Policy on Use of Fluoride

Purpose

The American Academy of Pediatric Dentistry (AAPD) affirms that the use of fluoride in the prevention of caries is safe and effective. The AAPD encourages dentists and dental professionals, other health care providers, public health officials, and parents/caregivers to optimize fluoride exposures to reduce the risk for caries and to enhance the remineralization of affected teeth.

Methods

This document was developed by the Liaison with Other Groups Committee, adopted in 1967¹ , and last revised in 2018². An electronic database search using the terms: fluoride, fluoridation, acidulated phosphate fluoride, fluoride varnish, fluoride therapy, and topical fluoride was conducted to develop and update this policy. The current update relied upon systematic reviews, expert opinions, and best current practices. The use of silver diamine fluoride is addressed in a separate AAPD policy.³

Background

Fluoride acts in three important ways to prevent caries: 1) by strengthening enamel through the creation of fluorapatite, 2) by remineralizing enamel, and 3) by affecting microbial metabolism and reducing acid production by cariogenic bacteria.⁴

Community water fluoridation is recognized as one of the 10 greatest public health achievements of the twentieth century because it is a beneficial and inexpensive population-based approach that can reach the entire community.⁵ By definition, community water fluoridation is the process of adjusting the fluoride in community water supplies to optimal concentration for preventing caries.⁶ Results from a recent systematic review on the economic evaluation of community water fluoridation reveal fluoridation of water is associated with fewer dental treatment costs.⁷ When public water is fluoridated to an optimal level, there is a 35 percent reduction in decayed, missing, and filled primary teeth and 26 percent fewer decayed, missing, and filled permanent teeth.⁸ The occurrence of dental fluorosis, causing dental esthetic concerns, has been reported to be 12 percent when public water contains 0.7 parts per million (ppm) or milligrams per liter (mg/L) fluoride.⁸ When combined with other dietary, oral hygiene, and preventive measures⁶, the use of fluorides can further reduce the incidence of caries.

When a child’s home drinking water supply does not contain fluoride, the caries-preventive benefits of fluoride can be achieved through the intake of daily fluoride supplements according to established guidelines.^6,9-11 Before supplements are prescribed, careful review of all dietary sources of fluoride (e.g., additional sources of drinking water [daycare, school, sports facilities, bottled water], other consumed beverages, prepared foods [including infant formula], toothpaste) will help establish the child’s true exposure to fluoride.^6,12,13 This information, along with the child’s assessed caries risk, can be used to determine a need for fluoride supplementation.

The mean fluoride concentration of ready-to-feed infant formulas in the United States (U.S.) is 0.15 ppm for milkbased formulas and 0.21 ppm for soy-based formulas.¹⁴ The more important issue, however, is the fluoride content of concentrated or powdered infant formula when reconstituted with fluoridated water. The range of fluoride (in ppm) for reconstituted powdered or liquid concentrate when reconstituted with water containing one ppm fluoride is 0.64 to 1.07.14 As communities adjust their municipal water supplies to align with the U.S. Department of Health and Human Services’ 2015 recommendation of 0.7 ppm fluoride¹⁵, the risk of dental fluorosis due to reconstituting infant formula with fluoridated water is decreased.

Significant cariostatic benefits can be achieved by the use of over-the-counter fluoride-containing products such as toothpastes, topically-applied gels, and oral rinses, especially in areas without fluoridated drinking water.^6,16-20 Toothbrushing with appropriate amounts of fluoride toothpaste twice daily is recommended for all children.^10,21 Monitoring children’s use of topical fluoride-containing products, including toothpaste, may prevent ingestion of excessive amounts of fluoride.^21,22 A grain-of-rice-sized amount of fluoridated toothpaste is appropriate for children younger than three years of age, while no more than a pea-sized amount is recommended for children ages three to six years.²² Numerous clinical trials have confirmed the anti-caries effect of professional topical fluoride treatments, including 1.23 percent acidulated phosphate fluoride ([APF]; 1.23 percent fluoride), five percent sodium fluoride varnish ([NaFV]; 2.26 percent fluoride), 0.9 percent difluorosilane varnish ([DFS]); 0.1 percent fluoride), 0.09 percent fluoride mouthrinse, and 0.5 percent fluoride gel/paste.^23-25 For children under the age of six years, five percent NaFV in unit doses (which reduces the potential for harm by limiting fluoride availability) is the only recommended professionallyapplied topical fluoride agent.²⁵

Professional fluoride products are intended for application by, or under the direction of, a licensed dental or medical care provider who is familiar with the child’s oral health status and can determine the need and frequency for application based upon a completed a caries risk assessment.²⁵

Some parents and caregivers are concerned about their child receiving fluoride and may refuse fluoride treatment even though fluoride is safe and effective.²⁶ This is similar to opposition to community water fluoridation.²⁷ Topical fluoride refusal and resistance may be a growing problem and mirror trends seen with vaccination refusal in medicine. Oral health promotion through patient education resources and social media may assist in addressing parental reluctance or misinformation about fluoride.

Policy statement

The AAPD:

• recognizes that drinking fluoridated water and brushing with fluoridated toothpaste twice daily are the most effective methods in reducing dental caries prevalence in children.
• encourages toothbrushing with appropriate amounts of fluoride toothpaste twice daily for all children.
• endorses and encourages the adjustment of fluoride content of public drinking water supplies to an optimal level (0.7 ppm) where feasible.
• encourages professionally-applied fluoride treatments for all individuals at risk for dental caries.
• supports the delegation of topical fluoride application to auxiliary dental personnel or other trained allied health professionals by prescription or order of a dentist after a comprehensive oral examination and caries-risk assessment or by a physician after a dental screening and caries-risk assessment have been performed.
• endorses the use of fluoride supplements according to established American Dental Association⁹ , American Academy of Pediatrics¹⁰, and AAPD¹¹ recommendations when fluoride levels in municipal drinking water are suboptimal and after consideration of sources of dietary fluoride and the caries risk of the child.
• encourages dental providers to talk to parents about the benefits of fluoride and to proactively address fluoride hesitance through chairside education.
• encourages dental team members to seek opportunities to provide evidence-based community education on the safe and economical dental caries-preventive benefits of fluoride through municipal water fluoridation.
• encourages the U.S. Food and Drug Administration to require food and beverage nutrition labels to include fluoride content. In the meantime, AAPD encourages manufacturers of all beverages and infant formula to include fluoride concentration with the nutritional content on food labels.
• encourages dental professionals to inform medical peers of the potential of dental fluorosis when excess fluoride is ingested prior to enamel maturation.
• encourages continued research on safe and effective fluoride products.