In recent years, there appears to have been an increase in total fluoride intake from a combination of sources such as fluoridated water, fluoride toothpaste, fluoride supplements, foods, beverages and other therapeutic fluoride–containing products for some people and segments of the U.S. population.^1,2 Parallel to this, clinicians, academicians and researchers have noted an apparent increase in the incidence in some people of very mild to mild fluorosis associated with fluoride intake.²

In response to ongoing concerns and consistent with the American Dental Association’s (ADA’s) evidence-based approach to developing scientifically sound clinical recommendations, the ADA Council on Scientific Affairs (CSA) commissioned a systematic review that appears on page 1457 in this issue.³ After completion of the systematic review, the ADA convened an expert panel in July 2008 to answer the following clinical questions:

– When should fluoride supplements be prescribed? (Does the use of fluoride supplements in children [birth-16 years old] prevent dental caries?)

– What is the recommended dosage for fluoride supplements? (Does the use of fluoride supplements in children [birth-16 years old] increase the risk of developing dental fluorosis in the absence of other identifiable causes?)

During the ADA’s evidence-based dentistry (EBD) expert panel workshop, the panel reviewed all relevant scientific studies, including this issue’s systematic review and others previously published, to develop evidence-based recommendations. Key to the panel’s discussion was the benefit of fluoride in reducing the risk of experiencing dental caries versus the potential for developing dental fluorosis, especially in light of total fluoride exposure. In addition to the review of the scientific literature, the panel also discussed the merits and disadvantages of fluoride in populations with limited access to care and supplement recommendations in other countries, including Canada, Great Britain and Australia.

The ADA expert panel is finalizing its clinical recommendations and will prepare a report for the CSA. Publication of the recommendations developed through this evidence-based approach is anticipated in the summer of 2009.

ADA clinical recommendations are intended to translate scientifically detailed, systematically assessed information from multiple sources into practical applications. As part of the ADA’s commitment to help dentists access, understand and apply the most current science to clinical practice, recommendations are developed, reviewed and updated as science evolves. In 2009, the ADA Center for Evidence-Based Dentistry is scheduled to publish recommendations on infant formula and fluoride. In addition, the center anticipates hosting an expert panel discussion on oral cancer screening to be followed by published recommendations. The CSA will review other clinical topics for future workshops and recommendations this month.

ADA evidence-based recommendations usually start with identifying clinical questions raised by member dentists supported with relevant scientific input from the CSA. In some instances, the CSA may determine the need for a systematic review prior to an expert panel discussion. The next step in the review process involves identifying subject-matter experts, methodology experts and stakeholders to form an expert panel.

Under the guidance of this panel, a comprehensive literature search is conducted to gather all available clinically relevant scientific evidence. The evidence then is analyzed by the panel during a three-day workshop to draft a report presenting specific recommendations. The final draft is circulated to external reviewers, including people and organizations potentially affected by the recommendations. As the final step in this process, the CSA reviews and considers all recommendations before publication. This clinical evolution results in a more comprehensive understanding of a topic than any one study can afford.

In any discussion and use of fluoride supplements, it is imperative to weigh the potential risk of developing mild fluorosis against the demonstrated benefit of caries prevention.^2,4 The National Health and Nutrition Examination Survey found that from 1988 through 1994 to 1999 through 2004, there was a 2 percent increase in the prevalence of dental caries in primary teeth among children aged 2 through 11 years, with 2-through 5-year-olds showing a significant increase—from 24 to 28 percent.⁵ Thus, dental caries continues to be a problem, especially in high-risk populations. Research also indicates the critical timing to maximize the benefits from fluoride to be from birth to 8 years of age.⁶ Timing, amount and duration of fluoride exposure all factor into optimizing the benefit from fluoride while at the same time minimizing the risk of developing any degree of fluorosis.

Oral health professionals and patients have seen the benefits of fluoride in caries reduction since the preventive effect of fluoride was first discovered. In the 2000 surgeon general’s report, the decline in the prevalence and severity of dental caries in the United States during the past 60 years was attributed largely to the increased use of fluoride.¹ Fluoridation of community water supplies (identified by the U.S. Centers for Disease Control and Prevention⁷ as one of 10 great public health achievements of the 20th century) and the use of fluoride-containing products remain safe and effective measures for preventing tooth decay.

To help to meet our patients’ needs and expectations in the future, the ADA Center for Evidence-Based Dentistry is developing a Web site dedicated to giving practitioners access to a centralized location of scientific information. This Web site, set to launch in spring 2009, will host summaries of systematic reviews and a registry at which clinicians can post topics of interest. The center also hosts workshops and conferences periodically to help dentists implement and disseminate information on EBD.

Working together, not only within our oral health profession but with other health care professions as well, we will be able to address patients’ present and future health care needs with sound, scientifically relevant clinical information to advance quality care for the patients we serve