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.
Click NEXT for Patient Information.