Proof of the caries-prevention power of fluoride has been available for years. Fluoride supplements are routinely given to children whose fluoride intake is deemed below the recommended level of 0.05 to 0.07 mg/kg body weight or whose risk for caries is high.1 The use of fluoride supplements in the form of drops, tablets, or lozenges began before the introduction of fluoride toothpaste and used to be an important source of fluoride exposure. Today, in the United States, where fluoride exposure is abundant, the further need for systemic fluoride supplementation should be questioned.
SOURCES OF FLUORIDE
The biggest sources of fluoride exposure are water and toothpaste, but other sources include mouth rinses, fluoride-coated dental floss, infant formula, and fluoride gels and varnishes applied at the dentist's office. The current supplementation recommendations are based on whether the child is drinking optimally fluoridated water, but they do not take into account other sources of exposure. Predicting actual fluoride exposure is very difficult because one cannot tell exactly how much toothpaste a child swallows, how much fluoridated water or beverages a child drinks, or how much fluoride is in food prepared with fluoridated water that the child eats. In addition, because of genetic variability, the same amount of exposure can have different outcomes in different children.2
RISKS OF OVEREXPOSURE
The biggest risk from fluoride ingestion in the United States is the development of dental fluorosis, which is a hypomineralization of the enamel that results from overexposure to fluoride during tooth development. Tooth enamel is susceptible to fluorosis up to the age of 8 years. After that, fluorosis is no longer a concern.3 The most susceptible age is 15 to 24 months for boys and 21 to 30 months for girls.3 The severity of fluorosis depends on the timing, amount, and duration of exposure, and the effects range from opaque, white patches or streaks on teeth to brown discoloration.
The prevalence of dental fluorosis has been rising in recent years, and the amount of fluoride ingested by children needed to be reexamined. On January 7, 2011, the US Department of Health and Human Services (HHS) along with the US Environmental Protection Agency (EPA) proposed a change in the recommended fluoride concentration in public water supplies. The proposed recommended concentration is 0.7 mg/L, which is the lowest amount of the previously recommended range of 0.7 to 1.2 mg/L.4 Currently, there is more danger of overexposure than underexposure, so the use of fluoride supplements should be kept to a minimum.
RESEARCH
In a recent systematic review commissioned by the American Dental Association Council on Scientific Affairs, a team of scientists looked at studies performed on the efficacy and dangers of fluoride supplements. Their overall conclusion was that the risk of fluorosis from supplement use should not be dismissed and accepted as inevitable. Used correctly, topical fluorides can provide the same caries-preventative benefits without significant systemic exposure and with no chance of causing fluorosis.5
PATIENT EDUCATION
PAs should use their patient education skills to inform parents about the danger of unnecessary fluoride overexposure. Educate them on proper tooth-brushing techniques, correct toothpaste amounts, and use of fluoride toothpaste as important caries-preventative methods. JAAPA
Yekaterina Manyoky is a student in the PA program at the University of Toledo, College of Medicine, in Toledo, Ohio. Brian Fink is an assistant professor and epidemiologist at the University of Toledo Health Science Campus. The authors have indicated no relationships to disclose relating to the content of this article.
Mary L. Hewett, PA-C, MS, department editor
REFERENCES
1. Warren JJ, Levy SM, Broffitt B, et al. Considerations on optimal fluoride intake using dental fluorosis and dental caries outcomes—a longitudinal study. J Public Health Dent. 2009;69(2):111-115.
2. Verkerk RH. The paradox of overlapping micronutrient risks and benefits obligates risk/benefit analysis. Toxicology. 2010;278(1):27-38.
3. Centers for Disease Control and Prevention. Recommendations for Using Fluoride to Prevent and Control Caries in the United States. CDC Web site. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm. Published August 17, 2001. Updated August 22, 2001. Accessed December 6, 2011.
4. US Department of Health and Human Services. News Release. HHS and EPA Announce New Scientific Assessments and Actions on Fluoride. HHS Web site. http://www.hhs.gov/news/press/2011pres/01/20110107a.html. Published January 7, 2011. Accessed December 6, 2011.
5. Ismail AI, Hasson H. Fluoride supplements, dental caries
and fluorosis: a systematic review. J Am Dent Assoc. 2008;
139(11):1457-1468.
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Patient Information
Does my child need fluoride supplements?
Fluoride is a mineral found in the earth's crust and is typically present in water. The amount of fluoride in the water varies with the location. Some communities have a large amount of fluoride in the water, and some have a very small amount. The US government issues recommendations on the amount of fluoride in the water that will allow more people to benefit safely from it.
WHAT IS GOOD ABOUT
FLUORIDE?
Fluoride has been proven to prevent or slow down the development of cavities. The United States and many other countries decided to put fluoride in the community water in order to protect teeth from decay. Fluoride supplements were developed for those people living in communities without fluoridated water. By using supplements, those people could still get the benefits of fluoride and protect their teeth. Later, fluoride toothpastes came on the market and cavity rates decreased even further. Eventually, even more fluoride-containing products became available. These ranged from fluoride mouth rinses to fluoride varnishes applied to the teeth by the dentist.
WHAT IS BAD ABOUT
FLUORIDE?
At the beginning, adding fluoride to the water dramatically decreased rates of dental cavities. However, as more and more fluoride-containing products came on the market, concern arose over getting too much fluoride. Swallowing too much fluoride while teeth are developing can cause them to have permanent white or brown spots or streaks, a condition called dental fluorosis. In the United States, dental fluorosis is mostly mild, with just white spots or streaks on the tooth surface. However, getting dental fluorosis is unnecessary and does not have to happen if care is taken to prevent exposure to too much fluoride during tooth development.
HOW CAN I PROTECT MY CHILD'S TEETH?
During infancy, breastfeed or use bottled water (without added fluoride) to prepare the baby's formula. Use fluoride-free toothpaste for the first year to get children used to brushing their teeth, and try to teach them not to swallow the toothpaste. Then, when children are old enough, you can switch to fluoride-containing toothpaste. The most important thing is supervision. Do not let your children brush their teeth by themselves until you are absolutely sure that they will not swallow the toothpaste. They need to spit out the toothpaste and rinse the mouth thoroughly.
Another important point is to use only a pea-sized amount of toothpaste and rub it into the bristles so that it does not fall off in clumps inside the mouth. Putting the toothpaste across the brush rather than along the brush is one way to measure out a pea-sized amount. Promote toothbrushing twice per day and make sure that the appropriate amount of time is spent actually brushing the teeth and not just playing and pretending to brush. Do not use fluoride supplements unless your doctor is absolutely sure that your child is at a great risk for cavities.
BOTTOM LINE
Overall, fluoride is good. It has been proven to decrease and prevent cavities. However, too much fluoride during tooth development can cause permanent white spots and streaks on the teeth. Supervised toothbrushing is one way you can limit your child's exposure to fluoride. JAAPA