyldisiloxane (HMDS)-diffusion method (1 mL-aliquot/analysis) to obtain preliminary measurement of agreement between the laboratories. In Phase-2, the laboratories analysed the same samples using a micro-diffusion method and known-addition technique with 200 µL-aliquot/analysis. Coefficients of Variation (CVs) and intra-class correlation coefficients (ICCs) were estimated using analysis of variance to evaluate the amount of variation within- and between-laboratories. Based on the results of the Phase-2 analysis, 20 human plasma samples were analysed and compared using the HMDS-diffusion method and known-addition technique in Phase-3. Results: Comparison of Phase-1 results showed no statistically significant difference among the laboratories for the overall data set. The mean between- and within-laboratory CVs and ICCs were < 0.13 and ≥0.99, respectively, indicating very low variability and excellent reliability. In Phase-2, the overall results for between-laboratory variability showed a poor CV (1.16) and ICC (0.44) for the micro-diffusion method, whereas with the known-addition technique the corresponding values were 0.49 and 0.83. Phase-3 results showed no statistically significant difference in fluoride concentrations of the plasma samples measured with HMDS-diffusion method and known- addition technique, with a mean (SE) difference of 0.002 (0.003) µg/mL. In conclusion, the known-addition technique could be a suitable alternative for the measurement of fluoride in plasma with microlitre-volume samples.

Determining an Upper Reference Value for the Urinary Fluoride-Creatinine Ratio in Healthy Children Younger than 7 Years.

The urinary fluoride/creatinine ratio (UF/Cr) in a spot urine sample could be a useful systemic F exposure monitoring tool. No reference value for UF/Cr currently exists, therefore this study aimed to establish an upper reference value for a UF/Cr, corresponding to excessive systemic F exposure, i.e., >0.07 mg F/kg body weight (b.w.)/day, in children. Subsidiary aims were to examine the relationship between (i) total daily F intake (TDFI) and 24-h urinary F excretion (DUFE); (ii) DUFE and UF/Cr, and (iii) TDFI and UF/Cr. Simultaneously collected TDFI, DUFE, and urinary creatinine (UCr) data in children <7 years were taken from UK studies conducted from 2002 to 2014 in order to calculate UF/Cr (mg/g) for each child. For the 158 children (mean age 5.8 years) included in the data analysis, mean TDFI and DUFE were 0.049 (SD 0.033) and 0.016 (SD 0.008) mg/kg b.w./day, respectively, and the mean UF/Cr was 1.21 (SD 0.61) mg/g. Significant (p < 0.001) positive linear correlations were found between TDFI and DUFE, DUFE and UF/Cr, and TDFI and UF/Cr. The estimated upper reference value for UF/Cr was 1.69 mg/g; this was significantly (p = 0.019) higher than the UF/Cr (1.29) associated with optimal F exposure (0.05-0.07 mg/kg b.w./day). In conclusion, the strong positive correlation between TDFI and UF/Cr confirms the strong association of these 2 F exposure variables and the value of a spot urine sample for prediction of TDFI (i.e., the most important risk factor in determining fluorosis occurrence and severity) in young children. Establishing an estimation of an upper reference value of 1.69 mg/g for UF/Cr in spot urine samples could simplify and facilitate their use as a valuable tool in large epidemiological studies.

Development of a Database of the Fluoride Content of Selected Drinks and Foods in the UK.

It is important to monitor systemic fluoride (F) intake from foods, drinks and inadvertent toothpaste ingestion in order to minimise the risk of dental fluorosis while maximising caries prevention. In the UK, an F database containing the F content of commercially available foods and drinks was compiled from 518 products analysed using an acid-diffusion method and F-ion-selective electrode. The individual products analysed ranged from <0.01 µg F/100 g for butter/margarine (miscellaneous foods group) to 1,054.20 µg F/100 g for canned sardines (fish group). These findings, along with the wide range of F contents found within the food groups, highlight the need for comprehensive F content labelling of food and drink products.