Fluoride - AAP

1 www.aap.org/oralhealth/pact
Protecting All Children’s Teeth
Fluoride

Introduction
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.
Used with permission from Lisa Rodriguez

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
Used with permission from Lisa Rodriguez

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.

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

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

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.

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.

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.Used with permission from Kathleen Marinelli, MD

Toothpaste
Toothpaste’s 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
Used with permission from Norman Tinanoff, DDS

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

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

Toothpaste Guidelines
The American Dental Association (ADA), American Academy of
Pediatric Dentistry (AAPD), and the American Academy of Pediatrics
(AAP) have all published the following recommendations:
•Suggest a “smear” or “grain of rice” amount of toothpaste starting at
tooth emergence for all children.
•For children ages 3 to 6, recommend a “pea-sized” amount of
fluoridated toothpaste.
Toothpaste recommendations are no longer “risk-based”.
http://www.aap.org/oralhealth/pact13

14
“Smear”
“Pea-sized”
Toothpaste Amounts

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.

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.

Fluoride Varnish
Varnish is 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.
Used with permission from Suzanne Boulter, MD

18
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.
Used with permission from Ian VanDinther

Fluoride Varnish
The United States Preventive Services Taskforce (USPSTF) in
2014 recommended that primary care clinicians apply fluoride
varnish to the teeth of all infants and children, starting with the
appearance of the first primary tooth through age 5, at least every 6
months.
• Recommendation applies to ALL children; no longer a risk-based
recommendation
• Assigned a “B” grade recommendation
AAP recommends that all children ages 5 and under should receive
a professional fluoride treatment at least every 6 months in the
primary care medical home.
Higher risk children should receive fluoride varnish applicationhttp://www.aap.org/oralhealth/pact19

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.
Because there is geographic variability in community water
fluoridation, it is important to know fluoride content of the water
children consume.

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.
Fluoride content of a town’s water can also be determined by
accessing CDC’s My Water's Fluoride Web site.
Used with permission from iSTOCK

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.

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. Fluoride supplements
should be prescribed only to children
whose community water source has
Suboptimal fluoride levels. Used with permission from Content Visionary

24
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. Children who have adequate access to (and are drinking)
appropriately fluoridated community water should NOT be
supplemented.
3. Children younger than 6 months and older than 16 years should
NOT be supplemented.

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).

26
Fluoride Supplements, continued
The American Dental Association (ADA) and the American Academy
of Pediatric Dentistry (AAPD) recommend fluoride supplements be
prescribed only to children at high risk for caries.
• Strength of recommendation: B
The United States Preventive Services Task Force (USPSTF) in
2014 recommended fluoride supplementation be prescribed to ALL
children older than 6 months whose primary water source is deficient
in fluoride.
• Strength of recommendation: B.
• The AAP endorses the USPSTF recommendation to prescribe
fluoride supplements to all children ages 6 months to 16 years
who drink sub-optimally fluoridated water.

Fluorosis
Fluorosis is caused by an increased
intake of fluoride during permanent
tooth formation.
Mild forms of fluorosis appear as
chalk-like, lacy markings on the
enamel.
White opacity can be seen on more
than 50% of the tooth in the
moderate form of dental fluorosis.
Severe fluorosis results in brown,
pitted, brittle enamel.
Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke
Pediatric Dentistry, Duke Children's Hospital
Fluorosis

28
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.
After 7 or 8 years of age, dental fluorosis
cannot occur because the permanent teeth
are fully developed, although not erupted.
Used with permission from Content Visionary

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

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 non-dental
health professionals.

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.

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

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 AAP suggests a “smear” of
toothpaste for children younger than
3 years of age and a "pea-sized"
amount for children ages 3 and above.
Used with permission from Michael SanFilippo

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.

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

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

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

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

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

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.

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

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

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

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

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.
3. American Academy of Pediatric Dentistry. Guideline on Fluoride Therapy. Updated
2014. Reference Manual 36(6): 171-74.
4. American Dental Association Council on Scientific Affairs. Professionally applied
topical fluoride. Evidence-based clinical recommendations. JADA. August 1, 2006.
137(8): 1151-1159.
5. American Dental Association Council on Scientific Affairs. Fluoride Toothpaste for
Young Children. J Am Dent Assoc. 2014;145(2):190-1.
6. 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.

References, continued
7. 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.
8. 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.
9. 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
10. 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.
11. Krol DM. Dental caries, oral health, and pediatricians. Curr Probl Pediatr Adolesc
Health Care. 2003; 33(8):253-270.
12. Lewis CW, Milgrom P. Fluoride. Pediatr Rev. 2003; 24(10):327-336.

13. 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.
14. 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.
15. 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.
16. 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.
17. 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.

18. US Environmental Protection Agency. 40 CFR Part 141.62. Maximum contaminant
levels for inorganic contaminants. Code of Federal Regulations 2002:428-9.
19. US Environmental Protection Agency. 40 CFR Part 143.3 National secondary
drinking water regulations. Code of Federal Regulations 2002; 614.
20. 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.
21. Wright JT, Hanson N, Ristic H, et al. Fluoride toothpaste efficacy and safety in
children younger than 6 years. J Am Dent Assoc. 2014; 145(2):182-9.
22. U.S. Preventive Services Task Force Recommendation Statement. Prevention of
Dental Caries in Children from Birth Through Age 5 Years. May 2014.
www.uspreventiveservicestaskforce.org/uspstf/uspsdnch.htm
23. Clark MB, Slayton RL; AAP Section on Oral Health. Fluoride use in caries
prevention in the primary care setting. Pediatrics. 2014 Sep;134(3):626-33.

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