Fluoride therapy is the use of fluoride products topically (applied to the tooth surface) or systemically (ingested in supplements or water) to prevent or reduce the incidence of dental caries (tooth decay).
Fluoride therapy may be initiated systemically before a child's teeth emerge during tooth development in order to strengthen tooth enamel (the hard outer surface of a tooth) and prevent dental caries. Fluoride may also be applied in the form of gels, foams, and varnishes to the tooth surface, which provides temporary protection. Topical methods are effective for adults and children. The use of fluoridated toothpaste and mouth rinses is another means of delivering fluoride therapy.
Fluoride therapy is contraindicated for children who are drinking fluoridated water and/or who are also receiving the optimal fluoride dosage (about 1.0 ppm) from foods and bottled beverages. Fluoride in dentifrices (toothpastes) and mouth rinses also has the potential of being ingested. Overexposure to fluoride while a child's teeth are forming under the gums results in fluorosis, an abnormal condition that affects the appearance of tooth enamel and can be very mild (a few white spots on a tooth) to severe (etching, pitting, and brown discoloration on many teeth).
Pediatricians, oral care professionals, and dental hygienists assess the amount of fluoride in a child's natural environment and caries risk before prescribing fluoride supplements or topical fluoride therapy. Usually, if a child lives in an area where fluoride has been added to the drinking water, supplements are not necessary. A pediatrician or oral care professional may recommend supplements if the child exhibits moderate-to-high risk for dental caries. However, supplementation should be done with caution, weighing the risks of fluoride overexposure against slightly more added protection.
Fluoride therapy can be administered through fluoride supplements, fluoridated water, and some bottled beverages containing fluoride. Carbonated drinks, juices, and bottled waters can contain fluoride in varying amounts. Often, the fluoride in these products is not printed on the labels. Some other foods and beverages are high in fluoride, including fish with bones, tea, poultry products, cereals, or infant formula made with fluoridated water. Food cooked in Tefloncoated pans also provides fluoride.
Breast-fed infants usually do not need supplements until after they are six months old. By that time, they may be drinking water from a cup or eating some foods that contain fluoride, so supplements still may not be necessary.
Fluoride supplements are dispensed in the United States and Canada as lozenges, oral solutions, tablets, and chewable tablets. Fluoride can also be prescribed in combination with a vitamin supplement as chewable tablets or in an oral solution. In the United States, common brand names for fluoride supplements are Fluoritab, Fluorodex, Flura, Flura-Drops, FluraLoz, Karidium, Luride, Luirde Lozi-Tabs, Pediaflor, Pharmaflur, and Phos-Flur. The vitamin/fluoride combination is sold as Adeflor, Cari-Tab, Mulvidren-F, Poly-Vi-Flor, Tri-Vi-Flor, and Vi-Daylin/F. These supplements are only available by prescription from a pediatrician or a oral care professional.
Dosing of fluoride supplements is different for every child. When determining the amount to prescribe, pediatricians and oral care professionals should consider all fluoride exposure in the child's environment and prescribe supplements with fluoride limits in mind. Recommended total daily fluoride intake has been set at 0.1-1.5 mg for the infant and child to three years of age, 1-2.5 mg for the four-to-six-year old, 1.5-1.5 mg for the seven-to-ten year old, and 1.5-4 mg for an adolescent and an adult.
Calcium supplements, or any products with aluminum hydroxide, should not be taken along with fluoride supplements. Each dose should be spaced at least two hours apart to achieve the maximum benefit of each.
Overexposure to fluoride is a concern to pediatricians and oral care professionals because it can result in fluorosis. Fluorosis, which is caused by exposure to excessive amounts of fluoride while the enamel is being formed, can affect both the primary (baby) teeth and permanent teeth. It does not affect the permanent teeth once they have fully developed. Most often, the fluorosis appears on the front incisors (front teeth) and less frequently on the molars. This characteristic poses a high cosmetic problem because the front teeth are most exposed when children speak or smile. There is no cure for fluorosis except cosmetic restoration, which can be costly.
Fluoride gels and foams are the most common form of topical fluoride application at the oral care professional's office. A flavored gel containing a concentration of fluoride is offered in a tray to the patient. There is one tray for the upper teeth and one for the lower teeth. The patient should sink his or her teeth into the tray and let the teeth bathe in the fluoride for a specific amount of time. The mouth should be emptied but not rinsed; then, the patient is instructed not to eat or drink for 30 minutes.
Fluoride varnishes that are being used in Europe have been found to be easier to apply and more durable for the patient; however, varnishes have not been approved for use as a fluoride treatment in the United States. With the varnishes used in Europe, the patient may also eat or drink soon after application. The residue is only removed when the patient's teeth are brushed.
Finally, the use of fluoride toothpaste and fluoridated mouth rinses may also be recommended for adults and children. According to the American Dental Association, young children under six often use too much fluoride toothpaste, and consistently swallow it. This has contributed significantly to excess fluoride ingestion. Careful monitoring of toothpaste amounts by parents and encouragement to spit, instead of swallowing the toothpaste, can drastically decrease the amount of fluoride a child ingests from dentifrices.
Composite resins and adhesives with fluoride are used by oral care professionals when filling cavities and cementing crowns into place. Sufficient amounts of topical fluoride are applied to protect adjacent teeth that normally are at risk for further wear and decay due to the location of the cavity (e.g., deep pits in molars) or the stress due to bridge and crown fittings.
Dental and medical insurance usually cover fluoride therapy as "routine care."
The oral care professional should thoroughly dry the patient's teeth before applying fluoride gels or foams. The varnishes, however, can be applied to damp teeth and still produce the desired effect. Fluoride dentifrices and mouth rinses require no special preparation.
When varnishes are used, the patient can generally eat before 30 minutes, the time he or she is required to wait after a fluoride treatment. This detail can be extremely important for patients with diabetes, who must eat frequently.
Fluoride treatments provide temporary protection against dental caries. They are not as effective as systemic intake of fluoridated water, but they can be extremely helpful to children who are at moderate-to-high risk for dental caries. Furthermore, they can also help in patients who need extra protection against root caries due to gum recession and xerostomia (dry mouth).
Health care team roles
The pediatrician has an important role in a child's oral health. The first person to be consulted about a child's dental needs, the pediatrician can monitor a child's oral hygiene, determine when to make referrals, and regulate fluoride therapy.
Oral care professionals and dental hygienists provide fluoride therapy, monitor oral hygiene, and also assess the amount of fluoride in a person's environment. The oral care professional also makes detailed repairs and suggests therapeutic plans for the child's dental health.
The pediatrician plays an important role in the education of parents regarding fluoride excess and safety issues about fluoride toothpastes and mouth rinses. Nurses and teachers also participate in parent education about fluoride usage and good dental habits. They can teach children about proper tooth brushing, especially the amount of toothpaste to use. These are lessons all adults need to learn as well. The educators can also encourage periodic testing of the water for fluoride levels in the community or at home, especially if water filters are used.
Dental caries— Tooth decay.
Enamel— The hard outer surface of a tooth.
Fluoride— A fluorine ion used to treat water or apply directly to tooth surfaces to prevent dental caries.
Incisors— Front teeth used for biting. Includes central and lateral incisors.
Primary teeth— The teeth a child has before permanent ones; primary teeth; baby teeth.
Systemic— Ingested as tablets or drops and circulates throughout the human body.
Topical— On the surface of a tooth.
Harris, N.O., and F. Garcia-Godoy, eds. Primary Preventive Dentistry. Stamford, CT: Appleton & Lange, 1999.
Author unspecified. "Sodium fluoride (Systemic)." USPDI-Volume II. Advice for the Patient: Drug Information in Lay Language. (April 2000): 0038.
Author unspecified. "Vitamins and Fluoride. (Systemic)." USPDI-Volume II. Advice for the Patient: Drug Information in Lay Language. (April 2000): 0074.
Beaulieu, E., and L.A. Dufour. "Early Childhood Caries: How You Can Help Preserve Teeth for Life." Consultant 40, no. 6 (May 2000): 1129.
Beltran-Aquilar, E.D., Goldstein, J.W., and S.A. Lockwood. "Fluoride Varnishes: A Review of Their Clinical Use, Cariostatic Mechanism, Efficacy, and Safety." Journal of the American Dental Association 131, no. 5 (May 2000): 589-597.
Hale, K.J., and K. Heller. "Fluorides: Getting the Benefits, Avoiding the Risks." Comtemporary Pediatrics 17, no. 2 (February 2000): 121.
Heilman, J.R., Kiritsy, M.C., Levy, S.M., and J.S. Wefel. "Assessing Fluoride Levels of Carbonated Soft Drinks." Journal of the American Dental Association 130, no. 11 (November 1999): 1593-1600.
Kuritzky, L. "Fluoride and Bacterial Content of Bottle Water vs. Tap Water." Neurology Alert 18, no. 11 (July 2000): 15.
Lewis, C.W., Grossman, D.C., Domoto, P.K., and R.A. Deyo. "The Role of the Pediatrician in the Oral Health of Children: A National Survey." Pediatrics 106, no. 6 (December 2000): 1475.
Warren, D.P., Henson, H.A., and J.T. Chan. "Dental Hygienist and Patient Comparisons of Fluoride Varnishes to Fluoride Gels." Journal of Dental Hygiene 74, no. 2 (Spring 2000): 94.