Prevent Caries With Fluoride
Dental caries remains a public health concern. In the United States, it is the most common chronic disease of childhood.
Public Health Concerns
Dental caries remains a public health concern. In the United States, it is the most common chronic disease of childhood. Globally, untreated caries in primary teeth is the 10th most common chronic condition in children, impacting 621 million individuals. Data from the US National Health and Nutrition Examination Survey 2011-2012 revealed that 23% of children between the ages of 2 and 5 and 56% of children between the ages of 6 and 8 experienced dental caries in a primary tooth. Among permanent dentition, 21% of children between the ages of 6 and 11 experienced dental caries. Of those children, 6% had untreated dental caries. The data also revealed that race and ethnicity play a role in dental caries prevalence among children between the ages of 2 and 8. For example, Hispanic (46%), and non-Hispanic black children (44%) had more reported dental caries than non-Hispanic white children (31%).
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Fluoride Sources
Fluoride is found in community water sources, foods, toothpastes, mouthrinses, and professional products. Roughly, 72% of the US population has fluoridated water. Current drinking water recommendations are 0.7 mg of fluoride/liter (mg/L) to prevent dental caries. This concentration provides a balance of reducing dental caries while minimizing the risk of dental fluorosis. Children who reside in communities with fluoridated tap water have less tooth decay than children who reside in nonfluoridated communities. The consumption of fluoridated water reduces dental caries in about 25% of children and adults.
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Oral Health Products
Manufactured sources of fluoride include toothpaste, mouthrinse, professionally applied products, and supplements. The CDC does not recommend that children younger than 2 use fluoride toothpaste unless prescribed by an oral health or medical professional. However, the ADA suggests that children’s deciduous teeth be brushed twice per day with a tiny smear of fluoride toothpaste as soon as they erupt. The ADA also recommends children age 3 and younger use no more than a smear or grain-of-rice-size amount of fluoride toothpaste. Children ages 3 to 6 should use no more than a pea-size amount of fluoride toothpaste during toothbrushing. Regardless of age, young children should be directly supervised while toothbrushing to minimize the risk of ingestion. Fluoride mouthrinses can be effective in caries prevention for children ages 6 to 18. A systematic review determined that the use of a prescription-strength mouthrinse containing 900 ppm fluoride (0.09%) at least weekly reduced dental caries risk.
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Professionally Applied Products
Professionally applied acidulated phosphate fluoride (APF) gels and foams were the most widely used method of in-office application in the US from the late 1960s to the early 2000s. APF gels and foams reduce the incidence of dental caries in primary and permanent teeth. Both APF gel and foam have a fluoride concentration of 12,300 ppm. The use of APF gel or foam on infants, young children, and patients with disabilities is no longer recommended due to the risk of ingestion. Fluoride varnish has overtaken APF gels and foams as the most common form of professional fluoride application. A panel convened by the ADA Council on Scientific Affairs recommends the application of 2.26% fluoride varnish or 1.23% fluoride APF gel, or a prescription-strength, home-use 0.5% fluoride gel or paste or 0.09% fluoride mouthrinse for patients age 6 and older who are at risk of dental caries. For children younger than 6, the panel only recommends 2.26% fluoride varnish.
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Silver Diamine Fluoride
Silver diamine fluoride (SDF)—while not used as a preventive measure for dental caries—is an important new therapy in the treatment of cavitated lesions for pediatric and special-needs populations. SDF is commonly used to arrest dental caries in children and adults. The American Academy of Pediatric Dentistry (AAPD) released new guidelines in 2017 on the use of SDF for dental caries in children and adolescents. The guidelines support the use of 38% SDF to arrest cavitated caries lesions in primary dentition.
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Toxicity
Fluoride toxicity can occur if recommended doses for fluoride additives are not followed. Acute fluoride toxicity is dependent on the dose-intake and a patient’s weight. While small ingestions of fluoride can cause gastrointestinal irritation, large amounts can lead to organ damage. The overconsumption of fluoride can also lead to fluorosis, skeletal fluorosis, and bony outgrowths. Elevated amounts of fluoride during enamel formation increase the risk of fluorosis. Repeated exposure of fluoride-concentrated foods and beverages early in a child’s life can increase this risk. Enamel defects are symptomatic of fluorosis and may present as white specks, striations, or rough pitted surfaces. Fluorosis can range from very mild to severe. Very mild fluorosis is often misdiagnosed because it can mimic other oral conditions such as tetracycline staining.
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Interprofessional Approach
An interprofessional collaborative approach is needed in order to address factors associated with caries risk and implement preventive measures. Primary care providers (PCPs) see children and their parents/caregivers the most often through well-child visits, which focus on disease prevention and the patient’s development and growth. Thus, oral health assessments, anticipatory guidance, and fluoride varnish application should be part of these visits. In most states, PCPs can apply fluoride varnish. However, barriers associated with performing oral health assessment include insufficient time to perform additional duties, lack of confidence in referring patients to local dentists, and inadequate training in oral health.
