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J Am Dent Assoc, Vol 133, No 10, 1405-1407.
© 2002 American Dental Association |
PRACTICAL SCIENCE |
Is it really a problem?
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ABSTRACT |
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 TOP ABSTRACT THE ROLE OF FLUORIDECONCLUSIONREFERENCES |
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Overview. Despite the recognition that fluoride levels in water can be controlled to offer caries protection with minimal risk of fluorosis, the cosmetic defect continues to appear. However, although the word "fluorosis" conjures up images of brown stained and pitted enamel, such severe cases rarely are seen in the United States. Children in this country are exposed to fluoride from numerous sources and the appearance of mild fluorosis is not unusual.
Conclusions and Practice Implications. In most cases, fluorosis is a minor cosmetic defect that should not be cause for alarm. Dentists should educate their patients about the optimal range of fluoride intake for caries protection, sources of fluoride and the possibility of fluorosis.
Fluorosis is a word that has crept into the dental lexicon and has had a mantle of gravity cast upon it far beyond its real importance. Any medical term ending in "osis" has a serious ring to it and refers to a proven condition or state, usually abnormal or diseased. Fluorosis is used to describe enamel that displays anything from barely detectable white flecks (very common) to severe brown staining with pitting (rare) that is attributable to ingestion of fluoride during tooth development. Unfortunately, over the years almost every enamel defect observed has been attributed to the presence of fluoride, even though Clarkson and O’Mullane1 have shown that occurrence of enamel opacities is actually lower in geographical areas where the water is fluoridated.
THE ROLE OF FLUORIDE
TOP
ABSTRACT
THE ROLE OF FLUORIDE
CONCLUSION
REFERENCES
It is interesting to recall that focusing on the clinical effects of fluoride began because of observations of brown mottled enamel in Colorado in the early 1900s.2 Subsequent research revealed that the presence of fluoride at certain levels in the water supply (1 part per million) gave rise to minimal mottling and a substantially lower prevalence of dental caries than that experienced in populations not exposed to fluoride through the water supply.2 Thus, researchers have long recognized that the reduction in the prevalence of dental caries associated with 1 ppm fluoride in the drinking water is accompanied by very mild or mild fluorosis (Figure
), with a prevalence of about 20 percent (depending on the fluorosis index used).3 (Currently, the optimal level of fluoride recommended by the ADA for drinking water is 0.7–1.2 ppm.4)
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Dean classified fluorosis in a community with up to about 1.2 ppm fluoride in water as "very mild." He described "very mild" as small, opaque, paper-white areas scattered irregularly over the tooth and involving less than 25 percent of the tooth surface.5 Frequently included in this classification are teeth showing no more than about 1 to 2 millimeters of white opacity at the tip of the summit of the cusps of the bicuspids or second molars. Because of Dean’s simple index, it has been possible to compare the prevalence and severity of fluorosis over many decades.11
Study results have revealed that the prevalence has increased over the years and that there has been a modest increase in some of the categories of severity.13,14 Is there cause for concern? As noted earlier, the gravity cast upon fluorosis exceeds its importance. Indeed, it is worth noting that the association between mottled teeth and fluoride in drinking water led to the discovery of the caries-protective effect of fluoride,2,12 and it is important to note that fluorosis is not a new phenomenon. Nevertheless, as with any agent, it is prudent to use the minimum amount required to achieve the maximum benefit with minimum adverse effects, however trivial those effects may be.
Fluoride supplements.
There are many reasons for the recorded increase in fluorosis in some parts of the world. Foremost among these is the inappropriate use of fluoride supplements. Fluoride supplements in the form of lozenges, tablets or drops should never be used in areas where water is fluoridated.15,16 Opinions differ in regard to the age at which supplementation should begin for children living in nonfluoridated areas, as well as the amount of fluoride supplement recommended.15,16 The Centers for Disease Control and Prevention has issued a recommended dietary supplement schedule (Table).17
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Fluoridated toothpaste. Fluorosis also is associated with use of fluoridated toothpastes during the first few years of life.20–22 Pendrys20 conducted a study and found that approximately 34 percent of cases of fluorosis in areas with nonfluoridated water were associated with use of fluoride toothpaste by children younger than two years old. In contrast, the study showed that 68 percent of the fluorosis cases in optimally fluoridated areas could be explained by children’s having ingested fluoride toothpaste during the first year of life. Other authors have stated that the odds ratio for the risk of developing fluorosis with the use of fluoridated toothpaste was 1.6 to 1.83.21,22
The Centers for Disease Control and Prevention17 has suggested the introduction of tooth-pastes containing reduced concentrations of fluoride for use by children to obviate the risk of developing fluorosis. However, little evidence is available that toothpastes containing reduced levels of fluoride are as clinically effective as regular toothpaste. Toothpaste manufacturers have recommended that only pea-sized amounts of toothpaste be placed on a toothbrush for use by children younger than 6 years old. However, this well-intentioned advice is offset by the production of toothpaste in flavors that are particularly attractive to children, thereby encouraging excessive ingestion.14
Infant formula. Researchers have recognized that powdered infant formula reconstituted with fluoridated drinking water may constitute a risk of developing mottled enamel.23 Approximately 9 percent of the fluorosis cases can be explained by use of reconstituted formula containing fluoridated water.20 Clearly, the role of reconstituted formula is small compared with that of toothpaste and fluoride supplements.
The likelihood that the permanent incisors will be affected through use of infant formula reconstituted with optimally fluoridated water is small.15,23 As Whitford15 pointed out, "the transitional or early maturation stage of enamel development is when the tissue is most susceptible to fluoride-induced changes ... these stages occur during third or fourth postpartum years for the permanent anterior teeth (22 to 26 months for maxillary central incisors), when the level of dietary fluoride in a community with fluoridated water is generally within the 0.04 to 0.07 mg/kg range per day." Recommendations have been made that water containing low amounts of fluoride (< 0.5 ppm fluoride) be used to reconstitute powdered infant formula. However, widespread implementation of this recommendation would place a large burden on caregivers to remedy what appears to be a minimal problem.
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CONCLUSION |
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TOPABSTRACTTHE ROLE OF FLUORIDECONCLUSIONREFERENCES |
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FOOTNOTES |
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REFERENCES |
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TOPABSTRACTTHE ROLE OF FLUORIDECONCLUSIONREFERENCES |
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