fluoride supplementation

Filling in Parents About Fluoride

JANE E. HOLT, DO and LINDA S. NIELD, MD—Series Editor
West Virginia University

Dr Holt is assistant professor of pediatrics at Harpers Ferry Family Medicine Center, Robert C. Byrd Health Sciences Center at West Virginia University in Harpers Ferry, WV.

LINDA S. NIELD, MD—Series Editor: Dr Nield is associate professor of pediatrics at West Virginia University School of Medicine in Morgantown.


Does my baby need to take fluoride? My baby care book says “yes,” but my friends have received different advice. One friend’s dentist prescribed it, while another friend’s pediatrician said it could be harmful. What’s the real story?


If a child does not have adequate exposure to fluoride, supplements should be prescribed. Parents should be made aware of fluoride’s role in preventing dental decay and promoting good oral health. Dental decay is the most common chronic disease in children aged 6 to 11 years and in adolescents. According to the CDC, dental decay is 4 times more prevalent than asthma in children aged 14 to 17 years.1 The CDC reports that from 1994 to 2004, 42% of children aged 2 to 11 years had caries in their primary teeth and 59% of adolescents had decay in their permanent teeth.1

The importance of fluoride. Dental decay is caused by caries-producing bacteria that exist in a hospitable oral environment. Fluoride, which can be administered topically or systemically, creates a less hospitable environment for these bacteria, thereby making teeth less vulnerable to decay. Remineralization of demineralized areas is promoted, and bacterial metabolism is slowed.2

Benefits of public water fluoridation. After studies in the 1930s and 1940s documented the benefits of fluoridation of public water supply systems for the prevention of dental decay, attempts were made to expose large portions of the US population to fluoride. The first public water supply system to be fluoridated was Grand Rapids, Michigan, in 1945. Since then, fluoridation programs have been employed across the country.

Optimal water fluoridation has reduced dental caries by about 60% over the past 50 years.3 Long-term use of fluoride has reduced the oral health costs of children by 50%, providing a substantial savings of health care dollars.3 The CDC proclaims public water fluoridation as one of the top 10 greatest public health achievements of the 20th century.4

When to consider fluoride supplementation. Despite efforts to adequately fluoridate public water supplies, some children do not have access to fluoridated water for various reasons. Patients whose water comes from private wells (which may contain some fluoride) and those who live in areas without publicly fluoridated water are at risk for dental decay and may need fluoride supplementation.

How to determine which patients need fluoride. Because of the risk of exposure to too much fluoride, it is important to determine which patients need supplementation. The American Dental Association recommendations state that clinicians need to account for all potential sources of fluoride and, if deficient, supplementation should be provided for those at highest risk for dental caries.3 To determine who is at high risk, the American Academy of Pediatric Dentistry (AAPD) provides a caries risk assessment tool on their web site at www.aapd.org.5

Patients at highest risk are those whose primary caregivers have active dental caries and low socioeconomic status. Children who consume more than 3 sugary snacks and beverages per day are considered high risk, as well as infants who are put to bed with bottles that contain liquids with natural or added sugars. Existing clinical disease also places patients at high risk for caries.5

fluoride supplementation in childrenPotential sources of fluoride. For the parent and clinician to determine the amount of fluoride to which a child is exposed, all potential sources of fluoride must be taken into consideration, starting with the water supply. According to the Department of Health and Human Services, the optimal fluoride concentration in water is 0.7 parts per million.6

Public water systems across the country have varying concentrations of fluoride. Parents and clinicians can find the amount in a particular public water source by visiting “My Water’s Fluoride” at the CDC web site or by contacting their local water utility.7

Private well water can contain naturally occurring fluoride, and a sample of the water should be sent to state or local health departments for testing to determine the exact amount.

Bottled water may or may not be fluoridated, and consumers can contact the bottler for fluoride concentrations if these are not listed on the label.

Breast milk does not contain fluoride even if the mother is consuming fluoridated water. Powdered or concentrated infant formulas do not contain fluoride; however, the water that reconstitutes the formula may contain fluoride.

After all sources of fluoride exposure are considered, and if the amount is deemed insufficient, fluoride should be prescribed on a case-by-case basis. Following the recommendations of the AAPD, clinicians can determine the amount of oral or topical supplements needed on the basis of the concentration of fluoride in the patient’s water supply.

What about fluorosis? When fluoride is used appropriately and judiciously, the child is at minimal risk for fluorosis. Fluorosis, caused by chronic excessive fluoride exposure, most commonly manifests as staining and disturbance of tooth enamel; however, it could also cause musculoskeletal pain.8 Parents who are resistant to giving their child fluoride must weigh the minimal long-term risk of fluorosis (mainly cosmetic) versus the long-term risks of severe dental decay (ie, pain and serious or potentially life-threatening infectious complications).9

To minimize the risk of fluorosis in children at high risk for dental caries, fluoride supplements and fluoride-containing products must be used with care. Parents should be advised to apply only a “smear” of fluoridated toothpaste, about the size of a grain of rice (E. Shulman, oral communication, October 2011), to the toothbrush before brushing for children younger than 2 years and a pea-size amount for children aged 2 to 5 years.2

Fluoride varnish should be considered for children at risk for caries in addition to fluoride supplements. Proper application by a dental or medical professional minimizes the risk of fluorosis.

Acknowledgment: The authors would like to thank Dr Elliot Shulman for his expert review of this work. Dr Shulman is an associate professor of pediatric dentistry at West Virginia University School of Medicine in Morgantown.