IntroductionFluoride is the negatively charged ionic form of the element fluorine that hasa high affinity for calcium. It plays an important role in the prevention ofdental caries.Although the primary mechanism of action of fluoride in preventing dentalcaries is topical, systemic mechanisms are also important. Fluoride acts inthe 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.
Learner ObjectivesUpon 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.
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. 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.
Systemic Sources of FluorideFluoride can be ingested through: Drinking water Other beverages Foods Toothpaste Fluoride supplements
Bottled WaterNo one source exists to tell consumers thefluoride content in bottled waters.The US Food and Drug Administration (FDA)does not require that fluoride content belisted on the labels of bottled waters.It is appropriate to assume that childrenwhose only source of water is bottled arenot receiving adequate amounts of fluoridefrom that source.
Commercial Beverages and FoodsMany 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 highfluoride 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.
ToothpasteToothpaste’s effects are mainly topical, but some toothpaste isswallowed 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.
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.
Fluoride Supplements, continuedCDC 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).
Fluoride Supplements, continuedThe 2010 ADA guideline* recommendsfluoride supplements be prescribedonly to children at high risk forcaries development. Strength ofrecommendation: BThe United States Preventive ServicesTask Force recommends fluoridesupplementation be prescribed atrecommended doses to children olderthan 6 months whose primary watersource is deficient in fluoride. Strength of recommendation: B
Topical Sources of FluorideFollowing are the most commonforms of topical fluoride: Toothpaste Fluoride mouthrinses Fluoride gels Fluoride varnish
ToothpasteToothpaste is the most recognizable source oftopical fluoride.The addition of fluoride to toothpaste beganin the 1950s.Brushing with fluoridated toothpaste is associatedwith a 24% reduction in decayed, missing, and filled tooth surfaces.The CDC concluded that the quality of evidence for fluoridated toothpastein reduction of caries is grade 1. Strength of recommendation is A for usein all persons.
Fluoride MouthrinsesMouthrinses containing fluoride are recommended in a “swish and spit”manner.Mouthrinses are available over the counter. Frequency of use rangesfrom daily to weekly.The CDC concluded that quality of evidence for fluoride mouthrinsesis Grade 1. Strength of recommendation is A with targeted effort atpopulations at high risk for dental caries.
Fluoride GelsFluoride gels are professionally applied or prescribed for homeuse under professional supervision. They are typically recommendedfor use twice per year.The CDC concluded that the quality of evidence for using fluoride gelto prevent and control dental caries in children is Grade 1. Strengthof recommendation is A, with targeted effort at populations at highrisk for caries.
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.
Fluoride VarnishApplication frequency for fluoride varnishranges from 2 to 6 times per year.The use of fluoride varnish leads to a33% reduction in decayed, missing,and filled tooth surfaces in the primaryteeth and a 46% reduction in thepermanent teeth.The CDC concluded that the quality of evidence for using fluoride varnishto prevent and control dental caries in children is Grade 1. Strength ofrecommendation is A, with targeted effort at populations at high risk fordental caries.
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.
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 Waters Fluoride Web site.
Well WaterWide variations in the natural fluorideconcentration of well water sources exist.Private wells should be tested for fluorideconcentration before prescribing supplements.Testing can be done through local and statepublic health departments or throughprivate laboratories.
Fluoride SupplementationWhen access to community water fluoridation is limited, fluoride can besupplemented in liquid, tablet, or lozenge form.Fluoride supplements require a prescription. A 2010 ADA guideline*recommends fluoride supplements be prescribed only to children determinedto be at high risk for the development of caries.
Supplementation Dosing ScheduleThe American Academy of Pediatrics, American Dental Association (ADA),and American Academy of Pediatric Dentistry (AAPD) have developed thefollowing 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.
FluorosisFluorosis is caused by an increasedintake of fluoride.Mild forms of fluorosis appear aschalk-like, lacy markings on thetooth’s enamel.In the moderate form of dentalfluorosis, a white opacity can beseen on more than 50% of the tooth.Severe fluorosis results in brown, pitted, brittle enamel.
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.
Prevalence of FluorosisThe prevalence of dental fluorosis has increased in the United Statesfrom 22.8% in 1986-1987 to 32% in 1999-2002.This can be attributed to the increased availability and ingestion ofmultiple sources of fluoride by young children, including: Foods Beverages Toothpaste Other oral care products Dietary fluoride supplements
Prevalence of Fluorosis, continuedSome 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-oldsMost of this fluorosis is mild and barely noticeable by non-dental healthprofessionals.
Prevalence of Fluorosis, continuedAlthough the effects of dental fluorosisare mainly aesthetic, the increasedprevalence mandates that healthprofessionals be aware of all possiblesources of fluoride beforeconsidering 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.
Fluorosis and ToothpasteAccording to the AAPD, the best way tominimize a childs risk for fluorosis is tolimit the amount of toothpaste on thetoothbrush.The AAPD suggests a “smear” oftoothpaste for children younger than2 years of age and a "pea-sized"amount for children ages 2 to 5.
Fluorosis and ToothpasteFor children younger than 2, the CDC suggests the pediatrician considerfluoride levels in the community drinking water, other sources of fluoride,and factors likely to affect susceptibility to dental caries when weighing therisk and benefits of fluoride toothpaste. The CDC does not give specificadvice 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.
Fluorosis and ToothpasteA 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” amountThe AAP endorses this recommendation.When deciding whether to use fluoridated toothpaste in children younger than2, the panel recommends considering: The childs risk of dental caries The risk of dental fluorosis The benefit of the topical application in the form of fluoridated toothpaste
Question #1What is the most critical age of susceptibility to fluorosis of thepermanent 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.
AnswerWhat is the most critical age of susceptibility to fluorosis of thepermanent 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.
Question #2True or False? The most important mechanism of action of fluorideis a systemic effect.A. True.B. False.
AnswerTrue or False? The most important mechanism of action of fluorideis a systemic effect.A. True.B. False.
Question #3Which of the following is the most important function of fluoride incaries prevention?A. Fluoride enhances remineralization of tooth enamel.B. Fluoride inhibits demineralization of tooth enamel.C. Fluoride negatively affects the acid producing capabilities of cariogenicbacteria.D. Fluoride displaces sugars from the surface of the teeth.E. All of the above are equally important.
AnswerWhich of the following is the most important function of fluoride incaries prevention?A. Fluoride enhances remineralization of tooth enamel.B. Fluoride inhibits demineralization of tooth enamel.C. Fluoride negatively affects the acid producing capabilities of cariogenicbacteria.D. Fluoride displaces sugars from the surface of the teeth.E. All of the above are equally important.
Question #4True or False? Fluoride supplements should be prescribed for high-riskchildren whose community water source is suboptimal.A. TrueB. False
AnswerTrue or False? Fluoride supplements should be prescribed for high-riskchildren whose community water source is suboptimal.A. TrueB. False
Question #5Which 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.
AnswerWhich 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.
References1. 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 appliedtopical 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 RecommendationsRegarding Fluoride Intake from Reconstituted Infant Formula and Enamel Fluorosis. AReport 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 toprevent 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.
References, continued6. Centers for Disease Control and Prevention. Surveillance for Dental caries, Dentalsealants, Tooth Retention, Edentulism, and Enamel Fluorosis-United States, 1988-1994 and 1999-2002. MMWR Surveillance Summaries. 2005. 54(03);1-44. Availableonline at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5403a1.htm. AccessedNovember 20, 2006.7. Centers for Disease Control and Prevention. Using Fluoride to Prevent and ControlTooth Decay in the United States Fact Sheet, updated Jan 2011.www.cdc.gov/fluoridation/fact_sheets/fl_caries.htm8. Department of Health and HumanServices. HHS Recommendation for Fluoride Concentration in Drinking Water forPrevention of Dental Caries. Federal Register. Vol. 76(9): January 13, 2011.9. Krol DM. Dental caries, oral health, and pediatricians. Curr Probl Pediatr AdolescHealth 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 ofdental caries. The Canadian Task Force on the Periodic Health Examination. Can MedAssoc J. 1995; 152(6): 836-46.
References, continued12. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride varnishes for preventingdental caries in children and adolescents. The Cochrane Database of SystematicReviews 2002, Issue 1. Art. No.: CD002279. DOI: 10.1002/14651858.CD002279. Thisversion 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 andadolescents. The Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.:CD002782. DOI: 10.1002/14651858.CD002782. This version first published online: 20January 2003 in Issue 1, 2003.14. Oral health in America: A Report of the Surgeon General. Rockville MD: USDepartment of Health and Human Services, National Institute of Dental andCraniofacial 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 Recommendationson the Prescription of Dietary Fluoride Supplements for Caries Prevention. A Report ofthe American Dental Association Council on Scientific Affairs. JADA. December 2010vol. 141(12): 1480-1489.
References, continued16. US Environmental Protection Agency. 40 CFR Part 141.62. Maximum contaminantlevels for inorganic contaminants. Code of Federal Regulations 2002:428-9.17. US Environmental Protection Agency. 40 CFR Part 143.3 National secondarydrinking water regulations. Code of Federal Regulations 2002; 614.18. United States Preventive Services Task Force. Guide to clinical preventiveservices, 2010-2011. Available online at: http://www.ahrq.gov/clinic/pocketgd.htm.Accessed January 28, 2011.