Children’s Oral Health & the
Primary Care Provider
Fluoride Therapies
Module 4
Module 4 Objectives:
 Discuss fluoride mechanism of action
 Discuss available fluoride therapies:
 Fluoride in Water
 Fluoride in Toothpaste
 Fluoride Supplements
 Fluoride varnish
Fluoride Mechanism of Action:
Main Effect
 Fluoride (F) enhances remineralization of
early lesions & inhibits demineralization of
intact tooth structure (topical effect)
 Fluoride also inhibits caries by affecting
the activity of cariogenic bacteria
Centers for Disease Control
and Prevention
 The main effect of fluoride is a topical,
localized and direct one on erupted or
erupting teeth
 “…frequent exposure to small amounts of
fluoride each day will best reduce the risk for
dental caries in all age groups…”
Available Fluoride Therapies
Fluoride in Water
 Decline in severity & prevalence of caries in
2nd half of 20th century; due in part to water
fluoridation
 Fluoridation is endorsed by Centers for Disease
Control and Prevention
 CDC lists community water fluoridation as one
of 10 great public health achievements of the
20th century
Fluoride in Water
 Ideal public health measure
 No health hazards
 Provides low-dose (1 ppm) fluoride topically
on a nearly continuous or high frequency basis
for those consuming it alone, or in foods or
beverages made with fluoridated water
 Very effective, safe, convenient & equitable
 Very low-cost & excellent cost/benefit ratio
Fluoride in Water
 Fluoride occurs naturally in the water of some
geographic locations; especially in Iowa
 The optimal fluoride level in drinking water is
0.7 – 1.2 parts per million; an amount proven
beneficial in reducing tooth decay
 Naturally occurring fluoride may be below or
above these levels in some areas
 93% of Iowa’s community water systems are
optimally fluoridated
Populations Receiving Fluoridated
Water in US: 2006
 69% of US population received optimally
fluoridated water in 2006
 Increase from 66% in 1992
 Range: 8.4% (Hawaii) to 100% (D.C.)
 2010 objective: 75% of US to have access
to fluoridated water
 Underutilized public health measure
What is the Fluoride Content in my Water?
http://apps.nccd.cdc.gov/MWF/index.asp
The Controversy About Infant
Formula & Fluoride in Water
 Bottled water is usually low in fluoride.
 disclosure of F content required only if F added
 Powdered or liquid concentrate infant formula
contains fluoride.
 manufactured from fluoridated community water
supply
 If formula is reconstituted with fluoridated water,
infants could theoretically consume more than
the recommended daily fluoride intake.
The Controversy About Infant
Formula & Fluoride in Water
To reduce the risk of mild fluorosis the CDC & the
ADA recommend:
 Use of ready-to-feed formula to help ensure infants
do not exceed the optimal daily fluoride intake
 If concentrate or powdered formula is primary
source of nutrition, it can be mixed with water that
is fluoride free or contains low levels of fluoride to
reduce the risk of excessive fluoride intake.
Fluoride Supplements
 Fluoride supplements are intended to
compensate for fluoride-deficient drinking water
 Dosage schedule requires knowledge of the
fluoride content of the child's primary drinking
water & other sources of fluoridated water
 Evidence for using fluoride supplements to
mitigate dental caries is mixed
Fluoride Supplements
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm
Fluoride Supplements:
Special Considerations
 Fluoride supplement should be considered for
children who are classified as high risk for
caries & live in areas with non-fluoridated
water.
 “Halo effect” – indirect benefit of fluoridated
water to nonfluoridated communities
 Families who are compliant with supplements
are often not the ones that need them
Dietary Sources of Fluoride
 Examples of products containing fluoride:
 Soft drinks & juice – approximate drinking water
levels
• Grape juice – high fluoride content
 Tea – high fluoride content
 Chicken products – high fluoride content
 Fish products
 Seafood
Fluoride Supplements & Fluorosis
Very Mild
Moderate
Severe
Fluorosis in Primary Teeth
 Less common & less severe than permanent




tooth fluorosis
Related to water fluoride levels
Associated with fluorosis in permanent teeth
Primarily a postnatal etiology
More common in primary molars; enamel not
formed at birth
 Primary incisor enamel
already formed at birth
2nd Baby Molar
Fluoride Toothpaste
 Provides moderate-dose (1000 ppm) fluoride
topically; 2-3 times per day
 Very effective, readily available & low cost
 Requires active use (people must brush their
teeth to receive benefit)
 Fluoride in toothpaste is taken up directly by
dental plaque & demineralized enamel
Fluoride Toothpaste
 Ingestion is a concern in younger children
 Amount dispensed is a key factor
smear
½ pea-sized
pea-sized
Recommended Amount of Fluoridated Toothpaste by Age
Fluoride Dentifrices for
Dental Caries Prevention
 While fluoride dentifrice
Melberg, JR. Int Dent J 1991; 41: 9-16
concentrations of 1000 ppm
are effective in caries
prevention, there is a doseresponse relationship, so
that (to some extent)
greater fluoride
concentrations result in
greater caries prevention
High Fluoride Toothpaste
 Provides higher-dose (up to 5000 ppm)
fluoride topically once or twice per day
 Somewhat more effective than conventional
toothpaste
 Requires active use (people must brush their
teeth to receive benefit)
 Prescription only & more costly
High Fluoride Toothpaste
 Recommended for high-caries risk individuals > 6
years of age
 Used 1-2 times daily like regular tooth paste
 About $12 per small (1.8 oz) tube
 Not indicated for children < 6 years due to ingestion
Fluoride Mouth Rinses
 Provides moderate-dose (226 ppm) fluoride
topically on a daily (or more frequent) basis
 Effective, available OTC & moderate cost
 Alcohol-free mouth rinse
 Requires active use (people must remember
to rinse daily)
 Not recommended for younger children who
can’t rinse & spit
Professionally Applied
Fluoride Gels and Foams
 Provides high-dose (12,300 ppm)
fluoride topically
 Under dentists’ control
 Requires dental visit
 Contraindicated in younger
children
 ingestion concerns
 trays are difficult to cope with
Professionally Applied
Fluoride Varnishes
 Provides high-dose (22,600 ppm) fluoride topically
 Under providers’ control
 Currently an “off-label” use
 Over 30 years of clinical study
 More effective than professional gels
 Majority of studies report 25-45% caries reduction
Fluoride Varnish:
Practical Advantages
 No need to be in a dental office for application
 Locally retained for several hours; varnish may release
fluoride for weeks
 Increase caries-inhibition properties by holding fluoride close
to tooth surface for longer duration
 Potential ingestion of fluoride is low, especially when
compared to gels/foams
 Teeth don’t need professional cleaning (prophylaxis)
 Prevents caries on smooth & pit and fissure sites
Summary Table of
Available Fluoride Therapies
FlToothpaste
High FlToothpaste
Fl- Mouth
Rinse
Gels and
Foams
Fl- Varnish
Moderate
(1000ppm)
High
(5000ppm)
Moderate
(226ppm)
High
(12,300ppm
)
Very High
(22,600ppm
)
Requires
Compliance



OTC



Dose
Prescription


Professional
Applied
Contraindicate
d for younger
children
No, if in
small
amounts



How Much Fluoride is too Much?
 Probable toxic dose of fluoride = 5mg F/kg
 7kg child (15.4 pounds)
 7kg child needs to ingest 35 mg of fluoride to be
toxic (nausea, abdominal pain, vomiting, diarrhea)
 A single dose of .25 mL of fluoride varnish
contains 5.65 mg fluoride
 An adult dose of .50 mL of fluoride varnish
contains 11.3 mg fluoride
 Acute lethal dose = 15–35mg F/kg
Summary: Fluoride Therapies
Module 4
 Fluoride enhances remineralization of early lesions &
inhibits demineralization of intact tooth structure
 Fluoride inhibits caries by affecting the activity of
cariogenic bacteria
 The main effect of fluoride is topical
 Community water fluoridation is a safe, effective &
inexpensive way to prevent caries
 Bottled water is generally low in fluoride
Summary: Fluoride Therapies
Module 4
 To reduce risk of fluorosis, the use of lower fluoride
water to reconstitute infant formula is recommended
 Distillation or reverse osmosis removes all fluoride
from water
 Carbon or charcoal filters do not remove fluoride
 “Halo effect” – indirect benefit of fluoridated water to
nonfluoridated communities
Summary: Fluoride Therapies
Module 4
 Fluoride toothpaste is very effective, readily available
& low cost
 Ingestion of fluoride toothpaste is a concern in
younger children
 Amount dispensed is a key factor
 High fluoride toothpaste is recommended for highcaries risk people
 Not indicated for children < 6 years due to ingestion
 Fluoride varnish provides high-dose fluoride topically
 Fluoride varnish is very effective in caries prevention
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2.
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5.
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7.
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Populations Receiving Optimally Fluoridated Public Drinking
Water --- United States, 1992—2006 MMWR July 11, 2008 /
57(27);737-741