BEST PRACTICES: FLUORIDE THERAPY

Fluoride Therapy
Latest Revision
2018

Purpose to designate fluoride simply as systemic or topical. Fluoride

The American Academy of Pediatric Dentistry intends that is swallowed, such as fluoridated water and dietary
these recommendations to help practitioners and parents supplements, may contribute to a topical effect on erupted
make decisions concerning appropriate use of fluoride teeth (before swallowed, as well as a topical effect due to
as part of the comprehensive oral health care for infants, increasing salivary and gingival crevicular fluoride levels).
children, adolescents, and persons with special health care Additionally, elevated plasma fluoride levels can treat the outer
needs. surface of fully mineralized, but unerupted, teeth topically.
Similarly, topical fluoride that is swallowed may have a
Methods systemic effect.12
This document was developed by the Liaison with Other Fluoridation of community drinking water is the most
Groups Committee and adopted in 1967. These recom- equitable and cost-effective method of delivering fluoride to
mendations by the Council of Clinical Affairs are a all members of most communities. 13 Water fluoridation at
revision of the previous version, last revised in 2014. To the level of 0.7-1.2 mg fluoride ion/L parts per million
update this guidance, an electronic search of the scientific fluoride (ppm F) was introduced in the U.S. in the 1940s.
literature from 2012 to 2017 regarding the use of systemic Since fluoride from water supplies is now one of several
and topical fluoride was completed. Database searches were sources of fluoride, the Department of Health and Human
conducted using the terms: fluoride caries prevention, fluorida- Services has recommended not having a fluoride range,
tion, fluoride gel, fluoride varnish, fluoride toothpaste, fluoride but rather to standardize all water to the 0.7 ppm F level. The
therapy, and topical fluoride. Because 720 papers were rationale is to balance the benefits of preventing dental caries
identified through these electronic searches, an alternate while reducing the chance of fluorosis.1
strategy of limiting the information gathering to systematic Community water fluoridation has been associated with
review using the term fluoride caries prevention yielded 95 the decline in caries prevalence in U.S. adolescents, from 90
papers since 2012. Nine well-conducted systematic reviews1-9 percent in at least one permanent tooth in 12-17 years-olds
and their references primarily were used for this update. in the 1960s, to 60 percent in a 1999-2004 survey.14 When
Expert opinions and clinical practices also were relied upon used appropriately, fluoride is both safe and effective in
for these recommendations. preventing and controlling dental caries. Although adverse
health effects (e.g., decreased cognitive ability, endocrine
Background disruption and cancer) have been ascribed to the use of
Fluoride has been a major factor in the decline in prevalence fluoride over the years, the preponderance of evidence from
and severity of dental caries in the U.S. and other econo- large cohort studies and systematic reviews does not support
mically developed countries. It has several caries-protective an association of such health issues and consumption of fluo-
mechanisms of action. Topically, low levels of fluoride in ridated water.1 Regarding cognitive ability, a recent study of
plaque and saliva inhibit the demineralization of sound mothers’ urinary fluoride levels and their child’s intelligence
enamel and enhance the remineralization of demineralized quotient (IQ) levels suggested an association with exposure
enamel. Fluoride also inhibits dental caries by affecting the levels greater than those recommended in the U.S. for water
metabolic activity of cariogenic bacteria. 10 High levels of fluoridation.15 However, a prospective study in New Zealand
fluoride, such as those attained with the use of topical gels did not support an association between fluoridated water
or varnishes, produce a temporary layer of calcium fluoride- and IQ measurements, 16 and a national sample in Sweden
like material on the enamel surface. The fluoride is released found no relationship between fluoride levels in water supplies
when the pH drops in response to acid production and be- and cognitive ability, non-cognitive ability, and education.17
comes available to remineralize enamel or affect bacterial Consumption of fluoride during the mineralization of teeth,
metabolism.11 The original belief was that fluoride’s primary
action was to inhibit dental caries when incorporated into
ABBREVIATIONS
developing dental enamel (i.e., the systemic route), but the
IQ: Intelligence quotient. NaFV: Sodium fluoride varnish. ppm F:
fluoride concentration in sound enamel does not fully explain parts per million fluoride. SDF: Silver diamine fluoride.
the marked reduction in dental caries. It is oversimplification

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 BEST PRACTICES: FLUORIDE THERAPY

caries in permanent teeth.27 Some topical fluoride gel and

Table. DIETARY FLUORIDE SUPPLEMENTATION SCHEDULE foam products are marketed with recommended treatment
Age <0.3 ppm F 0.3 to 0.6 ppm F >0.6 ppm F times of less than four minutes, but there are no clinical trials
showing efficacy of shorter than four-minute application
Birth to 6 months 0 0 0 times.28 There also is limited evidence that topical fluoride
6 mo to 3 years 0.25 mg 0 0 foams are efficacious in children.2 Children at risk for caries
3 to 6 years 0.50 mg 0.25 mg 0 should receive a professional fluoride treatment at least every
six months.28
6 to at least 16 years 1.00 mg 0.50 mg 0
Silver diamine fluoride ([SDF]; 5 percent F 44,800 ppm
F) recently has been approved by the U.S. Food and Drug
Administration and currently is used most frequently to arrest
however, can cause fluorosis (children 1-3 years of age being dentinal caries. SDF arrests caries by the antibacterial effect
most susceptible for fluorosis of the permanent incisors). of silver and by remineralization of enamel and dentin.9 Some
The National Health and Nutrition Examination Survey clinical trials show a caries arrest rate greater than 80 percent,7
1999-2004 study found 23 percent of the U.S. population but such studies have a high risk of bias and a wide variation
had very mild or mild fluorosis.18 Decisions concerning the of results, leading to conditional recommendations at this
administration of fluoride are based on the unique needs time.29 Although the product is highly concentrated, less than
of each patient, including the risks and benefits (e.g., risk a drop is needed to treat several caries lesions. The only re-
of mild or moderate fluorosis versus the benefits of decreasing ported side effects of SDF are that caries lesions stain black
caries increment and, in some cases preventing, devastating after treatment, and it will temporarily stain skin with contact.
dental disease). Home use of fluoride products for children should focus
Fluoride supplements also are effective in reducing pre- on regimens that maximize topical contact, in lower-dose
valence of dental caries and should be considered for children higher-frequency approaches.30 Meta-analyses of more than
at high caries risk who drink fluoride-deficient (less than 70 randomized or quasi-randomized controlled clinical trials
0.6 ppm F) water 19 (see Table). Determination of dietary show that fluoride toothpaste is efficacious in reducing pre-
fluoride before prescribing supplements can help reduce valence of dental caries in permanent teeth, with the effect
intake of excess fluoride. Sources of dietary fluoride may increased in children with higher baseline level of caries
include drinking water from home, day care, and school; with higher concentration of fluoride in the toothpaste,
beverages such as soda 20, juice21, and infant formula 22; pre- greater frequency of use, and supervision of brushing. 31,32 A
pared food23; and toothpaste. Concentrated infant formulas meta-analysis of eight clinical trials on caries increment in
requiring reconstitution with water have raised concerns preschool children also shows that tooth brushing with fluo-
regarding an increased risk of fluorosis. 24 Infants may be ridated toothpaste significantly reduces dental caries prevalence
particularly susceptible because of the large consumption of in the primary dentition.6 Using no more than a smear or
such liquid in the first year of life, while the body weight rice-size amount of fluoridated toothpaste for children less
is relatively low. 12 An evidence-based review found that than three years of age may decrease risk of fluorosis. Using
consumption of reconstituted infant formula can be associated no more than a pea-size amount of fluoridated toothpaste is
with an increased risk of mild fluorosis, but recommended appropriate for children aged three to six8 (see Figure). To
the continued use of fluoridated water. 25 One study has maximize the beneficial effect of fluoride in the toothpaste,
shown that dental fluorosis levels do not vary in fluoridated supervised tooth-brushing should be done twice a day and
areas regardless of premixed versus reconstituted formula.26 rinsing after brushing should be kept to a minimum or
Standardization of the optimal fluoride levels in drinking eliminated altogether.4 Other topical fluoride products (e.g.,
water to 0.7 ppm F, however, makes this issue moot.
Professionally-applied topical fluoride treatments are
efficacious in reducing prevalence of dental caries. The most
commonly used agents for professionally-applied fluoride
treatments are five percent sodium fluoride varnish ([NaFV]
2.26 percent F, 22,600 ppm F) and acidulated phosphate
fluoride (APF; 1.23 percent F, 12,300 ppm F). Meta-analyses
of 23 clinical trials, most with twice yearly application,
favors the use of fluoride varnish in primary and permanent
teeth. 2 Unit doses of fluoride varnish are the only profes-
sional topical fluoride agent that are recommended for
children younger than age six. 2 Meta-analyses of placebo-
controlled trials show that fluoride gels, applied at three Figure. Comparison of a smear (left) with a pea-sized (right) amount
month to one year intervals, also are efficacious in reducing of toothpaste.

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BEST PRACTICES: FLUORIDE THERAPY

prescription-strength home-use 0.5 percent fluoride gels 4. S cottish Intercollegiate Guideline Network, Dental
and pastes; prescription-strength, home-use 0.09 percent interventions to prevent caries in children. March 2014.
fluoride mouthrinse) have benefit in reducing dental caries Available at: “www.sign.ac.uk/assets/sign138.pdf ”.
in children six years or older.2 Acccessed October 10, 2017. (Archived by WebCite®
at: “http://www.webcitation.org/6xE7Ay0oY”)
Recommendations 5. Chou R, Cantor A, Zakher B, Mitchell JP, Pappas M.
1. There is confirmation from evidence-based reviews Prevention of Dental Caries in Children Younger Than
that fluoride use for the prevention and control of 5 Years Old: Systematic Review to Update the U.S. Pre-
caries is both safe and highly effective in reducing ventive Services Task Force Recommendation. Evidence
dental caries prevalence. Synthesis No. 104. AHRQ Publication No. 12-05170-
2. There is support from evidence-based reviews that EF-1. Rockville, Md.: Agency for Healthcare Research
fluoride dietary supplements are effective in reducing and Quality; 2014.
dental caries and should be considered for children 6. Santos APP, Nadanovsky P, Oliveira BH. A systematic
at caries risk who drink fluoride-deficient (less than review and meta-analysis of the effects of fluoride tooth-
0.6 ppm) water. paste on the prevention of dental caries in the primary
3. There is support from evidenced-based reviews that dentition of preschool children. Community Dent Oral
professionally applied topical fluoride treatments as five Epidemiol 2013;41(1):1-12.
percent NaFV or 1.23 percent F gel preparations are 7. Gao SS, Zhao IS, Hiraishi N, et al. Clinical trials of silver
efficacious in reducing caries in children at caries risk. diamine fluoride in arresting caries among children: A
4. There is support from evidence-based reviews that systematic review. Int Amer Assoc Dent Res 2016;1(3):
fluoridated toothpaste is effective in reducing dental 201-10.
caries in children with the effect increased in chil- 8. Wright JT, Hanson N, Ristic H, et al. Fluoride tooth-
dren with higher baseline level of caries, higher con- paste efficacy and safety in children younger than 6
centration of fluoride in the toothpaste, greater years. J Am Dent Assoc 2014;145(2):182-9.
frequency in use, and supervision. Using no more than 9. Zhao IS, Gao SS, Hiraishi N, et al. Mechanisms of silver
a smear or rice-size amount of fluoridated toothpaste diamine fluoride on arresting caries: A literature review.
for children less than three years of age may decrease Int Dent J 2018;68(2):67-76.
risk of fluorosis. Using no more than a pea-size 10. B uzalaf MA, Pessan JP, Honório HM, ten Cate JM.
amount of fluoridated toothpaste is appropriate for Mechanism of action of fluoride for caries control.
children aged three to six. Monogr Oral Sci 2011;22:97-114.
5. There is support from evidenced-based reviews that 11. Center for Disease Control and Prevention. Recom-
prescription-strength home-use 0.5 percent fluoride mendations for using fluoride to prevent and control
gels and pastes and prescription-strength home-use dental caries in the United States. MMWR Recomm
0.09 percent fluoride mouthrinse also are effective Rep 2001;50(RR-14):1-42.
in reducing dental caries 12. Tinanoff N. Use of fluoride. In: Berg J, Slayton RA, eds.
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fluoride for the arrest of cavitated caries lesions in 13. Division of Oral Health, National Center for Chronic
primary teeth as part of a comprehensive caries man- Disease Prevention and Health Promotion, Center for
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