Reducing the Risk for Enamel Fluorosis
CDC has developed recommendations to reduce the risk for
enamel fluorosis. The use of fluorides in community water supplies and in other
fluoride products can increase the risk of enamel fluorosis. Community
water fluoridation is a safe, effective and inexpensive way to prevent
tooth decay, and CDC recommends continuing and extending this practice.
Steps can be taken to reduce the risk for enamel fluorosis associated
with drinking water and other fluoride products.
These and other recommendations can be found in
Recommendations for Using Fluoride to Prevent and Control Dental Caries
in the United States. MMWR, August 17, 2001;50
(RR-14):1–42.
Who should be aware of recommendations to reduce the risk for
enamel fluorosis?
Parents and caregivers of children aged 8 or younger, as well as
health care and public health providers, consumer product industries,
and health agencies should know and follow these recommendations.
What can parents and caregivers do to reduce the risk?
Know the Fluoride Concentration in the Primary Source of
Drinking Water
All persons should know whether the fluoride concentration in their
primary source of drinking water is below optimal (less than 0.7 ppm), optimal
(0.7–1.2 ppm), or above
optimal (greater than 1.2 ppm). This knowledge is the basis for all individual and
professional decisions regarding use of other fluoride modalities
(e.g., fluoride toothpaste for children under 2 years of age, mouthrinse or supplements).
It is recommended that parents and caregivers of children,
especially children aged less than 6 years, know the fluoride
concentration in their child's drinking water. For example, in nonfluoridated
areas where the natural fluoride concentration is below optimal,
fluoride supplements might be considered, whereas in areas where the
natural fluoride concentration of more than 2 ppm, children should use
alternative sources of drinking water.
Supervise Use of Fluoride Toothpaste Among Children Aged Less
Than 6 Years
Children's teeth should be cleaned daily from the time the teeth erupt
in the mouth. Parents of children aged less than 6 years old should
brush the child's teeth (recommended particularly for preschool-aged
children) or supervise the toothbrushing. Because many children at
this age have not learned to control the swallowing reflex, parents
should encourage the child to spit excess toothpaste into the
sink to minimize the amount swallowed. See educational materials for
parents,
Brush Up on Healthy
Teeth.
Consult a Dentist or Other Health Care Provider Before Using
Fluoride Toothpaste for Children Less than 2 Years of Age
Parents and caregivers should consult a dentist or other health care
provider before introducing a child younger than 2 years old to fluoride
toothpaste.
Use no More than a Pea-sized Amount of Toothpaste
Parents and caregivers of children younger than 6 years of age who use
fluoride toothpaste should follow the directions on the label and place
no more than a pea-sized amount (0.25 g) of toothpaste on the
toothbrush. Indiscriminate use of toothpaste can result in inadvertent swallowing of
more fluoride than is recommended.
Use an Alternative Source of Water for Children 8 Years of Age or
Younger Whose Primary Drinking Water Contains Greater than 2 ppm Fluoride
In some regions of the United States, community water supply systems
and home wells contain a natural fluoride concentration of more than 2 ppm.
At this concentration, children younger than 8 years of age are at increased risk for
developing enamel fluorosis, including the moderate and severe forms,
and should have an alternative source of drinking water that preferably
contains fluoride at the recommended level.
What can health care and public health professionals do to
reduce the risk of fluorosis?
Counsel Parents and Caregivers Regarding Use of Fluoride Toothpaste
by Young Children, Especially Those Younger than 2 Years of Age
Use of fluoride toothpaste is a cost-effective way to reduce tooth
decay. However, there is an increased risk for enamel fluorosis for
children younger than 6 years of age, especially those younger than 2
years of age, because their
swallowing reflex is not well developed. Parents or caregivers should be
counseled on self-care recommendations for toothpaste use for these young children (i.e.,
limit the child's toothbrushing to not more than 2 times a day, apply a pea-sized
amount to the toothbrush, supervise toothbrushing, and encourage the
child to spit out excess toothpaste). For children younger than 2 years, the
dentist or other health care provider should consider the fluoride level
in the community drinking water, other sources of fluoride, and factors
likely to affect susceptibility to dental caries when weighing the risk
and benefits of using fluoride toothpaste.
Target Mouthrinsing to Children at High Risk for Developing
Tooth Decay
Because fluoride mouthrinse has resulted in only limited reductions in
tooth decay among schoolchildren, especially as their exposure
to other sources of fluoride has increased, its use should be targeted
to individuals and groups at high risk for decay. Children younger than
6 years of age should not use fluoride mouthrinse without consulting a
dentist or other health care provider because there is a risk for enamel fluorosis if such mouthrinses are repeatedly swallowed.
Judiciously Prescribe Fluoride Supplements
Fluoride supplements can be prescribed for children at high risk for
tooth decay and whose primary source of drinking water has a low fluoride
concentration. For children who are younger than 6 years of age, the dentist, physician, or
other health care provider should weigh the risk for developing decay without
fluoride supplements, the benefit of decay prevention offered by supplements,
and the potential for enamel fluorosis. Consideration of the child's
other sources of fluoride, especially drinking water, is essential in
determining this balance. Parents and caregivers should be informed of
both the benefits and the risks. The prescription dosage of fluoride
supplements should be consistent with the
schedule established by
American Dental Association (ADA), American Academy of Pediatric
Dentistry (AAPD), and American Academy of Pediatrics (AAP). Fluoride supplements can be prescribed for persons as
appropriate or used in school-based programs. When practical,
supplements should be prescribed as chewable tablets or lozenges to
maximize the topical effects of fluoride.
What can consumer product industries and health agencies do to
reduce the risk of fluorosis?
Label the Fluoride Concentration of Bottled Water
Producers of bottled water are encouraged to label the fluoride concentration of
their products. Such labeling will allow consumers to make informed
decisions and dentists, dental hygienists, and other health care
professionals to appropriately advise patients regarding fluoride intake
and use of their fluoride products.
Promote Use of Small Amounts of Fluoride Toothpaste Among
Children Younger Than 6 Years of Age
Labels and advertisements for fluoride toothpaste should promote use
of a pea-sized amount (0.25 g) of toothpaste on a child-sized
toothbrush for children younger than 6 years of age. Efforts to educate
parents and caregivers and to encourage supervised use of fluoride
toothpaste among young children can reduce swallowing of
excess toothpaste. See
Brush Up on Healthy Teeth.
Develop a Low-Fluoride Toothpaste for Children Younger Than 6
Years of Age
Manufacturers are encouraged to develop a dentifrice for children
younger than 6 years of age that is effective in preventing dental caries but
reduces
the risk for enamel fluorosis. A "child-strength" toothpaste with a
fluoride concentration lower than products currently available in the
United States could reduce the
risk for cosmetic concerns associated with swallowing of
toothpaste.
Collaborate to Educate Health Care Professionals and the Public
Professional health care organizations, public health agencies, and
suppliers of oral care products should collaborate to educate
health care professionals and the public regarding the
recommendations in this report. Broad collaborative efforts to educate
health care professionals and the public and to encourage behavior
change can promote improved, coordinated use of all types of fluoride
products.
Date last reviewed: October 8, 2008
Date last modified: August 9, 2007
Content source:
Division of Oral Health, National Center for Chronic Disease Prevention and
Health Promotion |