Fluoride

Cavities used to be a fact of life. But over the past few decades, tooth decay has been reduced dramatically. The key reason: fluoride.

Research has shown that fluoride reduces cavities in both children and adults. It also helps repair the early stages of tooth decay even before the decay becomes visible.

Many people continue to be misinformed about fluoride and fluoridation. That is unfortunate. Fluoride is like any other natural nutrient; it is safe and effective when used appropriately.

"Fluoride is needed throughout the lifespan to prevent and control tooth decay.  Better directed use of fluoride can lead to considerable savings in public and private resources without compromising the tremendous advances we've made in reducing tooth decay."
                          Dr. Jeffrey Koplan, Director of the United States Centers for Disease Control  & Prevention

Fluoride is a mineral that occurs naturally in almost all foods and water supplies. The fluoride ion comes from the element fluorine. Fluorine, the 13th most abundant element in the earth's crust, is never encountered in its free state in nature. It exists only in combination with other elements as a fluoride compound.  Fluoride compounds are naturally present in water, soil, air, and in most foods.

Fluoride is effective in preventing and reversing the early signs of dental caries (tooth decay). Researchers have shown that there are several ways through which fluoride achieves its decay-preventive effects.

It makes the tooth structure stronger, so teeth are more resistant to acid attacks. Acid is formed when the bacteria in plaque break down sugars and carbohydrates from the diet. Repeated acid attacks break down the tooth, which causes cavities.

Fluoride also acts to repair, or remineralize, areas in which acid attacks have already begun. The remineralization effect of fluoride is important because it reverses the early decay process as well as creating a tooth surface that is more resistant to decay.

Fluoride is available in two forms: topical and systemic.

Topical fluorides strengthen teeth already present in the mouth, making them more decay-resistant. Topical fluorides include toothpastes, mouth rinses and professionally applied fluoride therapies.

Systemic fluorides are those that are ingested into the body and become incorporated into forming tooth structures. Systemic fluorides can also give topical protection because fluoride is present in saliva, which continually bathes the teeth. Systemic fluorides include water fluoridation or dietary fluoride supplements in the form of tablets, drops or lozenges. As a result of the widespread availability of these various sources of fluoride, the decay rates in both the U.S. and other countries have greatly diminished.

It is important to note that the effective prevention of dental decay requires that the proper mix of both systemic and topical fluoride be made available to individuals. Your dentist can help you assess whether you are receiving adequate levels of fluoride for all family members from the two forms.

One method of self-applied topical fluoride that is responsible for a significant drop in the level of cavities since 1960 is use of a fluoride-containing toothpaste. The American Dental Association (ADA) recommends that everyone use a fluoride toothpaste displaying the ADA Seal of Acceptance. Not all toothpastes have earned this endorsement.

Other sources of self-applied fluoride are mouth rinses designed to be rinsed and spit out, either prescribed by your dentist or an over-the-counter variety. The ADA recommends the use of fluoride mouth rinses, but not for children under six years of age because they may swallow the rinse.

For patients who have unusual susceptibility to dental caries (due to dry mouth, medical conditions, or other factors) dentists may recommend a prescription fluoride gel or paste to be used in addition to regular toothpaste.

Professionally-applied fluorides are in the form of a gel or foam, and are applied by a dentist or dental hygienist during dental visits. These fluorides are more concentrated than the self-applied fluorides, and therefore are not needed as frequently.  If you have tooth colored fillings, porcelain veneers, porcelain crowns, or porcelain fused to metal crowns, acidulated fluoride gels should not be used (they will damage the restorations). Instead, neutral pH fluoride gels are available and will not harm esthetic filling materials or restorations.

The ADA recommends that dental professionals use any of the professional strength, tray-applied gels or foam products carrying the ADA Seal of Acceptance. There are no ADA-accepted fluoride professional rinses for use in dental offices, although several are marketed to dentists anyway.

Systemic fluorides such as community water fluoridation and dietary fluoride supplements are effective in reducing tooth decay. These fluorides provide topical as well as systemic protection because fluoride is present in the saliva.

All water contains some fluoride naturally. Community water fluoridation, which has been around for over 50 years, is simply the process of adjusting the fluoride content of fluoride-deficient water to the recommended level for optimal dental health. That recommended level is 0.7 - 1.2 parts fluoride per million parts water (ppm). The limit allowed by the United States Environmental Protection Administration ("EPA") is 4 ppm. 

Water fluoridation has been proven to safely reduce decay in both children and adults. Over the past several decades there have been over 140 carefully undertaken, documented, and published scientific studies undertaken in at least 20 different countries - all demonstrating the safety of drinking fluoridated water.  Water fluoridation is endorsed by nearly every major health and safety-related organization in the world. Community water fluoridation has been credited with reducing dental caries (tooth decay) by 18 to 40% in the United States.  The overwhelming success of community water fluoridation led the U.S. Center for Disease Control in 1999 to select  it as one of the ten great public health achievements of the twentieth century.
                                                                               References are contained in these links:
                                                                                (Morbidity & Mortality Weekly Report, CDC: October 22, 1999 / 48(41); 933)   

                                                                                (Morbiditiy & Mortality Weekly Report, CDC: December 24, 1999 / 48(50);1141)

Too much of anything can be bad for you. Fluoride is no exception.  If it is misused or used in excessive concentrations there can be some ill effects.  Drinking water with too much fluoride causes a condition known as dental fluorosis.  Dental fluorosis is a harmless, but unattractive, discoloring or mottling of the enamel characterized by chalky white specks and lines or by pitted and brown stained irregularities

Modern health experts recommend young children use only a pea-sized amount of toothpaste when brushing, and avoid swallowing toothpaste on a regular basis.  Parents should prevent young children from swallowing any source of fluoride beyond the recommended dose (like fluoride supplements meant for adults).  Children need a tiny amount of fluoride for normal tooth development - your children's dentist or pediatrician can help ensure just the right amount is being used.

While water fluoridation is an extremely effective and inexpensive means of obtaining the fluoride necessary for optimal tooth decay prevention, not everyone lives in a community with a centralized, public or private water source that can be fluoridated or that is fluoridated. For those individuals, fluoride is available in other forms.

For children ages six months to 16 years of age who do not live in fluoridated communities, dietary fluoride supplements (tablets, drops or lozenges) can be consumed as an alternative to water fluoridation for the prevention of tooth decay. Your dentist or physician can prescribe the correct dosage. It is based on the natural fluoride concentration of the child's drinking water and the age of the child (see the chart below).

For optimum benefits, use of dietary fluoride supplements should begin when a child is six months old and be continued daily until the child is 16 years old. The need for taking dietary fluoride supplements over an extended period of time makes dietary fluoride supplements less cost-effective than water fluoridation; therefore, dietary fluoride supplements are considerably less practical as a wide-spread alternative to water fluoridation as a public health measure. Fluoride supplements are only recommended for children living in non-fluoridated areas (like Montgomery County, Pennsylvania). Note also that bottled waters and beverages may have little or no fluoride.

It is important to consider that fluoridated water may be consumed from sources other than the home water supply, such as the workplace, school and/or day care, bottled water, filtered water and from processed beverages and foods prepared with fluoridated water. (However, many of the sources, like bottled waters, are deficient in fluoride). For this reason, dietary fluoride supplements should be prescribed by carefully following the recommended dosage schedule. Dietary fluoride supplements are not recommended for children residing in a fluoridated community.

Important Considerations When Using the Fluoride Supplement Dosage Schedule:

	Fluoride supplements require long-term compliance on a daily basis.
	All sources of fluoride must be evaluated with a thorough fluoride history.
	Patient exposure to multiple water sources can make proper prescribing complex.
	Ingestion of higher than recommended levels of fluoride by children has been associated with an increase in mild dental fluorosis (discoloration and pitting of enamel) in developing, unerupted teeth.
	If the fluoride level of drinking water at your home is unknown, the drinking water must be tested for fluoride content before supplements are prescribed. For testing of fluoride content, contact the local or state health department. Note that fluoride levels may vary considerably from one part of a community to another, depending on the nature and condition of water pipelines.

Conclusion

No matter how you get the fluoride you need -- whether it be through your drinking water, supplements, toothpaste, mouth rinse or professionally applied fluoride -- you can be confident that fluoride is silently at work fighting decay. Safe, convenient, effective ... however you describe it, fluoride fits naturally into any dental care program. For more information about the oral health benefits of fluoride, just ask your dentist.

Our office evaluates each patient's fluoride intake as part of our routine comprehensive examination.  We offer each patient an individualized program of preventive care, which includes recommendations for use of  topical fluoride when appropriate to their condition and desires. 

Internet Links for more information

	Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States
	Information on Water Fluoridation from the C.D.C.

© Copyright David J. Fox, D.M.D. 1996, 2000, 2001. All rights reserved.