2. 2 www.aap.org/oralhealth/pact
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
3. 3 www.aap.org/oralhealth/pact
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
4. 4 www.aap.org/oralhealth/pact
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. 5 www.aap.org/oralhealth/pact
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
6. 6 www.aap.org/oralhealth/pact
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
7. 7 www.aap.org/oralhealth/pact
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.
8. 8 www.aap.org/oralhealth/pact
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.
9. 9 www.aap.org/oralhealth/pact
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
10. 10 www.aap.org/oralhealth/pact
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
11. 11 www.aap.org/oralhealth/pact
Topical Sources of Fluoride
Following are the most common forms of topical fluoride:
Toothpaste
Fluoride mouthrinses
Fluoride gels
Fluoride varnish
12. 12 www.aap.org/oralhealth/pact
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
13. 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
15. 15 www.aap.org/oralhealth/pact
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.
16. 16 www.aap.org/oralhealth/pact
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.
17. 17 www.aap.org/oralhealth/pact
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. 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
19. 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
20. 20 www.aap.org/oralhealth/pact
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.
21. 21 www.aap.org/oralhealth/pact
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
22. 22 www.aap.org/oralhealth/pact
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. 23 www.aap.org/oralhealth/pact
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. 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.
25. 25 www.aap.org/oralhealth/pact
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. 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.
27. 27 www.aap.org/oralhealth/pact
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. 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
29. 29 www.aap.org/oralhealth/pact
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
30. 30 www.aap.org/oralhealth/pact
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.
31. 31 www.aap.org/oralhealth/pact
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.
32. 32 www.aap.org/oralhealth/pact
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
33. 33 www.aap.org/oralhealth/pact
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 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
34. 34 www.aap.org/oralhealth/pact
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.
35. 35 www.aap.org/oralhealth/pact
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
36. 36 www.aap.org/oralhealth/pact
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
39. 39 www.aap.org/oralhealth/pact
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
40. 40 www.aap.org/oralhealth/pact
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.
43. 43 www.aap.org/oralhealth/pact
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
44. 44 www.aap.org/oralhealth/pact
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
45. 45 www.aap.org/oralhealth/pact
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.
46. 46 www.aap.org/oralhealth/pact
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.
47. 47 www.aap.org/oralhealth/pact
References, continued
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.
48. 48 www.aap.org/oralhealth/pact
References, continued
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.
Editor's Notes
Notes:
In the human body, fluoride is mainly associated with bones and teeth.
A mineral structure of the tooth that includes fluoride (fluorapatite) is more resistant to demineralization than one without fluoride (hydroxyapatite).
See http://www.aap.org/oralhealth/pact/ch4_intro.cfm for a complete review of the pathogenesis of dental caries.
Notes:
Optimally fluoridated water is defined as 0.7 parts per million.
To learn about the water fluoridation for a particular city, access http://apps.nccd.cdc.gov/MWF/Index.asp.
More information about fluoride recommendations is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm.
Notes:
*Evidence has been presented by the CDC, the US Task Force on Community Preventive Services, and the Canadian Task Force on Preventive Health Care.
For more information, access the US Preventive Services Task Force Prevention of Dental Caries in Preschool Children Web page at http://www.uspreventiveservicestaskforce.org/uspstf/uspsdnch.htm.
Reference for community water fluoride proposed recommendation: Federal Register. Vol. 76, No. 9. January 13, 2011. pg 2386.
Links:
US Task Force on Community Preventive Services: http://www.uspreventiveservicestaskforce.org/uspstf/uspsdnch.htm
Canadian Task Force on Preventive Health Care: http://www.canadiantaskforce.ca
Notes:
A recent review by the Cochrane Collaboration concluded that regular use of fluoridated toothpaste is associated with a “clear reduction in caries increment.”
The review also found that the effect may be greater for persons with more severe decay.
Related Links:
CDC Grading System: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm#box1
CDC Coding System: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm#box2
Quality of Evidence Table: http://www.uspreventiveservicestaskforce.org/3rduspstf/ratings.htm
Notes:
A recent review by the Cochrane Collaboration concluded that regular use of fluoridated toothpaste is associated with a “clear reduction in caries increment.”
The review also found that the effect may be greater for persons with more severe decay.
Related Links:
CDC Grading System: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm#box1
CDC Coding System: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm#box2
Quality of Evidence Table: http://www.uspreventiveservicestaskforce.org/3rduspstf/ratings.htm
USPSTF Quality of Evidence Grading System used by the CDC:
Grade I - Evidence obtained from one or more properly conducted randomized clinical trials
Grade II-1 - Evidence obtained from one or more clinical trials without randomization
Grade II-3 - Evidence obtained from one or more well-designed cohort or case-control analytic studies
Grade II-4 - Evidence obtained from cross-sectional comparisons between times and places; or dramatic results in uncontrolled experiments
Grade III – Opinions of respected authorities on the basis of clinical experience, descriptive studies or case reports, or reports of expert committees.
The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms).
A—Strongly Recommended: The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.
B—Recommended: The USPSTF recommends that clinicians provide [the service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.
C—No Recommendation: The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D—Not Recommended: The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.
I—Insufficient Evidence to Make a Recommendation: The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
American Dental Association Council on Scientific Affairs. Fluoride Toothpaste for Young Children. J Am Dent Assoc. 2014;145(2):190-1.
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.
American Academy of Pediatric Dentistry. Guideline on Fluoride Therapy. Updated 2014. Reference Manual 36(6): 171-74.
Notes:
According to the Cochrane Collaboration, regular fluoride mouthrinse use reduces tooth decay in children, regardless of other fluoride sources, with an average 26% reduction in decayed, missing, and filled tooth surfaces.
Fluoride mouthrinse programs are sometimes utilized in schools.
Related Links:
CDC Grading System: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm#box1
CDC Coding System: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm#box2
Quality of Evidence Table: http://www.uspreventiveservicestaskforce.org/3rduspstf/ratings.htm
Reference: Twetman S, Petersson LG, Axelsson S, et al. Caries preventive effect of sodium fluoride mouthrinses: A systematic review of controlled clinical trials. Acta Odontol Scand 2004;62:233-230
Quality of Evidence Table: http://www.uspreventiveservicestaskforce.org/3rduspstf/ratings.htm
USPSTF Quality of Evidence Grading System used by the CDC:
Grade I - Evidence obtained from one or more properly conducted randomized clinical trials
Grade II-1 - Evidence obtained from one or more clinical trials without randomization
Grade II-3 - Evidence obtained from one or more well-designed cohort or case-control analytic studies
Grade II-4 - Evidence obtained from cross-sectional comparisons between times and places; or dramatic results in uncontrolled experiments
Grade III – Opinions of respected authorities on the basis of clinical experience, descriptive studies or case reports, or reports of expert committees.
The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms).
A—Strongly Recommended: The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.
B—Recommended: The USPSTF recommends that clinicians provide [the service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.
C—No Recommendation: The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D—Not Recommended: The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.
I—Insufficient Evidence to Make a Recommendation: The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
Notes:
The Cochrane Collaboration concluded that there is a clear evidence of a caries-inhibiting effect of fluoride gels, with an average 21% reduction in decayed, missing, and filled tooth surfaces.Related Links:
CDC Grading System: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm#box1
CDC Coding System: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm#box2
Quality of Evidence Table: http://www.uspreventiveservicestaskforce.org/3rduspstf/ratings.htm
Quality of Evidence Table: http://www.uspreventiveservicestaskforce.org/3rduspstf/ratings.htm
USPSTF Quality of Evidence Grading System used by the CDC:
Grade I - Evidence obtained from one or more properly conducted randomized clinical trials
Grade II-1 - Evidence obtained from one or more clinical trials without randomization
Grade II-3 - Evidence obtained from one or more well-designed cohort or case-control analytic studies
Grade II-4 - Evidence obtained from cross-sectional comparisons between times and places; or dramatic results in uncontrolled experiments
Grade III – Opinions of respected authorities on the basis of clinical experience, descriptive studies or case reports, or reports of expert committees.
The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms).
A—Strongly Recommended: The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.
B—Recommended: The USPSTF recommends that clinicians provide [the service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.
C—No Recommendation: The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D—Not Recommended: The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.
I—Insufficient Evidence to Make a Recommendation: The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
Notes:
Varnishes have been used extensively in Europe, Scandinavia, and Canada as preventive intervention for dental caries. Related Links:
CDC Grading System: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm#box1
CDC Coding System: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm#box2
Quality of Evidence Table: http://www.uspreventiveservicestaskforce.org/3rduspstf/ratings.htm
Related Videos:
Smiles for Life Application of Fluoride Varnish Video - http://products.talariainc.com/default.aspx?tut=555&pagekey=62948&s1=1193586
Illinois AAP Chapter Bright Smiles from Birth Video - http://illinoisaap.org/2010/08/bright-smiles-from-birth-training-video/
Notes:
Almost all state Medicaid programs have decided to pay medical professionals for the application of fluoride varnish to children’s teeth. Private payers are also beginning to pay for this service. Learn more at http://www2.aap.org/commpeds/dochs/oralhealth/State.html.
The Cochrane Collaboration concluded that fluoride varnishes applied professionally 2 to 4 times a year substantially reduces tooth decay in children.\
Related Links:
CDC Grading System: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm#box1
CDC Coding System: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm#box2
Quality of Evidence Table: http://www.uspreventiveservicestaskforce.org/3rduspstf/ratings.htm
Related Videos:
Applying Fluoride Varnish Video: http://www.aap.org/oralhealth/links-training-oralexamvideo.cfm#varnish
Pediatric Well-Child Visit: Oral Health Exam Video: http://www.aap.org/oralhealth/links-training-oralexamvideo.cfm#exam
Quality of Evidence Table: http://www.uspreventiveservicestaskforce.org/3rduspstf/ratings.htm
USPSTF Quality of Evidence Grading System used by the CDC:
Grade I - Evidence obtained from one or more properly conducted randomized clinical trials
Grade II-1 - Evidence obtained from one or more clinical trials without randomization
Grade II-3 - Evidence obtained from one or more well-designed cohort or case-control analytic studies
Grade II-4 - Evidence obtained from cross-sectional comparisons between times and places; or dramatic results in uncontrolled experiments
Grade III – Opinions of respected authorities on the basis of clinical experience, descriptive studies or case reports, or reports of expert committees.
The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms).
A—Strongly Recommended: The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.
B—Recommended: The USPSTF recommends that clinicians provide [the service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.
C—No Recommendation: The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D—Not Recommended: The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.
I—Insufficient Evidence to Make a Recommendation: The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
A grade “B” recommendation by USPSTF means that there is “high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial and that practices must offer or recommend this service”. Preventive services given A or B recommendations by the USPSTF must be covered by new and individual insurance plans of all types and by Medicaid and Medicaid-Managed care with no cost sharing.
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
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.
Notes:The HHS press release is available online at http://www.hhs.gov/news/press/2011pres/01/20110107a.html.
Visit the Campaign for Dental Health for more information about water fluoridation – www.ilikemyteeth.org.
Glossary:
Fluorosis: An abnormal condition (as mottled enamel of human teeth) caused by fluorine or its compounds
Notes:Learn more about the fluoridation status of your community’s water system at http://apps.nccd.cdc.gov/MWF/Index.asp.
Notes:
*For more information on the recommendations and decision from the ADA, see Evidence-Based Clinical Recommendations on the Prescription of Dietary Fluoride Supplements for Caries Prevention at http://jada.ada.org/cgi/content/full/141/12/1480.
Notes: American Academy of Pediatrics (AAP), American Dental Association (ADA), and American Academy of Pediatric Dentistry (AAPD)
The AAP/ADA/AAPD dosing schedule is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm#tab1.
Related Links:
CDC recommendations: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm
CDC Grading System: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm#box1
CDC Coding System: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm#box2
Quality of Evidence Table: http://www.uspreventiveservicestaskforce.org/3rduspstf/ratings.htm
Notes:
*Access the American Dental Association guideline at http://jada.ada.org/cgi/content/full/141/12/1480 and the chair side tool at http://ebd.ada.org/ClinicalRecommendations.aspx.
For more about the United States Preventive Services Task Force, visit http://www.ahrq.gov/clinic/uspstf/uspsdnch.htm.
The United States Preventive Services Taskforce (USPSTF) and the American Academy of Pediatrics (AAP) recommend primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for ALL children whose water supply is deficient in fluoride, not a risk-based assessment.
Dietary fluoride supplementation by prescription for children at high caries risk who do not have access to optimally fluoridated water is recommended by the American Academy of Pediatric Dentistry and the American Dental Association (ADA).
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
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. http://pediatrics.aappublications.org/content/134/3/626
Notes:
Dental (enamel) fluorosis is the most common manifestation, but skeletal fluorosis can also occur. Although extremely rare in the United States, skeletal fluorosis is seen in other countries, especially India and China.
Mild forms of fluorosis are difficult to see with the untrained eye.
Glossary:
Fluorosis: An abnormal condition (as mottled enamel of human teeth) caused by fluorine or its compounds
Notes:
Dental fluorosis is less prevalent and less severe in the primary teeth than the permanent dentition.
Source:
Notes:* From Surveillance for Dental caries, Dental sealants, Tooth Retention, Edentulism, and Enamel Fluorosis-United States, 1988-1994 and 1999-2002, available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5403a1.htm.
Beltrán-Aguilar ED, Barker L, Dye BA. Prevalence and severity of dental fluorosis in the United States, 1999-2004. NCHS data brief, no 53. Hyattsville, MD: National Center for Health Statistics. 2010
Notes:Review the AAPD recommendations at http://www.aapd.org/media/Policies_Guidelines/G_CariesRiskAssessment.pdf.
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. http://pediatrics.aappublications.org/content/134/3/626
Notes:Review the CDC recommendations at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm.