1. Protecting All Children’s Teeth
Fluoride

2. Introduction
Fluoride is the negatively charged ionic form of the element fluorine that has
a high affinity for calcium. It plays an important role in the prevention of
dental caries.
Although the primary mechanism of action of fluoride in preventing dental
caries is topical, systemic mechanisms are also important. 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.

3. Learner Objectives
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.

4. Fluoride Facts
 Fluoride has been available in the United States since the mid-1940’s.
 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.

5. Fluoride Facts, continued
 There is strong evidence* that community water fluoridation is
effective in preventing dental caries.
 The recommended concentration of fluoride in drinking water
was decreased in 2011 from 0.7-1.2 mg/L to 0.7 mg/L.
 Clinicians should balance the benefits of fluoride against the risk
of fluorosis when deciding whether to fluoridate water.
 Water filters may decrease 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.

6. Systemic Sources of Fluoride
Fluoride can be ingested through:
 Drinking water
 Other beverages
 Foods
 Toothpaste
 Fluoride supplements

7. 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 appropriate to assume that children
whose only source of water is bottled are
not receiving adequate amounts of fluoride
from that source.

8. Commercial Beverages and Foods
Many foods and beverages are made with community fluoridated water,
so they 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.

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

10. Toothpaste
Toothpaste’s effects are mainly topical, but some toothpaste is
swallowed by children and is available systemically.
Strategies to Minimize Toothpaste Ingestion
 Discourage children from swallowing
toothpaste.
 Encourage spitting of toothpaste.
 Supervise brushing until spitting can
be ensured.
 Limit the amount of toothpaste on the
toothbrush.

11. Fluoride Supplements
Supplements should be considered
especially for patients at high risk for
dental caries whose community water
source is suboptimal.
Supplements are available in liquid,
tablet, or lozenge form.

12. 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).

13. Fluoride Supplements, continued
The 2010 ADA guideline* recommends
fluoride supplements be prescribed
only to children at high risk for
caries development. 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

14. Topical Sources of Fluoride
Following are the most common
forms of topical fluoride:
 Toothpaste
 Fluoride mouthrinses
 Fluoride gels
 Fluoride varnish

15. Toothpaste
Toothpaste is the most recognizable source of
topical fluoride.
The addition of fluoride to toothpaste began
in the 1950s.
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.

16. Fluoride Mouthrinses
Mouthrinses containing fluoride are recommended in a “swish and spit”
manner.
Mouthrinses are available over the counter. Frequency of use ranges
from daily to weekly.
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.

17. 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.

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

19. 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.
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.

20. 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 announced
that the optimal fluoride concentration
is 0.7 ppm.
Because there is geographic variability in community water fluoridation,
it is important to know fluoride content of the water children consume.

21. 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. Providers can
contact the local water authority for
this information.
Fluoride content of a town’s water can also be determined by
accessing CDC’s My Water's Fluoride Web site.

22. 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.

23. Fluoride 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.

24. Supplementation Dosing Schedule
The American Academy of Pediatrics, American Dental Association (ADA),
and American Academy of Pediatric Dentistry (AAPD) have developed the
following dosing schedule for 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 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.

25. Fluorosis
Fluorosis is caused by an increased
intake of fluoride.
Mild forms of fluorosis appear as
chalk-like, lacy markings on the
tooth’s 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.

26. Fluorosis
Dental fluorosis occurs during tooth development.
Permanent teeth are more susceptible to
fluorosis than primary teeth.
The most critical ages of susceptibility are
0 to 6 years, especially between the ages
of 15 and 30 months.
After 7 or 8 years of age, dental fluorosis cannot
occur because the permanent teeth are fully
developed, although not erupted.

27. 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

28. Prevalence of Fluorosis, continued
Some form of dental fluorosis is found in the following age groups*:
 40% of US children ages 6-11 years
 49% of 12- to 15-year-olds
 42% of 16- to 19-year-olds
Most of this fluorosis is mild and barely noticeable by non-dental health
professionals.

29. 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.

30. 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.

31. 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.

32. 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. The CDC does not give specific
advice on how much toothpaste to use in children younger than 2.
For children younger than 6, the CDC recommends that parents:
1. Limit toothbrushing to 2 times a day.
2. Apply less than a pea-sized amount to the toothbrush.
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.

33. 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 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

34. 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.

35. 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.

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

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

38. 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.

39. 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.

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

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

42. 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.

43. 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.

44. 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.

45. References, continued
6. Centers for Disease Control and Prevention. Surveillance for Dental caries, Dental
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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.htm8. Department of Health and Human
Services. HHS Recommendation for Fluoride Concentration in Drinking Water for
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46. References, continued
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47. References, continued
16. US Environmental Protection Agency. 40 CFR Part 141.62. Maximum contaminant
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