46 American Dental Association For example, it has been reported in a number of studies that young children inadvertently swallow an average of 0.30 mg of fluoride from fluoride toothpaste at each brushing.44-48 If a child brushes twice a day, 0.60 mg of fluoride could be ingested inappropriately. This could slightly exceed the Adequate Intake (AI) values from Table 2. The 0.60 mg consumption is 0.10 mg higher than the AI value for children 6 to 12 months and is 0.10 mg lower than the AI for children from 1-3 years of age.40 Although toothpaste is not meant to be swallowed, children could consume the daily recommended Adequate Intake amount of fluoride from toothpaste alone. In order to decrease the risk of dental fluorosis, the American Dental Association (ADA) recommends:49 • For children younger than 3 years, caregivers should begin brushing children’s teeth as soon as they begin to come into the mouth by using fluoride toothpaste in an amount no more than a smear or the size of a grain of rice (Figure 4). Brush teeth thoroughly twice per day (morning and night) or as directed by a dentist or physician. Supervise children’s brushing to ensure that they use the appropriate amount of toothpaste. • For children 3 to 6 years of age, caregivers should dispense no more than a pea-sized amount (Figure 4) of fluoride toothpaste. Brush teeth thoroughly twice per day (morning and night) or as directed by a dentist or physician. Supervise children’s brushing to minimize swallowing of toothpaste.49 Additional information on this topic can be found in this Section, Question 29. It should be noted that the amounts of fluoride discussed here are intake, or ingested, amounts. When fluoride is ingested, a portion is retained in the body and a portion is excreted. Addition information on this topic can be found in this Section, Question 25. 24. Is there a need for prenatal dietary fluoride supplementation? Answer. There is no scientific basis to suggest any need to increase a woman’s daily fluoride intake during pregnancy or breastfeeding to protect her health. At this time, scientific evidence is insufficient to support the recommendation for prenatal fluoride supplementation for decay prevention for infants. Fact. The Institute of Medicine determined that, “No data from human studies document the metabolism of fluoride during lactation. Because fluoride concentrations in human milk are very low (0.007 to 0.011 ppm) and relatively insensitive to differences in the fluoride concentrations of the mother’s drinking water, fluoride supplementation during lactation would not be expected to significantly affect fluoride intake by the nursing infant or the fluoride requirement of the mother.”40 A 2005 a randomized, double blind study50 compared the amount of fluoride incorporated into primary teeth exposed to prenatal and post natal fluoride supplements to primary teeth that were exposed to only postnatal fluoride. The study concluded that teeth exposed to prenatal and postnatal fluoride supplements had no additional measurable fluoride other than that attributable to postnatal fluoride alone.50 This study confirmed the findings of a 1997 randomized, double blind study that evaluated the effectiveness of prenatal dietary supplementation which concluded that the data did not support the hypothesis that prenatal fluoride had a strong decay preventive effect on primary teeth.51 For children under three years old, use no more than a smear or grain-of-rice- sized amount of fluoride toothpaste. For children three to six years old, use only a pea- sized amount of fluoride toothpaste. Figure 4. Examples of Toothpaste Amounts for Children49