The use of fluoride in infants and children

Question 1

What is dental fluorosis?

Answer 1

A condition associated with abnormal enamel development occurring mainly in children younger than seven years of age, is associated with impaired biosynthesis of dental matrix. Manifestations can vary from minimal changes (Toxic Effect [TF] of 1), comprising 80% to 90% of the cases, and noted only by close dental examination; to rarer, florid, unsightly mottling and pitting of the teeth, enamel striations, and in severe cases, ‘snow-capped cusps’ and chalky-white teeth (TF of 2 or more), which may be unsightly and require cosmetic treatment. Secondary teeth are at the greatest risk for fluorosis at 15 to 24 months of age

Question 2

What are the stages of enamel development?

Answer 2

1. In the secretory stage, a protein matrix is laid down and mineral deposition begins.
2. In the transition stage, protein is removed and replaced.
3. In the maturation stage, protein is 95% replaced and mineralization is complete.

Question 3

How does topical flouride act to prevent dental caries?

Answer 3

1. Inhibits plaque by killing bacteria
2. Inhibits demineralization
3. Enhances remineralization of enamel

Question 4

How much fluoride is in toothpaste?

Answer 4

1. “pea-sized” portion 0.4mg

2. Full cover portion 1.0mg

Question 5

What are underlying considerations regarding the use of fluoride?

Answer 5

1. The primary mechanism of the action of fluoride in preventing tooth decay is topical.
2. Water fluoridation is an effective delivery method for topical fluoride.
3. Fluoridated toothpaste is an effective delivery method for topical fluoride.
4. The ingestion of more than the recommended daily dose of fluoride is associated with an increased risk of dental fluorosis.
5. In the absence of adequate topical fluoride exposure (eg, fluoridated toothpaste or water), additional fluoride products may be provided in the form of drops, chewable tablets and lozenges. The effectiveness of these products in preventing dental caries is low in school-aged children and has not been evaluated in infants and toddlers.
6. Some individuals may be susceptible to ‘carious challenge’. Because of either a genetic or an environmental predisposition to a high prevalence of caries, topical fluorides alone may be insufficient to prevent caries among these individuals (ie, additional fluoride may produce no net benefit and other measures such as antibacterial therapy and diet changes may be required)

Question 6

What are the recommendations regarding fluoride?

Answer 6

1. Add fluoride to municipal water if <0.3ppm to a target of 0.7ppm (balance between dental caries and fluorosis.
2. A statement of fluoride concentration should continue to be printed on the toothpaste tube, and the amount in a ‘pea-sized’ portion of toothpaste should be indicated.
3. Fluoride concentrations should be stated on any foods or drinks containing fluoride.
4. Children should use only a ‘pea-sized’ amount of toothpaste, and be encouraged not to swallow the excess.
5. Because the action of fluoride is topical, no fluoride should be given before teeth have erupted.
6. Supplemental fluoride should be administered (Table 1) only from the age of six months, and only if the following conditions prevail:
   a) the concentration of fluoride in drinking water is less than 0.3 ppm;
   b) the child does not brush his or her teeth (or have them brushed by a parent or guardian) at least twice a day; and
   c) if, in the judgment of a dentist or other health professional, the child is susceptible to high caries activity (family history, caries trends and patterns in communities or geographic areas).
7. Supplemental fluoride should be given in preparations that maximize the topical effect, such as mouthwashes or lozenges. Drops, if used, should be diluted with water and squirted on the teeth.

Question 7

What are the recommended supplemental fluoride concentrations for children?

Answer 7

Only if the fluoride concentration <0.3ppm:
0-6mo None
6-m-3y: 0.25mg/day
2-6y: 0.5mg/day
>6yo: 1mg/day