CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Fluoride Use in Caries Prevention in thePrimary Care SettingMelinda B. Clark, MD, FAAP,a Martha Ann Keels, DDS, PhD,b,c Rebecca L. Slayton, DDS, PhD,d SECTION ON ORAL HEALTH

abstractDental caries remains the most common chronic disease of childhood in theUnited States. Caries is a largely preventable condition, and fluoride hasproven effectiveness in caries prevention. This clinical report aims to clarifythe use of available fluoride modalities for caries prevention in the primarycare setting and to assist pediatricians in using fluoride to achieve maximumprotection against dental caries, while minimizing the likelihood of enamelfluorosis. Fluoride varnish application is now considered the standard of carein pediatric primary care. This report highlights administration, billing, andpayment information regarding the fluoride varnish procedure.

Dental caries (ie, tooth decay) is an infectious disease caused by bacteriaon the tooth surface metabolizing carbohydrates and producing acid,which dissolves tooth enamel. If unchecked, this process continuesthrough the tooth and into the pulp, resulting in pain and tooth loss. Thiscan further progress to local infections (ie, dental alveolar abscess or facialcellulitis), systemic infection, and, in rare cases, death. Dental caries in theUnited States is responsible for many of the 51 million school hours lostper year as a result of dental-related illness, which translates into lostwork hours for the adult caregiver.1 Early childhood caries is the singlegreatest risk factor for caries in the permanent dentition. Good oral healthis a necessary part of overall health, and studies have demonstratedadverse effects of poor oral health on multiple chronic conditions,including diabetes control.2 Therefore, failure to prevent caries has health,educational, and financial consequences at both the individual and societallevels.

Dental caries is the most common chronic disease of childhood,1 with 59%of 12- to 19-year-olds having at least 1 documented cavity.3 Caries isa “silent epidemic” that disproportionately affects poor, young, minoritypopulations and children living below 100% of the poverty level.1 In theUnited States, 25% of 2- to 5-year-old children from low socioeconomicand minority groups experience 80% of dental disease.4 Among 3- to 5-year-olds, untreated dental decay was significantly greater for non-

aDepartment of Pediatrics, Albany Medical Center, Albany, New York;bDepartment of Surgery and Pediatrics, Duke University, Durham,North Carolina; cThe Adams School of Dentistry, University of NorthCarolina at Chapel Hill, Chapel Hill, North Carolina; and dDepartment ofPediatric Dentistry, School of Dentistry, University of Washington,Seattle, Washington

Clinical reports from the American Academy of Pediatrics benefit fromexpertise and resources of liaisons and internal (AAP) and externalreviewers. However, clinical reports from the American Academy ofPediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

Drs Clark, Keels, and Slayton participated in the concept and design ofthe manuscript, analysis and interpretation of data, and drafting andrevising of the manuscript; and all authors approved the finalmanuscript as submitted.This document is copyrighted and isproperty of the American Academy of Pediatrics and its Board ofDirectors. All authors have filed conflict of interest statements with theAmerican Academy of Pediatrics. Any conflicts have been resolvedthrough a process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content of thispublication.

The guidance in this report does not indicate an exclusive course oftreatment or serve as a standard of medical care. Variations, takinginto account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

DOI: https://doi.org/10.1542/peds.2020-034637

Address correspondence to Melinda B. Clark, MD. Email: ClarkM@amc.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2020 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have nofinancial relationships relevant to this article to disclose.

To cite: Clark MB, Slayton RL, AAP SECTION ON ORALHEALTH. Fluoride Use in Caries Prevention in the PrimaryCare Setting. Pediatrics. 2020;146(6):e2020034637

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Hispanic Black and Hispanic children(19.3% and 19.8%, respectively) thanfor non-Hispanic white children(11.3%).4 This disparity persistedamong children 6 to 9 years and 13 to15 years of age.4 Dental caries isa global problem, with earlychildhood caries prevalence amongsocioeconomically disadvantagedgroups reported to be as high as70%.5 It has been suggested thathealth beliefs, self‐efficacy, access tocare, and parents’ attitudes andpractices related to dietary and oralhygiene behaviors may contribute tothis disparity.6

Children with special health careneeds, including those withdevelopmental delay, complexneurodevelopmental disabilities, orcongenital heart disease are alsoaffected disproportionately.7,8 Ina study of Head Start children, thosewith developmental delays hada caries prevalence ratio that was1.26 times higher than classmateswithout developmental delays.8 Thisdifference may be attributable tochallenges with home care routinessuch as toothbrushing and use ofmedications with high sugar content,among other factors.8 Children withspecial health care needs arefrequently considered as a groupwhen determining caries risk.However, some diagnoses placechildren at greater risk for caries,whereas other children are atdecreased or similar risk as childrenwithout special health care needs. Ina retrospective longitudinal study ofchildren with autism spectrumdisorder, Down syndrome, congenitalheart disease, and cerebral palsy,Frank et al7 determined that thecaries risk among the group ofchildren with special health careneeds was higher than among thecontrol subjects but the risk differedsignificantly by diagnosis. The cariesburden was greatest in children withcongenital heart disease, followed bythose with autism spectrumdisorders.7 For children with Down

syndrome, the risk was close to thatof controls and considerably lowerthan the other 3 groups of childrenwith special health care needs.7

Unfortunately, dental cariesprevalence in young childrenincreased between the previous 2national surveys, despiteimprovements among older children.9

Many children do not receive dentalcare at young ages, and because therisk of dental caries is heavilyinfluenced by parenting practices,pediatricians have a uniqueopportunity to participate in theprimary prevention of dental caries.The 2007–2016 Medical ExpenditurePanel Survey demonstrated that88.8% of infants and 1-year-olds haveoffice-based physician visits annually,compared with only 3.6% of infantsand 1-year-olds having general dentalvisits (American Academy ofPediatrics [AAP], unpublishedanalysis of 2007–2016 MedicalExpenditure Panel Survey, August2019). Studies show that health caredollars are saved with simple homeand primary care setting preventionmeasures.10

The development of dental cariesrequires 4 components: teeth,bacteria, carbohydrate exposure, andtime. Once teeth emerge, they becomecolonized with cariogenic bacteria.The bacteria metabolizecarbohydrates and create acid asa byproduct. The acid dissolves themineral content of enamel(demineralization) and, over time,with repeated acid attacks, theenamel surface disintegrates andresults in a cavity in the tooth.Protective factors that help toremineralize enamel include exposingthe teeth to fluoride, limiting thefrequency of carbohydrateconsumption (to 3 meals and 2healthy snacks per day), choosing lesscariogenic foods (selecting cheese orraw carrots over candy or crackers;selecting fresh fruit over dried fruit orprocessed fruit snacks), practicinggood oral hygiene (brushing twice

a day for 2 minutes and flossingbetween all teeth that touch), andreceiving regular dental assessmentsand care. If carious lesions areidentified early, the process can behalted or reversed by modifying thepatient’s individual risk andprotective factors. The AAP’spublications “Maintaining andImproving the Oral Health of YoungChildren”11 and Bright Futures:Guidelines for Health Supervision ofInfants, Children, and Adolescents12

discuss these concepts in greaterdepth and provide targetedanticipatory guidance. For primaryprevention to be effective, it isimperative that pediatricians beknowledgeable about the process ofdental caries, social determinants oforal health, prevention of the disease,and available interventions, includingfluoride.

Fluoride is available from manysources, divided into 3 majorcategories: tap water (and foods andbeverages processed with fluoridatedwater), home administered, andprofessionally applied. Thewidespread decline in dental caries inmany developed countries, includingthe United States, has been largelyattributable to the use of fluoride.Fluoride has 3 main mechanisms ofaction13:

1. Fluoride promotes enamelremineralization.

2. Fluoride reduces enameldemineralization.

3. Fluoride inhibits bacterialmetabolism and acid production.

The mechanisms of fluoride are bothtopical and systemic, but the topicaleffect is the most important,especially over the life span.14

There has been substantial public andprofessional debate about fluoride,and a great deal of information isavailable, often with confusing orconflicting messages. Excess fluorideingestion during tooth developmentcan result in subsurface

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hypomineralization and porositybetween the developing enamel rods,termed enamel fluorosis.15 Fluorosisof permanent teeth occurs whenexcessive fluoride is ingested duringthe time that tooth enamel is beingmineralized; therefore, the risk isinfluenced by both dose andfrequency of ingestion. Recentevidence also suggests a geneticsusceptibility or resistance to thedevelopment of fluorosis.16 Fluorosisdevelops in children younger than8 years, with the most susceptibleperiod for permanent maxillaryincisor fluorosis (central teeth)between 15 and 30 months ofage.17–19 The vast majority of enamelfluorosis is mild or very mild andcharacterized by small whitestriations or opaque areas not readilynoticeable to the casual observer andis of minimal clinical consequence.

Moderate and severe forms of enamelfluorosis are uncommon in the UnitedStates but have both an aestheticconcern and, potentially, a structuralconcern with pitting, brittle incisaledges and weakened groove anatomyin the permanent 6-year molars.20

After 8 years of age, there is nofurther risk of fluorosis except for thethird molars because all otherpermanent tooth enamel is fullymineralized.

Dental and governmentalorganizations (the American DentalAssociation [ADA], AmericanAcademy of Pediatric Dentistry[AAPD], and Centers for DiseaseControl and Prevention [CDC]) haveall published guidelines on theuse of fluoride. In 2001, the AAPendorsed the CDC publication“Recommendations for Using

Fluoride to Prevent and ControlDental Caries in the United States.”21

The 2 intents of this clinical reportare as follows:

1. to assist pediatricians in usingfluoride to achieve maximumprotection against dental caries,while minimizing the likelihood ofenamel fluorosis; and

2. to clarify what advice should begiven by pediatricians regardingfluoride in the primary caresetting.

CURRENT INFORMATION REGARDINGFLUORIDE USE IN CARIES PREVENTION

Sources of ingested fluoride includedrinking water, infant formula,fluoride toothpaste, prescriptionfluoride supplements, fluoride mouthrinses, professionally applied topical

FIGURE 1AAP Oral Health Risk Assessment Tool.

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fluoride, and some foods andbeverages.22 Preventive strategies forcaries can be tailored by focusing onkey risk factors for dental cariesassociated with diet, bacteria, saliva,and status of the teeth (both currentand previous caries experience).11

The AAP Oral Health Risk AssessmentTool (Fig 1) is recommended inBright Futures: Guidelines for HealthSupervision of Infants, Children, andAdolescents and endorsed by theNational Interprofessional Initiativeon Oral Health. This tool can be foundat www.aap.org/en-us/Documents/oralhealth_RiskAssessmentTool.pdf.

Table 1 provides condensedrecommendations for use of fluoridemodalities in patients at low and highrisk of caries as described in thefollowing sections.

Fluoride Toothpaste

Fluoride toothpaste has consistentlybeen proven to provide a caries-preventive effect for individuals of allages.21,23 In the United States, thefluoride concentration of over-the-counter (OTC) toothpaste rangesfrom 1000 to 1100 ppm. Thistranslates into 1 mg of fluoride in a1-inch (1 g) strip of paste. Apea-sized amount of toothpaste isapproximately one-quarter of an inch.Therefore, a pea-sized amount oftoothpaste containing 1000 to 1100ppm fluoride would haveapproximately 0.25 mg of fluoride.Most fluoride toothpastes inthe United States containsodium fluoride, sodiummonofluorophosphate, or stannousfluoride as the active ingredient.

Children younger than 6 years aremore likely to ingest toothpaste andincrease the risk of fluorosis.Fluorosis risk can be minimized byusing the recommended amounts oftoothpaste and storing toothpastewhere young children cannot access itwithout parental help. Parents shouldsupervise children younger than8 years to ensure the proper amountof toothpaste and effective brushingtechnique.

Recommendations and Dosing

The use of fluoride toothpaste shouldbegin with the eruption of the firsttooth. For children younger than3 years, the recommended amount isa smear or grain of rice size(approximately 0.1 mg of fluoride).Once the child has turned 3 years ofage and is more able to consistentlyexpectorate, a pea-sized amount oftoothpaste (approximately 0.25 mg offluoride) should be used.24,25 It ispreferable to spit, but not rinse, afterbrushing. Expectorating withoutrinsing reduces the amount offluoride swallowed and leaves somefluoride available in the saliva foruptake by the dental plaque. Parentsshould be strongly advised tosupervise their child’s use of fluoridetoothpaste to avoid overuse oringestion, especially with childrenwho have complexneurodevelopmental disabilities andcannot consistently expectorate.

High-concentration toothpaste (5000ppm) is available by prescriptiononly, and this decision is usually madeby a dental health professional. Theactive ingredient in this toothpaste is

sodium fluoride. This agent can berecommended for children 6 yearsand older and adolescents who are athigh risk of caries and who are able toexpectorate after brushing. Examplesof children for whom high-concentration fluoride toothpastemight be indicated are those withhistory of dental caries and newlesions, children with xerostomia, andthose with gastroesophageal refluxcausing dental erosion. Dental healthprofessionals may also prescribe thisagent for adolescents who areundergoing orthodontic treatmentbecause they are at increased risk ofcaries during this time.26

Fluoride Varnish

Fluoride varnish is a concentratedtopical fluoride applied to the teeththat sets on contact with saliva.Advantages of this modality are that itis well tolerated by infants and youngchildren, has a prolonged therapeuticeffect, and can be applied by bothdental and nondental healthprofessionals in a variety ofsettings.27 The concentration offluoride varnish is 22 600 ppm(2.26% fluoride ion), and the activeingredient is sodium fluoride. Theunit dose packaging from mostmanufacturers provides a specificmeasured amount (0.25 mL,providing 5 mg of fluoride ion). Theapplication of fluoride varnish duringan oral screening is of benefit tochildren, especially those with limitedaccess to dental care. The currentAAPD recommendation for childrenat high risk of caries is that fluoridevarnish be applied to the teeth every3 to 6 months.28 The 2013 ADA

TABLE 1 Summary of Fluoride Modalities for Low- and High-Risk Patients

Fluoride Modality Low Caries Risk High Caries Risk

Toothpaste Starting at tooth emergence (smear of paste until age 3, thenpea-sized)

Starting at tooth emergence (smear of paste until age 3, thenpea-sized)

Fluoride varnish Every 3–6 mo starting at tooth emergence Every 3 mo starting at tooth emergenceMouth rinse OTC Do not use Starting at age 6 y if the child can reliably swish and spitCommunity waterfluoridation

Yes Yes

Dietary fluoridesupplements

Yes, if drinking water supply is not fluoridated Yes, if drinking water supply is not fluoridated

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guideline recommends application offluoride varnish at least every6 months to both primary andpermanent teeth of those at elevatedcaries risk.29 Medicaid pays bothphysicians and dentists for theapplication of fluoride varnish in all50 states.

Under the Patient Protection andAffordable Care Act,30 payers arerequired to cover, without cost-sharing, preventive servicesrecommended by the US PreventiveServices Task Force (USPSTF) andBright Futures guidelines. TheUSPSTF recommended in 2014 thatprimary care clinicians apply fluoridevarnish to the primary teeth of allinfants and children starting at theage of primary tooth eruption (Brecommendation).31 All children5 years and younger deserve to haveapplication of fluoride varnish fullycovered, as per USPSTFrecommendations, as part of healthmaintenance and preventive care andfor fluoride varnish application to bea covered benefit and separately paidservice (ie, not considered incidentalto the office visit). All practicesshould be paid separately andappropriately according to thedefinition of the Current ProceduralTerminology (CPT) code, whichdefines fluoride application asa separately identifiable procedure.Fluoride varnish payment should notbe bundled with routine preventiveevaluation and management servicesbecause definitions of preventive careunder those specific CPT codes do notinclude fluoride varnish application.Information regarding coding, billing,and payment for fluoride varnishapplication can be found on the AAPWeb site (www.aap.org/oralhealth)and the Pew Center on the States Website (www.pewstates.org/research/analysis/reimbursing-physicians-for-fluoride-varnish-85899377335).Many AAP Chapters have chapter oralhealth advocates who promote andadvocate for pediatric oral healthwithin their community. Contact

information for these chapter oralhealth advocates can be found atwww.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Oral-Health/Pages/Chapter-Oral-Health-Advocates.aspx.

Indications for Use

In the primary care setting, fluoridevarnish should be applied at leastonce every 6 months for all childrenand every 3 months for children athigh risk for caries, starting when thefirst tooth erupts and until theestablishment of a dental home.Medical and dental professionals areencouraged to work in collaborationto ensure that fluoride varnish isbeing applied.

Instructions for Use

Fluoride varnish must be applied bya dentist, dental auxiliaryprofessional, physician, nurse, orother health care professional on thebasis of individual state practice acts.It should not be dispensed to familiesto apply at home. Application offluoride varnish is most commonlyperformed in the context of a well-child visit. Teeth are dried with a 2-inch gauze square, and then thevarnish is painted onto all surfaces ofthe teeth with a brush. The doserecommended for young children is0.25 mL, which is available in single-dose applicator kits. Children can eatand drink immediately afterapplication and are instructed to eatsoft foods and not to brush their teethon the evening after the varnishapplication to maximize the contacttime of varnish on the teeth. Childrenshould resume brushing twice dailywith fluoridated toothpaste thefollowing morning.

OTC Fluoride Rinse

OTC fluoride rinse provides a lowerconcentration of sodium fluoride thantoothpaste or varnish. Theconcentration is most commonly 230ppm (0.05% sodium fluoride). Expertpanels on this topic have concludedthat OTC fluoride rinses should not be

recommended for children youngerthan 6 years because of their limitedability to rinse and spit and increasedrisk of swallowing higher thanrecommended amounts of fluoride.32

A teaspoon (5 mL) of OTC fluoriderinse contains approximately 1 mg offluoride. For children older than6 years, OTC rinses provide additionaltopical fluoride that may assist in theprevention of enameldemineralization. However, theevidence for an anticaries effect islimited, and decisions to recommendOTC fluoride rinses should be madein consultation with the child’s dentalhealth care provider.33,34

Dietary Fluoride Supplements

The USPSTF recommended in 2014that primary care clinicians prescribedietary fluoride supplements forchildren living in communities withnonfluoridated water or who drinkwell water that does not containfluoride.31 Because there are manysources of fluoride in water suppliesand processed food and drinks, it isessential that all potential sources offluoride be assessed beforeprescribing a dietary supplement,including consideration of differingenvironmental exposures (dualhomes and child care). As a generalguideline, if the source of drinkingwater in the primary home isfluoridated tap or well water, childrenwill not require fluoridesupplementation, even if theyprimarily drink bottled water becausethe teeth are exposed to fluoridethrough food preparation andbrushing. The risk of fluorosis is highif fluoride supplements are given toa child consuming fluoridatedwater.35 Information about thefluoridation levels in manycommunity water systems can befound on the CDC Web site “MyWater’s Fluoride” (https://nccd.cdc.gov/doh_mwf/default/default.aspx).Not all communities report thisinformation to the CDC, so it may benecessary to contact the local waterdepartment to determine the level of

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fluoride in the community water. Wellwater must be tested for fluoridecontent before prescribingsupplements, and this testing isavailable in most areas through thestate or county public healthlaboratory. Challenges with dietaryfluoride supplementation includedetermining the child’s fluorideexposures and proper administrationof the medication.

It is important to note that theUSPSTF recommendations vary fromthe ADA and AAPD guidelines, whichboth recommend fluoridesupplementation only be consideredfor children who drink fluoride-deficient water and are also at highrisk for dental caries.36,37 No cariesrisk assessment tool has beenvalidated for pediatricians to use, butthe AAP Oral Health Risk AssessmentTool was piloted through the QualityImprovement Innovation Network,and more than 80% of practicesfound the tool easy to implementbecause clinicians did not need tosignificantly alter current practice toincorporate risk assessment.Identification of high-risk patients fororal health referral increased from11% to more than 87% with the useof this tool (Brightening Oral HealthWorkgroup and Quality ImprovementInnovation Networks, AAP,Brightening Oral Health: Teachingand Implementing Oral Health RiskAssessments in Pediatric Care project,unpublished data, 2009).

Guidelines for Use

The CDC-recommended fluoridesupplementation dosage schedule isprovided in Table 2. Supplements canbe prescribed in liquid, tablet, orlozenge form. Tablets are preferablefor children who can chew becausethey gain an additional topical benefitto the teeth during the chewingprocess. Liquid supplements arerecommended for younger childrenand should ideally be added to wateror put directly into the child’s mouth.Addition of the fluoride supplement

to milk or formula is notrecommended because absorption offluoride is reduced in the presence ofcalcium.38 The risk of fluorosis can beminimized by health care providersverifying that there are no othersources of fluoride exposure beforeprescribing systemic fluoridesupplements.

Other Sources of Fluoride

Fluoride is present in processed foodsand beverages and may be naturallyoccurring in some areas of thecountry. The presence of fluoride injuices and carbonated beverages doesnot counteract the cariogenic natureof these beverages.

Breastfeeding and Reconstitution ofInfant Formula

The AAP recommends exclusivebreastfeeding for the first 6 months oflife, and there is no need during thisperiod of time to supplement withfluoride or water that is fluoridated. Astudy of infant feeding practicesrevealed that 70% to 75% of motherswho fed their infants formula usedtap water to reconstitute thepowdered formula.39 According to2014 CDC data,40 approximately 74%of US households using a communitypublic water supply receivedoptimally fluoridated water.41 Beforethe emergence of the primary teeth,tap water can be used to reconstituteformula. There is a small risk offluorosis in the permanent dentitionif a fluoridated water source is usedto reconstitute formula.22 If familieselect to purchase water, it is

appropriate to buy water with noadded fluoride before toothemergence. After tooth emergence,formula should be mixed withoptimally fluoridated tap water ornursery water with fluoride, orfluoride supplements should beprescribed. It should be noted thatmost bottled water has suboptimalconcentrations of fluoride and thatfluoride content is not listed unlessfluoride is added by themanufacturer. Fluoride is often addedto “nursery” water, and this must bedeclared on the packaging. Dietaryfluoride supplements should not beprescribed for children drinkinginfant formula reconstituted withfluoridated water.

Community Water Fluoridation

Community water fluoridation is thepractice of adding a small amount offluoride to the water supply toachieve a fluoride concentration of0.7 ppm. Community waterfluoridation was heralded by the CDCas 1 of the top 10 public healthachievements of the 20th century.42

Community water fluoridation isa safe, efficient, and cost-effective wayto prevent tooth decay and has beenshown to reduce tooth decay by25%.43 It prevents tooth decay byproviding both topical and systemicexposure of low levels of fluoride tothe teeth over time. Although morethan 210 million Americans live incommunities with optimallyfluoridated water, more than 70million others do not have access tofluoridated water in their publicwater system.41 The fluoridationstatus of a community water supplycan be determined by contacting thelocal water department or accessingthe CDC Web site “My Water’sFluoride” (https://nccd.cdc.gov/doh_mwf/default/default.aspx).

Recommended Concentration

Community water fluoridation wasinitiated in the United States in the1940s. In 2015, the US Department ofHealth and Human Services finalized

TABLE 2 Fluoride Supplementation Schedulefor Children

Age Fluoride Ion Level in DrinkingWater, ppma

,0.3 0.3–0.6 .0.6

Birth to 6 mo None None None6 mo to 3 y 0.25 mg/db None None3–6 y 0.50 mg/d 0.25 mg/d None6–16 y 1.0 mg/d 0.50 mg/d None

Source: Centers for Disease Control and Prevention.21

a 1.0 ppm = 1 mg/L.b 2.2 mg of sodium fluoride contains 1 mg of fluoride ion.

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a recommendation to lower theoptimal fluoride concentration indrinking water to 0.7 mg/L.44 Thisfluoride concentration replaced theprevious recommendation, which wasbased on climate and ranged from0.7 mg/L in warmest climates to1.2 mg/L in coldest climates.44 Thechange was recommended becauserecent studies revealed no variationin water consumption by youngchildren on the basis of climate and toadjust for an overall increase influoride intake through foods andbeverages processed with fluoridatedwater, fluoridated mouth rinses, andfluoride toothpastes.

Evidence Supporting Community WaterFluoridation

Despite overwhelming evidencesupporting the safety and preventivebenefits of fluoridated water,community water fluoridationcontinues to be a controversial andhighly emotional issue. Opponentsexpress a number of concerns thathave been addressed or disproven byvalidated research. The onlyscientifically documented adverseeffect of excess (nontoxic) exposureto fluoride is fluorosis. An increase inthe incidence of mild enamel fluorosisamong teenagers has been cited asa reason to discontinue fluoridation,although this is a cosmetic conditionwith no detrimental health outcomes.Recent opposition has sometimescentered on the question of whodecides whether to fluoridate: electedand/or public officials or the voters.Some opponents believefluoridation to be mass medicationand call into question the ethics ofcommunity water fluoridation, butcourts have consistently upheld thatit is legal and appropriate fora community to adopt a fluoridationprogram.45 Opponents expressconcern about the quality andsource of fluoride, claiming that theadditives (fluorosilicic acid, sodiumfluoride, or sodium fluorosilicate),in their concentrated form, arehighly toxic byproducts of the

production of phosphate fertilizerand may include othercontaminants, such as arsenic.The quality and safety of fluorideadditives are ensured by Standard60 of the National SanitationFoundation/American NationalStandards Institute, a programcommissioned by the USEnvironmental Protection Agency(EPA), and testing is conducted toconfirm that the concentrations ofarsenic or other substances arebelow those allowed by the EPA.46

Finally, there have been manyunsubstantiated or disproven claimsthat fluoride leads to kidney disease,bone cancer, and compromised IQ.More than 3000 studies or researcharticles have been published on thesubject of fluoride or fluoridation.47

Few topics have been as thoroughlyresearched as community waterfluoridation, and the overwhelmingweight of the evidence (along withover 75 years of experience) supportsthe safety and effectiveness of thispublic health practice.

Naturally Occurring Fluoride in DrinkingWater

The optimal fluoride concentration indrinking water is 0.7 ppm, an amountproven beneficial in reducing toothdecay.44 Naturally occurring fluoridemay be below or above these levels insome areas. Under the Safe DrinkingWater Act,48 the EPA requiresnotification by the water supplier ifthe fluoride concentration exceeds 2ppm. In areas where naturallyoccurring fluoride concentrations indrinking water exceed 2 ppm, peopleshould consider an alternative watersource or home water treatments toreduce the risk of fluorosis in youngchildren.49 Well water should betested for the concentration offluoride, and this testing is mostcommonly performed through thelocal health department.

Fluoride Toxicity

Toxic levels of fluoride are possible,particularly in children, resulting

from ingesting large quantities offluoride supplements, fluoridatedtoothpaste, or fluoride mouth rinse.The toxic dose of elemental fluoride is5 to 10 mg of fluoride/kg of bodyweight.50 Lethal doses in childrenhave been calculated to be between8 and 16 mg/kg. When prescribingsodium fluoride supplements, itis recommended to limit thequantity prescribed at one time tono more than a 4-month supply.Parents should be advised to keepfluoride products out of the reachof young children and to supervisetheir use.

Fluoride-Removal Systems

A number of water treatment systemsare effective in removing fluoridefrom water,51 including reverseosmosis and distillation. Parentsshould be counseled on the use ofthese and activated alumina filters inthe home and, should they choose touse one that removes fluoride, thepotential adverse effects on thefamily’s oral health. Commonly usedhome carbon filters (eg, Brita or PUR)do not remove fluoride.51 Familiesconcerned about heavy metals orother impurities in their home watersupply can use an activated carbonfilter and still retain the benefits offluoridated water.

Silver Diamine Fluoride

Silver diamine fluoride (SDF) isa minimally invasive, low-cost liquidsolution that is painted on cavitatedlesions. In young children, SDFprovides a nonsurgical technique tomanage carious lesions until the childcan cope with traditional restorativedental care and, potentially, avoidsedation or a general anesthetic.52

SDF has been used in Japan for morethan 40 years and was cleared by theUS Food and Drug Administration in2014 to treat tooth sensitivity inadults.53,54 Similar to fluoridevarnish, SDF (38% solution) has beenused off-label in children and adultsto stabilize dental caries and reducedental sensitivity. At present, the use

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of SDF in the United States is largelylimited to the dental professionbecause there are no formalprofessional guidelines for useoutside of dentistry. SDF is indicatedfor the arrest of cavitated cariouslesions in primary teeth as part ofa comprehensive caries managementprogram.52 Information about SDF isincluded in this report in expectationof questions to pediatricians aboutthis increasingly publicizedintervention and increasing numbersof SDF-treated teeth seen in pediatricpractices. The mechanism of SDFaction is poorly understood, but silverions are known to be antimicrobial,and the fluoride prevents furtherenamel demineralization. After SDFapplication, the lesions must befollowed to assess their hardnessstate. Additional treatments can beapplied to obtain sufficient hardness.The only known contraindication toSDF is silver allergy, but SDF is notindicated for carious lesions involvingthe pulp. The only significant adverseeffect of SDF is that the carious lesionturns black (Figs 2 and 3), which canbe esthetically problematic for some.SDF can also temporarily stain theskin black if it accidentally comes intocontact with the epithelium, and SDFcan cause mucosal irritation forapproximately 48 hours after mucosalcontact. Care must be taken whenapplying SDF to a cavitated lesion toavoid contact with the child’s mucosaor skin. Details of SDF applicationtechnique for dental healthprofessionals are delineated in theAAPD Chairside Guide.54

SUGGESTIONS FOR PEDIATRICIANS

1. Know how to assess caries risk. Asrecommended by the AAP in“Maintaining and Improving theOral Health of Young Children” andthe fourth edition of BrightFutures, pediatricians shouldperform oral health riskassessments on all children atevery routine well-child visitbeginning at 6 months of age. TheOral Health Risk Assessment Toolhas been developed by the AAPand Bright Futures and endorsedby the National InterprofessionalInitiative on Oral Health. This toolcan be accessed at www.aap.org/en-us/Documents/oralhealth_RiskAssessmentTool.pdf. The toolis a guide to help clinicianscounsel patients about oral healthand counsel in reducing risk.

2. Recommend use of fluoridatedtoothpaste starting at the eruption

of the first tooth. A smear or grainof rice sized amount isrecommended for childrenyounger than 3 years, and a pea-sized amount of toothpaste isappropriate for most childrenstarting at 3 years of age (seeFig 4).

3. Apply fluoride varnish accordingto the periodicity schedule and billusing the CPT code 99188.Fluoride varnish is a proven tool inearly childhood caries prevention.Additional training on oralscreenings, fluoride varnishindications and application, andoffice implementation can befound in the Smiles for LifeCurriculum Course: Caries RiskAssessment, Fluoride Varnish andCounseling55 at www.smilesforlifeoralhealth.org.Additionally, the AAP Children’soral health Web site is a resourcefor oral health practice tools athttps://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Oral-Health/Pages/Oral-Health-Practice-Tools.aspx.

4. Know how to determine theconcentration of fluoride ina child’s primary drinking waterand determine the need forsystemic supplements.21

5. Advocate for water fluoridation inyour local community. Publicwater fluoridation is an effectiveand safe method of protecting themost vulnerable members of ourpopulation from dental caries.Pediatricians are encouraged toadvocate on behalf of public waterfluoridation in their communitiesand states. For additionalinformation and water fluoridationfacts and detailed questions andanswers, see the following:

o http://www.ilikemyteeth.org;

o www.ada.org/en/public-programs/advocating-for-the-public/fluoride-and-fluoridation/fluoridation-facts;and

FIGURE 2Permanent staining of carious lesions afterSDF application. Photograph courtesy of Mar-tha Ann Keels, DDS, PhD.

FIGURE 3Three-year stabilization of a carious lesion on 1primary molar after SDF application. Photo-graph courtesy of Martha Ann Keels, DDS, PhD.

FIGURE 4Diagram of smear versus pea-sized amount offluoride toothpaste.

8 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on September 3, 2021www.aappublications.org/newsDownloaded from

o http://www.cdc.gov/fluoridation/.

6. Understand indications for SDFand be able to recognize theclinical appearance of SDF-treated teeth.

LEAD AUTHORS

Melinda B. Clark, MD, FAAPMartha Ann Keels, DDS, PhDRebecca L. Slayton, DDS, PhD

SECTION ON ORAL HEALTH EXECUTIVECOMMITTEE, 2018–2019

Patricia A. Braun, MD, MPH, FAAP,ChairpersonSusan A. Fisher-Owens, MD, MPH, FAAP

Qadira Ali Huff, MD, MPH, FAAPJeffrey M. Karp, DMDAnupama Rao Tate, DMDJohn H. Unkel, DDS, MD, MPA, FAAPDavid Krol, MD, MPH, FAAP, Immediate PastChairperson

LIAISONS

Tooka Zokaie, MPH, CLSSGB – AmericanDental AssociationMatt Crespin, MPH, RDH – American DentalHygienists’ AssociationJohn Fales, DDS, MS – American Academy ofPediatric Dentistry

STAFF

Ngozi Onyema-Melton, MPH, CHESLauren Barone, MPH

ABBREVIATIONS

AAP: American Academy ofPediatrics

AAPD: American Academy ofPediatric Dentistry

ADA: American Dental AssociationCDC: Centers for Disease Control

and PreventionCPT: Current Procedural

TerminologyEPA: US Environmental Protection

AgencyOTC: over-the-counterSDF: silver diamine fluorideUSPSTF: US Preventive Services

Task Force

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

REFERENCES

1. US Department of Health and HumanServices. Oral Health in America: AReport of the Surgeon General.Rockville, MD: National Institute ofDental and Craniofacial Research; 2000

2. Mealey BL. Periodontal disease anddiabetes. A two-way street. [publishedcorrection appears in J Am Dent Assoc.2008;139(3):252]. J Am Dent Assoc.2006;137(suppl):26S–31S

3. Tomar SL, Reeves AF. Changes in theoral health of US children andadolescents and dental public healthinfrastructure since the release of theHealthy People 2010 Objectives. AcadPediatr. 2009;9(6):388–395

4. Dye BA, Li X, Thorton-Evans G. Oral healthdisparities as determined by selectedhealthy people 2020 oral health objectivesfor the United States, 2009–2010. NCHSData Brief. 2012;(104):1–8

5. Ramos-Gomez F, Kinsler J, Askaryar H.Understanding oral health disparitiesin children as a global public healthissue: how dental health professionalscan make a difference. J Public HealthPolicy. 2020;41(2):114–124

6. Tinanoff N, Baez RJ, Diaz Guillory C,et al. Early childhood cariesepidemiology, aetiology, risk

assessment, societal burden,management, education, and policy:global perspective. Int J Paediatr Dent.2019;29(3):238–248

7. Frank M, Keels MA, Quiñonez R, RobertsM, Divaris K. Dental caries risk variesamong subgroups of children withspecial health care needs. Pediatr Dent.2019;41(5):378–384

8. Chi DL, Rossitch KC, Beeles EM.Developmental delays and dental cariesin low-income preschoolers in the USA:a pilot cross-sectional study andpreliminary explanatory model. BMCOral Health. 2013;13:53

9. Dye BA, Thornton-Evans G. Trends inoral health by poverty status asmeasured by Healthy People 2010objectives. Public Health Rep. 2010;125(6):817–830

10. Stearns SC, Rozier RG, Kranz AM, PahelBT, Quiñonez RB. Cost-effectiveness ofpreventive oral health care in medicaloffices for young Medicaid enrollees.Arch Pediatr Adolesc Med. 2012;166(10):945–951

11. Section on Oral Health. Maintaining andimproving the oral health of youngchildren. Pediatrics. 2014;134(6):1224–1229

12. Hagan JF, Shaw JS, Duncan PM, eds..Promoting Oral Health. Bright Futures:Guidelines for Health Supervision ofInfants, Children, and Adolescents, 4thed. Elk Grove Village, IL: AmericanAcademy of Pediatrics; 2017:205–217

13. Lynch RJM, Navada R, Walia R. Low-levels of fluoride in plaque and salivaand their effects on thedemineralisation and remineralisationof enamel; role of fluoride toothpastes.Int Dent J. 2004;54(5 suppl 1):304–309

14. Featherstone JD. Prevention andreversal of dental caries: role of lowlevel fluoride. Community Dent OralEpidemiol. 1999;27(1):31–40

15. Aoba T, Fejerskov O. Dental fluorosis:chemistry and biology. Crit Rev Oral BiolMed. 2002;13(2):155–170

16. Everett ET. Fluoride’s effects on theformation of teeth and bones, and theinfluence of genetics. J Dent Res. 2011;90(5):552–560

17. DenBesten PK. Biological mechanismsof dental fluorosis relevant to the useof fluoride supplements. CommunityDent Oral Epidemiol. 1999;27(1):41–47

18. Ismail AI, Bandekar RR. Fluoridesupplements and fluorosis: a meta-

PEDIATRICS Volume 146, number 6, December 2020 9 by guest on September 3, 2021www.aappublications.org/newsDownloaded from

analysis. Community Dent OralEpidemiol. 1999;27(1):48–56

19. Levy SM, Broffitt B, Marshall TA,Eichenberger-Gilmore JM, Warren JJ.Associations between fluorosis ofpermanent incisors and fluoride intakefrom infant formula, other dietarysources and dentifrice during earlychildhood. J Am Dent Assoc. 2010;141(10):1190–1201

20. National Center for Health Statistics;National Center for Chronic DiseasePrevention and Health Promotion. Dataquality evaluation of the dentalfluorosis clinical assessment data fromthe National Health and NutritionExamination Survey, 1999–2004 and2011–2016. Vital Health Stat. 2019;2(183):1–32

21. Centers for Disease Control andPrevention. Recommendations for usingfluoride to prevent and control dentalcaries in the United States. MMWRRecomm Rep. 2001;50(rr):1–42

22. Berg J, Gerweck C, Hujoel PP, et al.;American Dental Association Council onScientific Affairs Expert Panel onFluoride Intake From Infant Formulaand Fluorosis. Evidence-based clinicalrecommendations regarding fluorideintake from reconstituted infantformula and enamel fluorosis: a reportof the American Dental AssociationCouncil on Scientific Affairs. J Am DentAssoc. 2011;142(1):79–87

23. Wong MCM, Clarkson J, Glenny A-M,et al. Cochrane Reviews on the benefits/risks of fluoride toothpastes. J DentRes. 2011;90(5):573–579

24. Wright JT, Hanson N, Ristic H, Whall CW,Estrich CG, Zentz RR; American DentalAssociation, Council on ScientificAffairs. Fluoride toothpaste efficacy andsafety in children younger than 6 years:a systematic review. J Am Dent Assoc.2014;145(2):182–189

25. Scottish Intercollegiate GuidelinesNetwork. Prevention and Managementof Dental Decay in the Pre-School Child.A National Guideline. Edinburgh,Scotland: Scottish IntercollegiateGuidelines Network; 2005

26. Al-Mulla A, Karlsson L, Kharsa S,Kjellberg H, Birkhed D. Combination ofhigh-fluoride toothpaste and no post-brushing water rinsing on enameldemineralization using an in-situ caries

model with orthodontic bands. ActaOdontol Scand. 2010;68(6):323–328

27. American Dental Association Council onScientific Affairs. Professionally appliedtopical fluoride: evidence-based clinicalrecommendations. J Am Dent Assoc.2006;137(8):1151–1159

28. American Academy of PediatricDentistry. Fluoride therapy. In: TheReference Manual of PediatricDentistry. Chicago, IL: AmericanAcademy of Pediatric Dentistry; 2018:262–265. Available at: www.aapd.org/media/Policies_Guidelines/G_fluoridetherapy.pdf. Accessed March 25,2019

29. Weyant RJ, Tracy SL, Anselmo TT, et al;American Dental Association Council onScientific Affairs Expert Panel onTopical Fluoride Caries PreventiveAgents. Topical fluoride for cariesprevention: executive summary of theupdated clinical recommendations andsupporting systematic review.[published correction appears in J AmDent Assoc. 2013;144(12):1335]. J AmDent Assoc. 2013;144(11):1279–1291

30. Patient Protection and Affordable CareAct, 42 USC x18001 (2010)

31. Moyer VA; US Prevention Services TaskForce. Prevention of dental caries inchildren from birth through age5 years: US Preventive Services TaskForce recommendation statement.Pediatrics. 2014;133(6):1102–1111

32. Maternal and Child Health BureauExpert Panel. Topical fluoriderecommendations for high-riskchildren: development of decisionsupport matrix. 2007. Available at: www.mchoralhealth.org/PDFs/TopicalFluorideRpt.pdf. Accessed March25, 2019

33. Adair SM. Evidence-based use offluoride in contemporary pediatricdental practice. Pediatr Dent. 2006;28(2):133–142–198

34. Twetman S, Petersson L, Axelsson S,et al. Caries-preventive effect of sodiumfluoride mouthrinses: a systematicreview of controlled clinical trials. ActaOdontol Scand. 2004;62(4):223–230

35. Pendrys DG, Katz RV, Morse DE. Riskfactors for enamel fluorosis ina fluoridated population. AmJ Epidemiol. 1994;140(5):461–471

36. Rozier RG, Adair S, Graham F, et al.Evidence-based clinicalrecommendations on the prescriptionof dietary fluoride supplements forcaries prevention: a report of theAmerican Dental Association Council onScientific Affairs. J Am Dent Assoc.2010;141(12):1480–1489

37. American Academy of PediatricDentistry. Best practices: fluoridetherapy. In: The Reference Manual ofPediatric Dentistry. Chicago, IL:American Academy of PediatricDentistry; 2018:262–265. Available at:https://www.aapd.org/research/oral-health-policies–recommendations/.Accessed March 25, 2019

38. Buzalaf MAR, Whitford GM. Fluoridemetabolism. Monogr Oral Sci. 2011;22:20–36

39. Fein SB, Grummer-Strawn LM, Raju TNK.Infant feeding and care practices in theUnited States: results from the InfantFeeding Practices Study II. Pediatrics.2008;122(suppl 2):S25–S27

40. Centers for Disease Control andPrevention. 2014 fluoridation statistics.Available at: https://www.cdc.gov/fluoridation/statistics/2014stats.htm.Accessed October 14, 2020

41. Centers for Disease Control andPrevention. Water fluoridation data &statistics. Available at: www.cdc.gov/fluoridation/statistics/index.htm.Accessed March 25, 2019

42. Centers for Disease Control andPrevention. Ten great public healthachievements–United States,1900–1999. MMWR Morb Mortal WklyRep. 1999;48(12):241–243

43. US Department of Health and HumanServices, Centers for Disease Controland Prevention. Statement on theevidence supporting the safety andeffectiveness of community waterfluoridation. Available at: www.cdc.gov/fluoridation/pdf/Scientific-Statement-on-Community-Water-Fluoridation-h.pdf.Accessed May 5, 2019

44. US Department of Health and HumanServices Federal Panel on CommunityWater Fluoridation. US Public HealthService Recommendation for fluorideconcentration in drinking water for theprevention of dental caries. PublicHealth Rep. 2015;130(4):318–331

10 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on September 3, 2021www.aappublications.org/newsDownloaded from

45. Burt BA, Eklund S. Dentistry, DentalPractice, and the Community, 6th ed. StLouis, MO: Elsevier Saunders; 2005

46. Centers for Disease Control andPrevention. Water fluoridationadditives. Available at: https://americanfluoridationsociety.org/wp-content/uploads/2017/05/f-Water-Fluoridation-Additives-Engineering-Fact-Sheet-CDC-2011.pdf. Accessed March 25,2019

47. Cheng KK, Chalmers I, Sheldon TA.Adding fluoride to water supplies. BMJ.2007;335(7622):699–702

48. Safe Water Drinking Act, 42 USC x300f(1974)

49. American Dental Association Division ofCommunications. For the dentalpatient: infants, formula and fluoride.J Am Dent Assoc. 2007;138(1):132

50. Shulman JD, Wells LM. Acute fluoridetoxicity from ingesting home-use dentalproducts in children, birth to 6 years ofage. J Public Health Dent. 1997;57(3):150–158

51. Van Winkle S, Levy SM, Kiritsy MC,Heilman JR, Wefel JS, Marshall T. Waterand formula fluoride concentrations:significance for infants fed formula.Pediatr Dent. 1995;17(4):305–310

52. Crystal YO, Marghalani AA, Ureles SD,et al. Use of silver diamine fluoride fordental caries management in childrenand adolescents, including those withspecial health care needs. Pediatr Dent.2017;39(5):135–145

53. American Academy of PediatricDentistry. Policy on the Use of SilverDiamine Fluoride for Pediatric DentalPatients. Chicago, IL: American Academy

of Pediatric Dentistry; 2018. Available at:https://www.aapd.org/media/Policies_Guidelines/P_SilverDiamine.pdf.Accessed March 24, 2019

54. American Academy of PediatricDentistry. Chairside Guide: SilverDiamine Fluoride in the Management ofDental Caries Lesions. Chicago, IL:American Academy of PediatricDentistry; 2018. Available at: https://www.aapd.org/media/Policies_Guidelines/R_ChairsideGuide.pdf.Accessed March 24, 2019

55. Douglass AB, Clark MB, Maier R, et al.Smiles for Life: A National Oral HealthCurriculum. 3rd ed. Leawood, KS:Society of Teachers of Family Medicine;2010, Available at: www.smilesforlifeoralhealth.com. AccessedMarch 28, 2019

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DOI: 10.1542/peds.2020-034637 originally published online November 30, 2020; 2020;146;Pediatrics 

HEALTHMelinda B. Clark, Martha Ann Keels, Rebecca L. Slayton and SECTION ON ORAL

Fluoride Use in Caries Prevention in the Primary Care Setting

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