Fluoride Supplementation

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American Academy of Pediatrics.

Committee

on Nutrition

Fluoride

Supplementation

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Since publication of the previous statement on fluoride, which was issued by the Committee on Nutrition in 1979,’ further information has emerged regarding the mode of action of fluoride in preventing caries.27 There has also been growing recognition of the narrow therapeutic range of flu-oride and the danger of excess fluoride ingestion which results in dental mottling (fluorosis).8 This statement reviews some of the newer information about fluoride and offers guidance on the optimal use of fluoride supplements.

MODES OF ACTION

Fluoride has both systemic and topical actions that are of importance in dental health. Systemi-cally, fluoride acts on teeth prior to their eruption by being built into the crystal structure of the enamel and making it resistant to decay. In addi-tion, fluoride limits enamel demineralization and encourages its remineralization into a stable struc-ture.5 The result is to reduce the likelihood of tooth decay.24 The mineralization of primary teeth be-gins in utero, and this has led to the suggestion that fluoride supplements be given in pregnancy. How-ever, there is little evidence of the effectiveness of fluoride supplementation in pregnancy.7’9 The per-manent first molars start mineralization of their crowns shortly after birth.’#{176}Mineralization of per-manent teeth continues up to 6 years of age. Thus, the systemic effects of fluoride are exerted during this period.’0 Conversely, excess fluoride ingestion during this period can cause fluorosis.” The opti-mal systemic fluoride dosage to prevent caries ap-pears to be 0.05 to 0.07 mg/kg/d.’2 The narrowness of the therapeutic range is emphasized by the fact that mild fluorosis has been seen with oral intakes greater than 0.1 mg/kg/d.’3 Thus, it is important to

examine carefully the data on the age at which

fluoride supplementation is started and its relation-ship to caries prevention. At present, there is no evidence that starting fluoride supplementation

earlier than 1 year of age results in any further caries prevention in permanent teeth.’#{176}On the other hand, starting fluoride supplementation prior to 1 year of age does provide additional protection for deciduous teeth.’#{176}This becomes a pediatric issue because most dentition occurs at such an early age.

Preeruptive excess fluoride intake affects dental enamel mineralization and results in mottling of the teeth (fluorosis). For the permanent teeth, the most critical period of vulnerability to excess fluo-ride occurs at approximately 2 years of age. Because enamel formation is virtually complete by age 5 to 6 years, systemic effects of fluoride are, for the most part, accomplished by this time. Topical effects, however, remain important.

Fluoride acts topically (ie, directly on erupted teeth) by promoting remineralization and, in addi-tion, possibly through antibacterial effects.2 These topical effects appear to be significant mechanisms for the prevention of tooth decay. It is likely that regular exposure of the tooth surface to low doses of fluoride may be more critical to preventing caries than the amount of “systemic” fluoride ingested during tooth formation.’4 The amounts of fluoride ingested from eating tooth paste can be an impor-tant source because tooth paste contains 1 mg of fluoride per gram. Precautions should be observed.

The relative roles of topical v systemic effects of fluoride are still being debated.’5 It is clear, how-ever, that the presence of fluoride during the period of tooth formation alone will not prevent tooth decay as effectively as the combination of systemic fluoride plus regular topical application of fluoride to erupted teeth. To be effective, topically applied fluoride must be used regularly,6”4 as the high level of fluoride found in enamel shortly after topical application is maintained for less than 1 month.

METHODS OF PROVIDING FLUORIDE

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AMERICAN ACADEMY OF PEDIATRICS 759

the proper level is made locally, and the practice of fluoridation varies considerably across the country.

Other methods of providing fluoride include flu-oride-containing drops, tablets, mouthwashes, gels,

0 and dentifrices. Several available preparations con-tam both fluoride and vitamins. Their combined use is necessary only in infants who require supple-mental vitamins. Parents should be aware of the dangers of fluoride overdose and should be cau-tioned not to exceed the prescribed amount. Al-though effective, the success of these alternative methods is heavily dependent upon the motivation of the parents to ensure that the preparations are taken daily in a proper dose. Studies have shown that parents are frequently unable to devote their attention to fluoride administration, and as a corn-rnunity measure, none of these methods is as effec-tive as fluoridation of the water supply.’6’17

On the other hand, for children living in areas without water fluoridation, toothpastes containing fluoride are a particularly important source of flu-oride. Virtually unknown 25 years ago, these prod-ucts now command more than 90% of the market and may account for the observed decline in dental caries prevalence in populations not otherwise re-ceiving fluoride supplements.’8”9

USE OF FLUORIDE FOR YOUNG INFANTS

In the 1979 statement, the Committee discussed

0 the literature for and against introducing fluoride supplementation at 2 weeks of life v delaying sup-plementation until 6 months ofage.’ The increasing realization of the important role that topical fluo-ride plays in the prevention of dental caries’4 and the realization that early systemic fluoride inges-tion will not prevent dental caries in permanent teeth, unless there is continued exposure to fluo-ride, has led to a reexamination of the use of fluo-ride before 6 months of age. An additional concern regarding the use of fluoride supplements prior to 6 months is the possible effect of transiently high levels of fluoride, which might occur if infants were given fluoride supplements on a once-a-day ba-sis.5’7”4”8 In experimental studies, peaking of plasma fluoride levels in animals has resulted in fluorosis.’320’2’ However, present data suggest that the current fluoride dosage’ would not be sufficient to cause fluorosis. It is also important to realize that, from the time of birth, fluoride is incorporated into the deciduous teeth and reduces caries in these teeth.’#{176}The issue of fluorosis is further complicated by the variation in infant-feeding patterns occur-ring during this time.

Infants Who Consume Only Milk

0 The amount of fluoride consumed by the infant fed only milk is difficult to determine. Human milk

contains 16 ± 5 sg of fluoride per liter,22 a small amount. The amount of fluoride absorbed is un-known but is probably equivalent to absorption from other milks (65%)23 The amount of fluoride

in human milk is related only slightly to the amount of fluoride in the mother’s diet.24 There may be other elements, such as strontium, acting together with fluoride to reduce caries.25 It is of interest to note that, in areas that use water fluoridation, infants fed only human milk and not receiving fluoride supplements had caries rates comparable to those of formula-fed infants.26 Therefore, it may not be necessary to give fluoride supplements to breast-fed infants who are living in an area where the water is adequately fluoridated. The pediatri-cian must determine whether there is a need for fluoride supplementation, ie, for infants receiving breast milk only (no water, juice, or solid foods).

The manufacturers of infant formula now make their products with defluoridated water so that the fluoride content is <0.3 ppm. This simplifies the calculation of an infant’s total intake of fluoride.

Infants

Who Consume

Fluoride

and Solid Foods

Although most infant foods have a low level of fluoride, some contain appreciable amounts. The fluoride intake of6-month-old infants in the United States has been estimated to vary from 0.207 to 0.541 mg/d (0.03 to 0.07 mg/kg/d).27 Although large amounts of fluoride have been obtained from for-mulas and water, dry cereals and vegetable products have also contributed significant amounts. Data on fluoride intake in Canadian infants show that in-take varies considerabl?8 but is similar to that of infants in the United States.

Solid foods are commonly added to the diet after 4 months of age, and by 6 months of age many infants are consuming a varied diet. Although large amounts of solid foods are not likely to be consumed at any one sitting, and thus peak blood levels are unlikely to be a problem, the total amount of fluo-ride added to the diet may be appreciable. However, the intake of solid foods reduces fluoride absorption to about 60% of intake.29’30 Total fluoride intakes with the supplementation doses suggested below have been calculated to not exceed the optimal dosage range of 0.05 to 0.07 mg/kg/d.

FLUORIDE SUPPLEMENTATION

The fluoride content of the water supply varies locally. Thus, any dosage regimen must take into consideration the local conditions. In addition, the fluoride content of processed foods and carbonated beverages must be taken into account in consider-ing a child’s total intake of fluoride.8 At present, data on the fluoride content of processed foods and

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TABLE.

Fluoride Supplementation Schedule for Infants and Children

REFERENCES

1. American Academy of Pediatrics, Committee on Nutrition: Fluoride supplementation: Revised dosage schedule. Pedi-atrics1979;63:150-152

2. Thylstrup A, Fejerskov 0, Brunn C: Enamel changes and dental caries in 7-year-old children given fluoride tablets from shortly after birth. Caries Res 1979;13:265-276

3. Aasenden R, Peebles TC: Effects of fluoride supplements-tion from birth on human deciduous and permanent teeth. Arch Oral Biol 1974;19:321-326

4. Adair SM, Wei SHY: Supplemental fluoride recommenda-tions for infants based on dietary fluoride intake. Caries Res 1978;12:76-82

5. Holloway PJ, Levine RS: The value of self-applied fluorides at home. Intl Dent J 1981;31:232-239

6. Mellberg JR, Nicholson CR, Rips LW, et al: Fluoride dep-osition in human enamel in vivo from professionally applied fluoride prophylaxis paste. J Dent Res 1976;55:976-979

beverages are insufficient to allow adjustment of dosage schedules for children in areas in which supplemental fluoride is recommended. Dosage reg-imens are based on the age of the child, as well as the fluoride content in the local water supply, with the intention of providing sufficient fluoride for caries prevention, while at the same time avoiding an excess that may cause dental mottling. Ideally, the fluoride content of the local water supply in all communities should be adjusted to a level between 0.7 and 1.0 ppm. In communities that have insuf-ficient fluoride in the local water supply, fluoride supplementation should be used according to the dosage schedule shown in the Table. This dosage schedule is identical with that presented in the Committee statement of 1979.’ The fluoride can be

provided in the form of drops or tablets.

There is some concern that children 2 to 4 years of age who are using fluoride-containing dentifrices or mouthwashes may swallow them instead of spit-ting them out.’4”8’332 This may well lead to exces-sive fluoride intake (up to 1 mg of fluoride per day from the dentifrices alone) and could result in mild cases of fluorosis. For these reasons, the Committee recommends that, if a fluoride-containing dentifrice is used by a toddler, only a very small amount of toothpaste should be placed on the brush. In addi-tion, parents should be advised to teach their chil-dren not to swallow the toothpaste.

Because many children do not see a dentist for the first few years of life, the pediatrician should assume responsibility for overseeing proper fluoride usage as follows: (1) determine the fluoride concen-tration of the local water supply for all of your patients, (2) know and use the fluoride supplemen-tation schedule appropriately, and (3) counsel par-ents with regard to the proper use of fluoride-containing dentifrices (toothpastes and gels).

SUMMARY

This statement reviews the rationale for the use of fluoride supplements for infants and children. The concept of fluoridation of water supplies as an effective and cost-beneficial method of reducing

Age (yr)

Fluoride W

Concentration in Local ater Supply (ppm)

<0.3 0.3-0.7 >0.7

0-2 0.25 0 0

2-3 0.50 0.25 0

3-16 1.00 0.50 0

* Values are milligrams of fluoride supplement per day.

Supplementation should begin in the first 2 weeks after

birth.

caries prevalence in the general population is strongly supported. In the absence of an adequately fluoridated water supply, fluoride supplements should be given to all children. This should begin at about 2 weeks of age; the dosage will depend on the concentration of fluoride in the local water supply. Fluoride-containing dentifrices are an im-portant source of topical fluoride, but it is essential that parents be aware of the danger of excessive fluoride intake and that they teach their children to avoid swallowing toothpaste.

COMMITTEE ON NUTRITION,

1985-1986

Laurence Finberg, MD, Chairman Harry S. Dweck, MD

Norman Kretchmer, MD Frederick Holmes, MD Alvin M. Mauer, MD John W. Reynolds, MD Robert W. Suskind, MD

Liaison Representatives John D. Benson, PhD Stanley G. Miguel, PhD George A. Purvis, PhD Richard C. Theuer, PhD Rudolph M. Tomarelli, PhD Alice Smith, RD

A. Harold Lubin, MD Ann Prendergast, RD, MPH Margaret Cheney, PhD Reginald Sauve, MD Mary Serdula, MD Joginder Chopra, MD Thorsten J. Fjellstedt, PhD Stephen Joseph, MD

Ms. Patricia Daniels, RD, MS

Section Liaison

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AMERICAN ACADEMY OF PEDIATRICS 761 7. Stookey GK: Perspective on the use of prenatal fluoride: A

reactor’s comments. J Dent Child 1981;48:126-127

8. Powell JA, Norbert LD, Hargreaves JA: Fluorosis and dental caries in children receiving fluoride supplementation. J Dent

0 Res 1983;62:203

9. Driscoll WS: A review of clinical research on the use of prenatal fluoride administration for prevention of dental caries. J Dent Child 1981;48:109-117

10. Marthaler TM: Fluoride supplements for systemic effects in caries prevention, in Johansen E, Taves DR, Olson TO (eds): Continuing Evaluation on the Use of Fluorides, sym-posium 11. Boulder, CO, AAAS Selected Symposium West-view Press, 1979, pp 33-59

1 1. Moller IJ: Fluorides and dental fluorosis.

mt

Dent J

1982;32:135-147

12. Forrester DJ, Schultz EM (ads): International Workshop on Fluorides and Dental Caries Reductions. Baltimore, Univer-sity of Maryland, 1974

13. Forsman B: Early supply of fluoride and enamel: Fluorosis. Scand J Dent Res 1977;85:22-30

14. Dowell TB, Joyston-Bechal 5: Fluoride supplements-Age related dosages. Br Dent J 1981;150:273-275

15. Bruun C, Poulsen 5, Costergaard V, et al: Preemptive ac-quisition of fluoride by surface enamel of permanent teeth after daily use of F supplements. Caries Res 1983;17:89-91 16. Murray JJ: Fluoride supplements-Alternatives to water

fluoridation. J R Soc Health 1977;97:48-51

17. Gray AS, Gunther DM: Supplemental fluorides: A commu-nity health centre project in preventive dentistry. Can J Public Health 1976;67:55-58

18. Ekstrand J, Koch G, Petersson LG: Plasma fluoride concen-trations in pre-school children after ingestion of fluoride tablets and toothpaste. Caries Res 1983;17:379-384

19. Hargreaves JA, Thompson GW, Wagg BJ: Changes in caries prevalence in Isle of Lewis children 1971 and 1981. Caries Res 1983;17:554-559

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20. Kruger BJ: The effect of different levels of fluoride on the ultrastructure of ameloblasts in the rat. Arch Oral Biol

1970;15:109-114

21. Suttie JW, Carlson JR, Faltin EC: The effects of alternating periods of high- and low-fluoride ingestion on dairy cattle. J Dairy Sci 1972;55:790-804

22. Lonnerdahl B: Composition of human milk, in Pediatric Nutrition Handbook, ed 2. Elk Grove Village, IL, American Academy of Pediatrics, 1985

23. Spak CJ, Ekstrand J, Zylberstein D: Bioavailability of

flu-oride added to baby formula and milk. Caries Res

1982;16:249-256

24. Spak CJ, Hardell LI, de Chateau P: Fluoride in human milk. Acta Paediatr Scand 1983;72:699-701

25. Curzon MEJ: Combined effect oftrace elements and fluoride on caries: Changes over ten years in northwest Ohio (USA). J Dent Res 1983;62:96-99

26. Walton JL, Messer LB: Dental caries and fluorosis in breast-fed and bottle-fed children. Caries Res 1981;15:124-137

27. Ophaug RH, Singer L, Harland BF: Estimated fluoride intake of 6-month-old infants in four dietary regions of the United States. Am J Clin Nutr 1980;33:324-327

28. Dabeka RW, McKenzie AD, Conacher HBS, et al: Deter-mination of fluoride in Canadian infant foods and calcula-tion of fluoride intakes by infants. Can J Public Health 1982;73:188-191

29. Welling PG: Influence of food and diet on gastrointestinal drug absorption: a review. J Pharmacokinet Biopharm

1977;5:291-334

30. Ekstrand J, Ehrnebo M: Influence of milk products on fluoride bioavailability in man. Eur J Clin Pharmacol 1979;16:211-215

31. Ericsson Y, Wei SHY: Fluoride supply and effects in infants and young children. Pediatr Dent 1979;1:44-54

32. Dowell TB: The use of toothpaste in infancy. Br Dent J 1981;150:247-249

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1986;77;758

Pediatrics