Statements On Fluoride 210104

Statements on Fluorides and Fluoridation to Prevent Dental Caries
Prepared by CJH 210104

1. General statements on fluoride use

• The FDI recognises the need for an adequate intake of fluoride to ensure proper growth and
development of all tissues and to minimise, or prevent, dental caries.

FDI Policy Statement on Fluoride and Fluoridation for the Control of Dental Caries, FDI Dental World –
May/June 1993

2. Statements on fluoridation of water supplies to reduce dental caries

• Community water fluoridation is safe and cost-effective and should be introduced
and maintained wherever it is socially acceptable and feasible. The optimum water
fluoride concentration will normally be within the range 0.5-1.0 mg /1.

Fluorides and Oral Health, Report of a WHO Expert Committee on Oral Health Status and Fluoride
Use, WHO, Geneva 1994.

• The FDI recognises and endorses fluoridation of community water supplies as a safe and
effective public health measure to prevent dental caries.

• The FDI endorses fluoridation of reticulated drinking water as a sound public health measure
to reduce the prevalence of dental caries and further, recognises community water fluoridation as
a primary public health measure which is presently the foundation for all other measures and
procedures to prevent dental caries.

• The FDI recommends that where there has been a substantial reduction in the
prevalence of dental caries fluoridation should be continued in order to maintain the caries
reduction.

• The FDI recognises that in some localities in developing countries, natural water supplies may
contain excessive amounts of fluoride and it may be desirable to reduce the fluoride concentration

FDI Policy Statement on Fluoride and Fluoridation for the Control of Dental Caries, FDI Dental World – May/June
1993

• The International Association for Dental Research (IADR), considering that dental
caries (tooth decay) ranks among the most prevalent chronic diseases worldwide; and
recognizing that the consequences of tooth decay include pain, suffering, infection, tooth
loss, and the subsequent need for costly restorative treatment; and taking into account that
over 50 years of research have clearly demonstrated its efficacy and safety; and noting
that numerous national and international health-related organizations endorse fluoridation
of water supplies; fully endorses and strongly recommends the practice of water
fluoridation for improving the oral health of nations.

IADR Policy Statements (adopted 1979, updated 1999)

3. Statements on Salt fluoridation

• Salt fluoridation at a minimum concentration of 200 mg F -/kg, should be considered as a
practical alternative to water fluoridation.

Fluorides and Oral Health, Report of a WHO Expert Committee on Oral Health Status and Fluoride Use,
WHO, Geneva 1994.

• The FDI regards salt fluoridation only as an alternative where water fluoridation is not
possible.

May/June 1993

4. Statements on Milk Fluoridation

• Encouraging results have been reported with milk fluoridation but more studies are
recommended.

Fluorides and Oral Health, Report of a WHO Expert Committee on Oral Health Status and Fluoride Use,
WHO, Geneva 1994.

• The FDI recognises that encouraging results in reduction of dental caries has been
achieved with milk fluoridation. Only a small number of studies have been reported and the
FDI believes that, although the method is promising, further studies are required.

May/June 1993

5. Statements on Fluoride Toothpaste
• Because fluoridated toothpaste is a highly effective means of caries control,
every effort must be made to develop affordable fluoridated toothpastes for use in
developing countries. The use of fluoride toothpastes being a public health measure,
it would be in the interest of countries to exempt them from the duties and taxation
applied to cosmetics.

• Fluoridated-toothpaste tubes should carry advice that, for children under 6 years of
age. brushing should be supervised and only a very small amount (less than 5 mm) should
be placed on the brush or chewing-stick. The caries-preventive effectiveness of
toothpastes with lower levels of fluoride, manufactured especially for use by children,
should be fully studied.
• Fluoridated toothpastes with candy-like flavours and toothpastes containing
fluoride at a concentration of 1500 ppm or more are not recommended for use by
children under 6 years of age.

• The group encourages manufacturers of fluoride toothpastes to provide adequate
technical knowledge and support for local production of effective fluoride
toothpastes in developing countries to achieve maximum availability to the public.

• The group recommends that toothbrushing with effective fluoride toothpastes be
included as an integral component of public health programmes to improve oral health.
Clinical effectiveness of some fluoride-containing toothpastes. A Group of Experts. Bulletin of the
World Health Organization, 1982 60 (4):633-638

• The FDI recognises that use of a toothpaste containing fluoride is an effective measure to
reduce dental caries and endorses the use of fluoride-containing toothpastes.

• The concentration of fluoride in toothpaste as sodium fluoride, sodium monofluorophosphate,
stannous fluoride or amine fluorides, should be regulated by national regulatory authorities.

• Depending an factors which vary geographically and nationally the FDI recognises that a
concentration of available fluoride with between 1000 and 1450 parts per million is safe and
effective fluoride concentration in toothpaste

• The FDI also recognises that the use of other discretionary fluoride, toothpastes and topical
fluoride applications augment the anti-caries effect of systemic fluorides.

1993

6. Statements on Fluoride Supplements
• Fluoride tablets and drops have limited application as a public health measure. In
areas with medium to low caries prevalence a conservative prescribing policy should
be adopted: a dose of 0.5 mg F -/day should be prescribed for individuals at risk
from the age of 3 years. In areas with high caries prevalence, a dosage regimen
should be used, starting at 6 months of age, that takes into account the fluoride
content of the drinking-water.

• Where fluoridation of public water supplied is not possible the FDI recognises that
daily fluoride supplements, administered in drops or tablets, can provide effective
protection from dental caries.
• While the FDI does not endorse the use of pre-natal fluoride supplements it
recognises that, if such supplements are used, they will not harm either mother or
unborn child.

1993

• The International Association for Dental Research (AADR), realizing that dental caries
(tooth decay) ranks among the most prevalent chronic diseases world-wide; and
recognizing that the consequences of tooth decay include pain, infection, tooth loss, the
subsequent need for costly restorative treatment, and absence from work and school;

and recognizing that, while fluoridation of water supplies is the most effective and least
expensive measure to prevent tooth decay, large numbers of people do not currently
have access to the benefits of community fluoridation; and, taking into account that
over 20 years of research have clearly demonstrated the safety and efficacy of dietary
fluoride supplements; now, therefore, 1. Strongly recommends use of dietary fluoride
supplements in areas where optimal fluoridation of water supplies is not available, and, 2.
Urges researchers and health authorities of countries within each IADR Division to
develop and promote dosage schedules for dietary fluoride supplements that are
suitable for their particular area.

IADR Policy Statements

7. Statements on Topical Fluorides

• The FDI recognises that professionally applied topical fluoride is a safe and
effective procedure to reduce dental caries.

• The FDI recognises home use of topical fluorides, prescribed professionally, as a
safe and effective procedure for the prevention of dental caries.

• The FDI recognises that use of fluoride mouth rinses is a safe and effective
method to reduce dental caries and further recognises that fluoride mouth rinses of a
concentration of 230 parts per million should be available for purchase directly by
consumers. Mouth rinses with a higher concentration (900 parts per million) should be
available only under the supervision or prescription of a dentist.
FDI Policy Statement on Fluoride and Fluoridation for the Control of Dental Caries, FDI Dental World
– May/June 1993

8. Other Statements on Fluorides

Many other statements exist relating to the safety of fluoride and use. Statements relating to
research have not been included here.

Recommendations from “Fluorides and Oral Health, Report of a WHO Expert Committee on
Oral Health Status and Fluoride Use, WHO, Geneva 1994.”

1. There is a need to carry out detailed fluoride mapping for existing water sources, as well as
hydrological studies to show flow lines and hydrogeochemical surveys in areas where fluorosis is
endemic. Governments in the affected areas should establish clear guidelines on exploitation of
groundwater so that sinking boreholes in high fluoride zones can be avoided.

2. Countries that have industries that emit fluoride into the atmosphere or have mines of fluoride-rich
minerals should introduce and enforce environmental protection measures.

3. Dietary practices that increase the risks of infants and young children being overexposed to fluoride
from all sources should be identified and appropriate action taken.

4. Dental fluorosis should be monitored periodically to detect increasing or higher-than-acceptable
levels of fluorosis. Action should be taken when fluorosis is found to be excessive by adjusting
fluoride intake from water, salt or other sources. Biomarkers should be used, where practical, to
assess current fluoride exposure to predict further risk of fluorosis.

5. In view of the endemic nature of unsightly dental fluorosis in a number of regions, research on the
development of affordable technology for partial defluoridation in households and communities is
recommended.

6. The effectiveness of all caries-preventive programmes should be regularly monitored.

7. Community water fluoridation is safe and cost-effective and should be introduced and maintained
wherever it is socially acceptable and feasible. The optimum water fluoride concentration will
normally be within the range 0.5-1.0 mg /1.

8. Salt fluoridation at a minimum concentration of 200 mg F- /kg, should be considered as a practical
alternative to water fluoridation.

9. Encouraging results have been reported with milk fluoridation but more studies are recommended.
10. Fluoride tablets and drops have limited application as a public health measure. In areas with medium
to low caries prevalence a conservative prescribing policy should be adopted: a dose of 0.5 mg F- /day
should be prescribed for individuals at risk from the age of 3 years. In areas with high caries
prevalence, a dosage regimen should be used, starting at 6 months of age, that takes into account the
fluoride content of the drinking-water.

11. Only one systemic fluoride measure should be used at any one time.

12. Because fluoridated toothpaste is a highly effective means of caries control, every effort must be
made to develop affordable fluori dated toothpastes for use in developing countries. The use of
fluoride toothpastes being a public health measure, it would be in the interest of countries to exempt
them from the duties and taxation applied to cosmetics.

13. Fluoridated-toothpaste tubes should carry advice that, for children under 6 years of age. brushing
should be supervised and only a very small amount (less than 5 mm) should be placed on the brush or
chewing-stick. The caries-preventive effectiveness of toothpastes with lower levels of fluoride,
manufactured especially for use by children, should be fully studied.

14. Fluoridated toothpastes with candy-like flavours and toothpastes containing fluoride at a concentration
of 1500 ppm or more are not recommended for use by children under 6 years of age.

15. In low-fluoride communities, school-based brushing and mouthrinsing programmes are recommended,
but their adoption should be based on the cost of implementation and the caries status of the
community. Fluoride mouth-rinsing is contraindicated in children under 6 years of age.

16. Further research on the effectiveness of fluoride in preventing, rootsurface caries is recommended.

Press Release WHO/14 - 15 February 1994

WHO ADVOCATES AFFORDABLE FLUORIDE TOOTHPASTES FOR THE DEVELOPING COUNTRIES

Fluoride toothpaste is now the most widely used method of prevention in the world, but its cost remains a deterrent for
many of the world's poorer populations. This was the conclusion reached by a WHO Expert Committee meeting a few
months before this year's World Health Day, on 7 April, which will focus on oral health. Among measures to promote
greater access to these toothpastes, the Committee proposed exemption from duties and taxation, since fluorides are
added for the sake of public health and not for cosmetic purposes.

According to data presented at a recent meeting in Geneva, more than 800 million people throughout the world now
benefit from fluorides, the most common naturally occurring fluorine chemical compounds, as a means of controlling
caries and maintaining oral health. This is mostly achieved through the fluoridation of water for (210 million people), salt
(50 million) or toothpaste (450 million). Ground water in its natural condition almost always contains fluorides, but in
concentrations that vary widely from one place to another.

Fluoride has been known for several decades to be effective against dental caries, and it acts in several different ways.
When present in dental plaque and saliva, it hastens the remineralization of incipient enamel lesions before cavities can
become established. It also interferes with glycolysis, the process by which bacteria metabolize sugars to produce acid.
In higher concentrations, it has a bactericidal effect and when ingested during the period of tooth development,
fluoride is thought to make the enamel more resistant to later acid attacks.

The other side of the story is that high concentrations of fluoride may give rise to fluorosis, with the appearance of
white patches and lines on the teeth. Mild fluorosis cannot be detected by the untrained eye, but may present
unaesthetic forms when it is more severe. The ideal balance must thus be found to ensure the benefit of effective
fluoride protection against caries while avoiding the damaging forms of fluorosis, which the WHO experts nevertheless
regard as acceptable in a mild form.

From the public health standpoint, they advocate as a general rule a strategy of low but regular exposure to fluorides,
while the application of higher concentrations, especially gels, should be reserved for patients particularly vulnerable to
caries.

This goal is described in the report adopted in Geneva as "maintaining a constant, low-level of fluoride in as many mouths
as possible", and when it is attained by adding fluoride to water, salt or toothpaste, the change in incidence of dental
caries in the population in question soon becomes evident. Many scientific studies show that when significant population
exposure to fluoride begins in any community where previously there was little or none, a decline in the incidence of
dental caries in children will become evident within about two years. Incidence among adults will also be reduced,
although the decline will be less evident.

For programmes of prevention to be effective, all sources of fluoride absorbed by individuals in their environment must
be taken into account, so that total intake does not exceed the optimal dose for oral health and health in general. The
experts convened by WHO have stressed that in communities where water fluoridation is not possible, for technical or
financial reasons, fluoridation of salt may be regarded as a suitable alternative. Switzerland is a good example of a
country where this method has resulted in a large reduction in dental caries in children and young people. Another
alternative is fluoridation of milk, a process which has shown promising results in certain community projects undertaken
by WHO.

However, it is the use of fluoride toothpastes that has been subjected to the most rigorous clinical testing. More than
100 trials have shown that brushing the teeth with a fluoride toothpaste will reduce the incidence of dental caries by
about 25% in only 2-3 years and more than twice that figure if used consistently from infancy. In view of the fact that

cost remains a barrier for its widespread use in many developing countries, the experts called for efforts to make
fluoride toothpastes, that are effective in preventing dental caries, affordable for use by underprivileged populations.

They also recommended that water fluoridation should be introduced and maintained whenever possible, since this is a
safe and cost-effective process. They recommended a range of fluoride concentration for water of 0.5 to 1 mg per litre.
Fluoridated salt should contain a minimum concentration of 200 mg per kilo.

This clear stand by the WHO Expert group in favour of fluoridation for the prevention of dental caries comes as a
curtain raiser to 1994, which Dr Hiroshi Nakajima, the Director-General of WHO, has decided to devote to the theme
of oral health. Not only on 7 April, but throughout the year that is now starting, the Member States of the
Organization, the medical profession and the public will be mobilized to give greater attention to this important aspect
of public health.

IADR Policy Statements –

FLUORIDATION OF WATER SUPPLIES

The International Association for Dental Research (IADR), considering that dental caries (tooth decay) ranks among the
most prevalent chronic diseases worldwide;

and recognizing that the consequences of tooth decay include pain, suffering, infection, tooth loss, and the subsequent
need for costly restorative treatment; and

taking into account that over 50 years of research have clearly demonstrated its efficacy and safety; and

noting that numerous national and international health-related organizations endorse fluoridation of water supplies;

fully endorses and strongly recommends the practice of water fluoridation for improving the oral health of nations.

(adopted 1979, updated 1999)

DIETARY FLUORIDE SUPPLEMENTS

The International Association for Dental Research (AADR), realizing that dental caries (tooth decay) ranks among the
most prevalent chronic diseases world-wide; and

Recognizing that the consequences of tooth decay include pain, infection, tooth loss, the subsequent need for costly
restorative treatment, and absence from work and school; and

Recognizing that, while fluoridation of water supplies is the most effective and least expensive measure to prevent
tooth decay, large numbers of people do not currently have access to the benefits of community fluoridation; and

Taking into account that over 20 years of research have clearly demonstrated the safety and efficacy of dietary
fluoride supplements; now, therefore,

1. Strongly recommends use of dietary fluoride supplements in areas where optimal fluoridation of water supplies
is not available, and

2. Urges researchers and health authorities of countries within each IADR Division to develop and promote
dosage schedules for dietary fluoride supplements that are suitable for their particular area.

REFERENCES

Accepted Dental Therapeutics, American Dental Association, 38th ed., 1979, 385 pp.

Committee on Nutrition, American Academy of Pediatrics, Fluoride Supplementation: Revised Dosage Schedule,
Pediatrics, Vol. 63, No. 1, January, 1979

Report of ORCA on Caries-preventive Fluoride Tablet Programs, Caries Res, Vol. 12, Supplement 1, 1978, 112 pp.

IADR, Policy Statement, J Dent Res, Nov. 1979.

AADR, Policy Statement accepted July 10, 1980.

(adopted 1983)

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