Protecting All Childrens Teeth

Fluorid
e

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Introduction
Used with permission from Lisa Rodriguez

Fluoride plays an important role in the prevention of dental

caries.
The primary mechanism of action of fluoride in preventing
dental caries is topical. Fluoride acts in the following ways
to prevent dental caries:
1. It enhances remineralization of the tooth enamel. This is
the most important effect of fluoride in caries prevention.
2. It inhibits demineralization of the tooth enamel.
3. It makes cariogenic bacteria less able to produce acid
from carbohydrates.

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Learner Objectives
Used with permission from Lisa Rodriguez

Upon completion of this presentation, participants will be able

to:

State the 3 mechanisms of action of fluoride in dental

caries prevention
Summarize the available sources of fluoride and their
relative benefits
List strategies to minimize the development of fluorosis
Discuss the fluoride supplementation guidelines
Recognize the various forms of fluorosis and recall their
prevalence
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Fluoride Facts

Fluoride has been available in the United States since the mid
1940s.

In 2008, 64.3% of the population served by public water

systems
received optimally fluoridated water.

Public water fluoridation practice varies by city and state.

Water fluoridation was recognized by the Centers for Disease

Control and Prevention (CDC) as one of the 10 greatest public
health achievements of the 20th century.

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Fluoride Facts, continued

There is strong evidence* that community water fluoridation is

effective in preventing dental caries.

In

2011, the U.S Dept of Health and Human Services proposed that

community water systems adjust the concentration of fluoride in

drinking water to 0.7 mg/L ppm (change from 0.7-1.2 mg/L).

This proposal has not been finalized.

Water

filters may alter the fluoride content of community water.

Activated charcoal filters and cellulose filters have a negligible effect

Reverse osmosis filters and water distillation remove almost all fluoride
from water

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Sources of Systemic Fluoride

Exposure

Fluoride can be ingested through:

Drinking water (naturally occurring or water system
additive)
Other beverages
Foods
Toothpaste
Fluoride dietary supplements

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Bottled Water

No one source exists to tell consumers the fluoride content

in bottled waters.
The US Food and Drug Administration (FDA) does not require
that fluoride content be listed on the labels of bottled
waters.
It is reasonable to assume that children whose only source of
water is bottled are not receiving optimal amounts of
fluoride from that source.

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Commercial Beverages and Foods

Many foods and beverages are made with community

fluoridated water, so may contain fluoride.
Foods such as seafood and certain teas can also have a
naturally high fluoride content.
This must all be taken into account when determining daily
fluoride intake.

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Infant Nutrition
Human breast milk contains
almost no fluoride, even when
the nursing mother drinks
fluoridated water.

Used with permission from Kathleen Marinelli, MD

Powdered infant formula contains

little or no fluoride, unless mixed
with fluoridated water. The
amount of fluoride ingested will
depend on the volume of
fluoridated water mixed with the
formula.
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Toothpaste
Toothpastes effects are mainly topical, but some toothpaste is
swallowed by children and results in systemic fluoride exposure.
Strategies to Minimize Toothpaste Ingestion
Limit the amount of toothpaste on the
toothbrush
Discourage children from swallowing
toothpaste
Encourage spitting of toothpaste
Supervise brushing until spitting can
be ensured

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Used with permission from Norman Tinanoff, DDS

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Topical Sources of Fluoride

Following are the most common forms of topical
fluoride:

11

Toothpaste
Fluoride mouthrinses
Fluoride gels
Fluoride varnish

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Toothpaste
Toothpaste is the most recognizable source of
topical fluoride.
The addition of fluoride to toothpaste began
in the 1950s.
Used with permission from Rocio B. Quinonez, DMD, MS, MPH;
Associate Professor Department of Pediatric Dentistry, School
of Dentistry University of North Carolina

Brushing with fluoridated toothpaste is associated

with a 24% reduction in decayed, missing, and filled tooth surfaces.
The CDC concluded that the quality of evidence for fluoridated
toothpaste in reduction of caries is grade 1. Strength of
recommendation is A for use in all persons.

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Fluoride Mouthrinses
Mouthrinses containing fluoride are recommended in a swish and
spit manner for children at least age 6.
Mouthrinses are available over the counter.

Daily use of a 0.05% sodium fluoride rinse may benefit children over 6 years
who are at high risk for dental caries
No additional benefit shown beyond daily fluoridated toothpaste use for
children at low risk for caries

The CDC concluded that quality of evidence for fluoride

mouthrinses
is Grade 1. Strength of recommendation is A with targeted effort at
populations at high risk for dental caries.

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Fluoride Gels

Fluoride gels are professionally applied or prescribed for home

use under professional supervision. They are typically
recommended
for use twice per year.
The CDC concluded that the quality of evidence for using fluoride
gel
to prevent and control dental caries in children is Grade 1. Strength
of recommendation is A, with targeted effort at populations at high
risk for caries.

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Fluoride Varnish
Varnish is a professionally applied,
sticky resin of highly concentrated
fluoride (up to 22,600 ppm).

Used with permission from Suzanne Boulter, MD

15

In the United States, fluoride

varnish
has been approved by the FDA for
use as a cavity liner and root
desensitizer, but not specifically as
an anti-caries agent.
For caries prevention, fluoride
varnish is an off label product.

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Fluoride Varnish
Application frequency for fluoride varnish
ranges from 2 to 6 times per year.
The use of fluoride varnish leads to a
33% reduction in decayed, missing,
and filled tooth surfaces in the primary
teeth and a 46% reduction in the
permanent teeth.
Used with permission from Ian VanDinther

The CDC concluded that the quality of evidence for using fluoride
varnish to prevent and control dental caries in children is Grade 1.
Strength of recommendation is A, with targeted effort at populations at
high risk for dental caries.

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Community Water Fluoridation

The goal of community water fluoridation is to maximize dental
caries prevention while minimizing the frequency of enamel
fluorosis.
In January 2011, the US Department of Health and Human
Services
proposed 0.7 ppm be considered the optimal fluoride
concentration
in drinking water.

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Because there is geographic variability in community water

fluoridation, it is important to know fluoride content of the water
children consume.
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Water Fluoridation

The US Environmental Protection

Agency requires that all community
water supply systems provide
customers an annual report on the
quality of water, including fluoride
concentration. Families or providers
can contact the local water authority
for this information.
Used with permission from
iSTOCK

18

Fluoride content of a towns water can also be

determined by
accessing CDCs My Water's Fluoride Web site.
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Well Water

Wide variations in the natural fluoride concentration of well

water sources exist.
Private wells should be tested for fluoride concentration
before prescribing supplements.
Testing can be done through local and state public health
departments or through private laboratories.

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Fluoride Dietary Supplementation

When access to community water fluoridation is limited, fluoride

can be supplemented in liquid, tablet, or lozenge form.
Fluoride supplements require a prescription. A 2010 ADA
guideline* recommends fluoride supplements be prescribed only
to children determined to be at high risk for the development of
caries whose community water source is suboptimal.

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Supplementation Dosing Schedule

The AAP, ADA, and AAPD have developed the following
recommendations regarding fluoride supplementation:
1. All sources of fluoride must be considered, including primary
drinking water, other sources of water, prescriptions from the
dentist, fluoride mouthrinse in school, and fluoride varnish.
2. Supplementation should be provided to high-risk children if fluoride
access is limited.
3. Children younger than 6 months and older than 16 years should
NOT be supplemented.
4. Children who have adequate access to (and are drinking)
appropriately fluoridated community water should not be
supplemented.

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Fluoride Supplements, continued

CDC Quality of Evidence to Support the Use of Fluoride
Supplements
Children 6 years and younger: Grade II-3. Strength of
recommendation of C with targeted effort at populations at high
risk for dental caries.
Children 6-16 years: Grade 1. Strength of recommendation of A
with targeted effort at populations at high risk for dental caries.
Pregnant women: Quality of evidence against providing
fluoride
supplementation to pregnant women to benefit their children is
Grade 1. Strength of recommendation of E (good evidence to
reject the use of the modality).

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Fluoride Supplements, continued

The 2010 ADA guideline* recommends
fluoride supplements be prescribed only
to children at high risk for caries.
Strength of recommendation: B
The United States Preventive Services
Task Force recommends fluoride
supplementation be prescribed at
recommended doses to children older
than 6 months whose primary water
source is deficient in fluoride. Strength of recommendation: B

Used with permission from Content Visionary

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Fluorosis
Fluorosis is caused by an
increased intake of fluoride.

Fluorosis

Mild forms of fluorosis appear as

chalk-like, lacy markings on the
tooths enamel.
In the moderate form of dental
fluorosis, a white opacity can be
seen on more than 50% of the tooth.
Severe fluorosis results in brown,
pitted, brittle enamel.

24

Used with permission from Martha Ann Keels, DDS, PhD; Division Head of
Duke Pediatric Dentistry, Duke Children's Hospital

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Fluorosis
Dental fluorosis occurs during tooth
development.
Permanent teeth are more susceptible to
fluorosis than primary teeth.
Most critical ages of susceptibility are
0 to 6 years, especially between the ages
of 15 and 30 months.

Used with permission from Content Visionary

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After 7 or 8 years of age, dental fluorosis cannot

occur because the permanent teeth are fully
developed, although not erupted.

Prevalence of Fluorosis
The prevalence of dental fluorosis has increased in the United States
from 22.8% in 1986-1987 to 32% in 1999-2002.
This can be attributed to the increased availability and ingestion of
multiple sources of fluoride by young children, including:
Foods
Beverages
Toothpaste
Other oral care products
Dietary fluoride supplements

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Prevalence of Fluorosis, continued

Some form of dental fluorosis is found in the following age
groups*:

40% of US children ages 6-11 years

48% of 12- to 15-year-olds
42% of 16- to 19-year-olds
Most of this fluorosis is mild and barely noticeable by nondental
health professionals.

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Prevalence of Fluorosis, continued

Although the effects of dental fluorosis are mainly

aesthetic, the increased prevalence mandates that
health professionals be aware of all possible
sources of fluoride before considering
supplementation.

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Fluorosis and Toothpaste

Ingestion of toothpaste increases

the risk of enamel fluorosis.
If fluoridated toothpaste is used,
strategies to limit the amount
swallowed include limiting the
amount placed on the brush and
observing the child as they
brush.

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Used with permission from Rocio B. Quinonez, DMD, MS, MPH; Associate Professor
Department of Pediatric Dentistry, School of Dentistry University of North Carolina

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Fluorosis and Toothpaste

According to the AAPD, the best way to

minimize a child's risk for fluorosis is to
limit the amount of toothpaste on the
toothbrush.
The AAPD suggests a smear of
toothpaste for children younger than
2 years of age and a "pea-sized"
amount for children ages 2 to 5.
Used with permission from Michael SanFilippo

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Fluorosis and Toothpaste

For children younger than 2, the CDC suggests the pediatrician
consider fluoride levels in the community drinking water, other
sources of fluoride, and factors likely to affect susceptibility to
dental caries when weighing the risk and benefits of fluoride
toothpaste. For children younger than 6, the CDC recommends that
parents:
1. Limit tooth brushing to 2 times a day.
2. Apply less than a pea-sized amount of toothpaste to the brush.
3. Supervise tooth brushing and encourage children to spit out
excess toothpaste.
4. Keep toothpaste out of the reach of young children to avoid
accidental ingestion.

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Fluorosis and Toothpaste

A 2007 Maternal and Child Health Bureau expert panel
recommended:
All children at high risk for dental caries use fluoride toothpaste
Children younger than age 2 use a smear of fluoride toothpaste
Children aged 2-6 years use a slightly larger, pea-sized amount
The AAP endorses this recommendation.

When deciding whether to use fluoridated toothpaste in children

younger than 2, the panel recommends considering:
The child's risk of dental caries
The risk of dental fluorosis
The benefit of the topical application in the form of fluoridated
toothpaste

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Question #1
What is the most critical age of susceptibility to
fluorosis of
the permanent teeth?
A. Between 0 and 15 months of age
B. Between 15 and 30 months of age
C. Between 30 and 45 months of age
D. The risk of fluorosis in the permanent teeth is equal
across all ages
E. None of the above

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Answer
What is the most critical age of susceptibility to
fluorosis of
the permanent teeth?
A. Between 0 and 15 months of age
B. Between 15 and 30 months of age
C. Between 30 and 45 months of age
D. The risk of fluorosis in the permanent teeth is equal
across all ages
E. None of the above

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Question #2
True or False? The most important mechanism of
action of fluoride is a systemic effect.
A. True
B. False

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Answer
True or False? The most important mechanism of
action of fluoride is a systemic effect.
A. True
B. False

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Question #3
Which of the following is the most important function
of
fluoride in caries prevention?
A. Fluoride enhances remineralization of tooth enamel
B. Fluoride inhibits demineralization of tooth enamel
C. Fluoride negatively affects the acid producing capabilities
of cariogenic bacteria
D. Fluoride displaces sugars from the surface of the teeth
E. All of the above are equally important

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Answer
Which of the following is the most important function
of
fluoride in caries prevention?
A. Fluoride enhances remineralization of tooth enamel.
B. Fluoride inhibits demineralization of tooth enamel.
C. Fluoride negatively affects the acid producing capabilities
of cariogenic bacteria.
D. Fluoride displaces sugars from the surface of the teeth.
E. All of the above are equally important.

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Question #4
True or False? Fluoride supplements should be prescribed for
high-risk children whose community water source is optimal.
A. True
B. False

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Answer
True or False? Fluoride supplements should be prescribed for
high-risk children whose community water source is optimal.
A. True
B. False

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Question #5
Which of the following is a symptom of mild fluorosis?
A. A white opacity on more than 50% of the tooth
B. Dark spots on the teeth
C. Brown, pitted, brittle enamel
D. Chalk-like, lacy markings on the enamel
E. None of the above

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Answer
Which of the following is a symptom of mild fluorosis?
A. A white opacity on more than 50% of the tooth
B. Dark spots on the teeth
C. Brown, pitted, brittle enamel
D. Chalk-like, lacy markings on the enamel
E. None of the above

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References
1. American Academy of Pediatric Dentistry. Guideline on Infant Oral Health
Care. Council on Clinical Affairs. Reference Manual 2011. 33(6): 124-128.
2. American Academy of Pediatric Dentistry. Policy on Early Childhood Caries
(ECC): Classifications, Consequences, and Preventive Strategies. Pediatr Dent
2011, 33(6): 47-49.
3. American Dental Association Council on Scientific Affairs. Professionally
applied topical fluoride. Evidence-based clinical recommendations. JADA.
August 1, 2006. 137(8): 1151-1159.
4. Berg J, Gerweck C, Hujoel PP, et al. Evidence-Based Clinical
Recommendations Regarding Fluoride Intake from Reconstituted Infant
Formula and Enamel Fluorosis. A Report of the American Dental Association
Council on Scientific Affairs. JAMA. January 2011 vol. 142(1): 79-87.
5. Centers for Disease Control and Prevention. Recommendations for using
fluoride to prevent and control dental caries in the United States. MMWR.
2001; 50(RR-14): 1-42. Available online at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm. Accessed
November 20, 2006.

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References, continued
6. Centers for Disease Control and Prevention. Surveillance for Dental caries,
Dental sealants, Tooth Retention, Edentulism, and Enamel Fluorosis-United
States, 1988-1994 and 1999-2002. MMWR Surveillance Summaries. 2005.
54(03);1-44. Available online at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5403a1.htm. Accessed
November 20, 2006.
7. Centers for Disease Control and Prevention. Using Fluoride to Prevent and
Control Tooth Decay in the United States Fact Sheet, updated Jan 2011.
www.cdc.gov/fluoridation/fact_sheets/fl_caries.htm 8. Department of Health
and Human Services. HHS Recommendation for Fluoride Concentration in
Drinking Water for Prevention of Dental Caries. Federal Register. Vol. 76(9):
January 13, 2011.
9. Krol DM. Dental caries, oral health, and pediatricians. Curr Probl Pediatr
Adolesc Health Care. 2003; 33(8):253-270.
10. Lewis CW, Milgrom P. Fluoride. Pediatr Rev. 2003; 24(10):327-336.
11. Lewis DW, Ismail AI. Periodic health examination: 1995 update: 2.
Prevention of dental caries. The Canadian Task Force on the Periodic Health
Examination. Can Med Assoc J. 1995; 152(6): 836-46.

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References, continued
12. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride varnishes for
preventing dental caries in children and adolescents. The Cochrane
Database of Systematic Reviews 2002, Issue 1. Art. No.: CD002279. DOI:
10.1002/14651858.CD002279. This version first published online: 21
January 2002 in Issue 1, 2002.
13. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Topical fluoride
(toothpastes, mouthrinses, gels, or varnishes) for preventing dental caries in
children and adolescents. The Cochrane Database of Systematic Reviews
2003, Issue 1. Art. No.: CD002782. DOI: 10.1002/14651858.CD002782. This
version first published online: 20 January 2003 in Issue 1, 2003.
14. Oral health in America: A Report of the Surgeon General. Rockville MD:
US Department of Health and Human Services, National Institute of Dental
and Craniofacial Research, National Institutes of Health; 2000. Available
online at: http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral. Accessed
November 20, 2006.
15. Rozier RG, Adair S, Graham F, et al. Evidence-Based Clinical
Recommendations on the Prescription of Dietary Fluoride Supplements for
Caries Prevention. A Report of the American Dental Association Council on
Scientific Affairs. JADA. December 2010 vol. 141(12): 1480-1489.

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References, continued
16. US Environmental Protection Agency. 40 CFR Part 141.62. Maximum
contaminant levels for inorganic contaminants. Code of Federal Regulations
2002:428-9.
17. US Environmental Protection Agency. 40 CFR Part 143.3 National
secondary drinking water regulations. Code of Federal Regulations 2002;
614.
18. United States Preventive Services Task Force. Guide to clinical
preventive services, 2010-2011. Available online at:
http://www.ahrq.gov/clinic/pocketgd.htm. Accessed January 28, 2011.

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