Safety l Fluoridation Facts 53 Fluoride Toothpaste Fluoride toothpastes are effective in helping to prevent tooth decay but have been identified as a major risk factor for enamel fluorosis when used inappropriately.42,43,89 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. (See Figure 4 in Question 23.) 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. The reason for including age information on directions for use for fluoride toothpaste is because it takes into account the ages during which teeth are most susceptible to dental fluorosis (during the time when the teeth are forming under the gums). Additionally, until approximately six years of age, children have not developed the full ability to spit and not swallow toothpaste. Inadvertently swallowing toothpaste during brushing can increase the risk of dental fluorosis. After age eight, the enamel formation of permanent teeth (with the exception of the third molars) is basically complete 68 therefore, the risk of developing dental fluorosis is over. Because dental fluorosis occurs while teeth are forming under the gums, individuals whose teeth have erupted are not at risk for enamel fluorosis. Additional information on this topic can be found in this Section, Question 27. Numerous studies have established a direct relationship between young children brushing with more than a pea-sized amount of fluoride toothpaste and the risk of very mild or mild dental fluorosis in both fluoridated and nonfluoridated communities.42,43,48,71,89 It was noted that 34% of the dental fluorosis cases in a nonfluoridated community were explained by children having brushed with fluoride toothpaste more than once per day during the first two years of life.90 In the optimally fluoridated community, 68% of the fluorosis cases were explained by the children using more than a pea-sized amount of toothpaste during the first year of life.90 However, recognizing that the risk tooth decay can start before a child’s first birthday, it is considered important to begin using a fluoride toothpaste when the child’s first tooth appears in the mouth.49 Dietary Fluoride Supplements A systematic review published in 2006 concluded that the use of supplements during the first six years of life, and especially during the first three years, is associated with a significant increase in dental fluorosis.91 Dietary fluoride supplements should only be prescribed for children at high risk for tooth decay who live in nonfluoridated areas.41 Dietary fluoride supplements should be prescribed according to the dosage schedule found in the Evidence- based Clinical Recommendations on the Prescription of Dietary Fluoride Supplements for Caries Prevention: A Report of the American Dental Association Council on Scientific Affairs published in 2010.41 The current dietary fluoride supplement schedule41 is shown in the Benefits Section, Question 12, Table 1. Determination of the level of risk for tooth decay is accomplished through the use of a professional caries risk assessment that assists the health provider identify and assess factors that could contribute to the development of cavities.41 A child’s caries (cavity) risk should be assessed on a routine basis because risk status can be affected by changes in the child’s development, home conditions, dietary regimen and oral hygiene practices. Additional information on caries risk assessments can be found on the ADA website.92 Because of the many sources of fluoride in the diet, proper prescribing of fluoride supplements can be complex. It is suggested that all sources of fluoride be evaluated with a thorough fluoride history before supplements are prescribed for a child.41 This evaluation should include testing of the home water supply if the fluoride concentration is unknown. Families on community water systems should contact their water supplier to ask about the fluoride level. Consumers with private wells should have the water tested yearly to accurately determine the fluoride content. Additional information on this topic can be found in the Benefits Section, Question 4.