52 American Dental Association 28. Is it safe to use fluoridated water to reconstitute infant formula? Answer. It is safe to use fluoridated water to reconstitute infant formula. Fact. Fluoridated water can be used to prepare infant formula. However, if the child is exclusively consuming infant formula reconstituted with fluoridated water, there could be an increased chance of mild dental fluorosis.86 To lessen this chance, parents can use low- fluoride bottled water some of the time to mix infant formula. These bottled waters are labeled as de- ionized, purified, demineralized, or distilled. However, parents should be aware that using these types of waters exclusively means an infant does not receive the amount of fluoride the Institute of Medicine indicated is required to prevent tooth decay.40 On the other hand, the exclusive use of nonfluoridated water to reconstitute infant formula will not guarantee that an infant will not develop dental fluorosis. The chance of development of dental fluorosis exists through approximate eight years of age when the permanent teeth are still forming under the gums. Fluoride intake from other sources during this time such as toothpaste, mouthrinse and dietary fluoride supplements also contributes to the chance of dental fluorosis for children living in nonfluoridated and fluoridated communities.84 In response to the report of the National Research Council (NRC) Fluoride in Drinking Water: A Scientific Review of EPA’s Standards9 in November 2006, and with an abundance of caution, the ADA issued the Interim Guidance on Fluoride Intake for Infants and Young Children (Interim Guidance). The Interim Guidance is no longer current and has been replaced. Unfortunately, those opposed to fluoridation continue to publicize and use the Interim Guidance in efforts to halt fluoridation. The Interim Guidance was replaced in January 2011 by the ADA Evidence-Based Clinical Recommendations Regarding Fluoride Intake From Reconstituted Infant Formula and Enamel Fluorosis A Report of the American Dental Association Council on Scientific Affairs.84 The report encourages clinicians to follow the American Academy of Pediatrics guidelines for infant nutrition which advocates exclusive breastfeeding until the child is aged 6 months and continued breastfeeding until the child is at least 12 months of age, unless specifically contraindicated. Additionally, the ADA report, designed for use by clinical practitioners, offers the following suggestions to practitioners to use in advising parents and caregivers of infants who consume powdered or liquid concentrate infant formula as the main source of nutrition:84 • Suggest the continued use of powdered or liquid concentrate infant formulas reconstituted with optimally fluoridated drinking water while being cognizant of the potential risk of enamel fluorosis development.89 • When the potential risk of enamel fluorosis development is a concern, suggest ready-to-feed formula or powdered or liquid concentrate formula reconstituted with water that either is fluoride free or has low concentrations of fluoride.84 It should be noted that the Centers for Disease Control and Prevention,85 as well as other agencies, such as the U.S. Department of Health and Human Services,86 American Public Health Association,87 and health departments such as the New York State Health Department88 provide similar information regarding the use of fluoridated water to reconstitute infant formula. 29. What can be done to reduce the occurrence of dental fluorosis in the U.S.? Answer. The vast majority of enamel fluorosis in the United States can be prevented by limiting the ingestion of topical fluoride products (such as toothpaste) and recommending the appropriate use of dietary fluoride supplements — without denying young children the decay prevention benefits of community water fluoridation. Fact. Tooth decay has decreased substantially in the United States because more children today are benefitting from access to fluoride which is available from a wider variety of sources than decades ago. Many of these sources are intended for topical use only however, when they are used, some fluoride is inadvertently swallowed by children.42,43,89 Inappropriate ingestion of topical fluoride can be minimized, thus reducing the risk for dental fluorosis without reducing decay prevention benefits.