Sources of fluoride intake in children

Water consumption in the United States in 1994-96 and implications for water fluoridation policy

OBJECTIVES

The purpose of this project was to describe current water consumption patterns and to compare them to findings from earlier studies. Current water consumption data also were used to reevaluate the association between water consumption and climate. These findings are of importance in estimating fluoride intake from fluoridated water.

METHODS

Findings from the 1994-96 Continuing Survey of Food Intakes by Individuals (CSFII) were compared to those from two earlier dietary studies, the 1977-78 Nationwide Food Consumption Survey (NFCS) and the pioneering research of Galagan and colleagues in the 1950s. Food consumption data were analyzed for 14,619 persons with food and beverage intake data for two 24-hour periods in the CSFII.

RESULTS

Increased consumption of infant formulas and decreased consumption of tap water and cow's milk were seen in the CSFII for infants compared to the NFCS. Older children and adults showed increased consumption of carbonated beverages and juices. While Galagan and colleagues found about a 60 percent increase in water consumption between the coldest (55 degrees F) and warmest (85 degrees F) conditions, only a 20 percent difference was seen between the winter and summer months in certain regions in the CSFII.

CONCLUSIONS

No obvious strong or consistent association between water intake and month or season was apparent in these recent data. These findings are preliminary, and suggest that water fluoridation policy requires further research regarding water consumption and climate.

Fluoride intake and prevalence of dental fluorosis: trends in fluoride intake with special attention to infants

BACKGROUND

Although the predominant beneficial effect of fluoride occurs locally in the mouth, the adverse effect, dental fluorosis, occurs by the systemic route. The caries attack rate in industrialized countries, including the United States and Canada, has decreased dramatically over the past 40 years. However, the prevalence of dental fluorosis in the United States has increased during the last 30 years both in communities with fluoridated water and in communities with nonfluoridated water. Dental fluorosis is closely associated with fluoride intake during the period of tooth development.

METHODS

We reviewed the major changes in infant feeding practices that have occurred since 1930 and the changes in fluoride intakes by infants and young children associated with changes in feeding practices.

RESULTS AND CONCLUSIONS

Based on this review, we conclude that fluoride intakes of infants and children have shown a rather steady increase since 1930, are likely to continue to increase, and will be associated with further increase in the prevalence of enamel fluorosis unless intervention measures are instituted.

RECOMMENDATIONS

We believe the most important measures that should be undertaken are (1) use, when feasible, of water low in fluoride for dilution of infant formulas; (2) adult supervision of toothbrushing by children younger than 5 years of age; and (3) changes in recommendations for administration of fluoride supplements so that such supplements are not given to infants and more stringent criteria are applied for administration to children.

Water consumption and nursing characteristics of infants by race and ethnicity

OBJECTIVES

The purpose of this project was to determine racial/ethnic differences in water consumption levels and nursing habits of children younger than 2 years old.

METHODS

Data from the 1994-96 Continuing Survey of Food intakes by individuals (CSFII) were used for these analyses. Water consumption and breast-feeding data on 946 children younger than 2 years old were used.

RESULTS

For black non-Hispanic children younger than 2 years old (n = 121), 5.3 percent of the children were currently being breast fed. This percentage was less than that seen in other racial/ethnic groups. For white non-Hispanic children (n = 620), this percentage was 10.8 percent; for Hispanic children (n = 146), 12.2 percent; for "other" children, 18.5 percent (n = 59). Black non-Hispanic children had the highest total water consumption (128.6 ml/kg/day) among all groups, white non-Hispanic had the lowest (113.2 ml/kg/day). These differences were not statistically significant in multivariate regression modeling. Black non-Hispanic children also drank more tap water (21.3 ml/kg/day) than white non-Hispanic children (12.7 ml/kg/day) and Hispanic children (14.9 ml/kg/day). The difference was statistically significant in multivariate regression modeling.

CONCLUSIONS

The differences in breast feeding and water consumption observed among black children younger than 2 years of age could be a factor in the observed higher levels of fluorosis in black children compared to other children.

Dietary determinants of dental caries and dietary recommendations for preschool children

OBJECTIVES

The purpose of this review, commissioned by the Administration for Children and Families, the Health Resources and Services Administration, the Health Care Financing Administration, and the Department of Agriculture's Food and Nutrition Service, was to update the evidence of the dietary factors that affect dental caries, and subsequently formulate dietary recommendations for preschool children based on principles of cariology.

METHODS

Literature on the dental caries process, dietary factors affecting dental caries initiation and progression, and nutrition education and counseling were reviewed and synthesized. Dietary guidelines for children at various ages were then constructed based on the review.

RESULTS

Dental caries in preschool children is due to a combination of factors, including colonization of teeth with cariogenic bacteria, type of foods and frequency of exposure of these foods to the cariogenic bacteria, and susceptible teeth. Caries risk is greatest if sugars are consumed at high frequency and are in a form that is retained in the mouth for long periods. Sucrose is the most cariogenic sugar because it can form glucan that enables firm bacterial adhesion to teeth and limits diffusion of acid and buffers in the plaque. There is emerging interest in the effects of tooth development and its role in the future dental caries risk of the child.

CONCLUSIONS

Nutrition education and counseling for the purposes of reducing caries in children is aimed at teaching parents the importance of reducing high frequency exposures to obvious and hidden sugars. Guidelines include: avoiding frequent consumption of juice or other sugar-containing drinks in the bottle or sippy cup, discouraging the behavior of a child sleeping with a bottle, promoting noncariogenic foods for snacks, fostering eating patterns consistent with the Food Guide Pyramid, limiting cariogenic foods to mealtimes, rapidly clearing cariogenic foods from the child's oral cavity either by toothbrushing or by consumption of protective foods, and restricting sugar-containing snacks that are slowly eaten (e.g., candy, cough drops, lollipops, suckers). Along with nutritional factors, a comprehensive approach to preventing dental caries in preschool children must include improved general dietary habits, good oral hygiene, appropriate use of fluorides, and access to preventive and restorative dental care.

Comparison of dental arch measurements in the primary dentition between contemporary and historic samples

The purpose of this study was to investigate secular changes that may have occurred in dental arch dimensions by comparing a sample of contemporary North American white children (born between 1992 and 1995) in the primary dentition to those children found in an earlier study of North American white children (born between 1946 and 1948). The sample of contemporary children has been followed prospectively since birth and was assessed at 4(1/2) to 5 years of age. Data for the historic sample were obtained from 5-year-old children who were enrolled in the Iowa Growth Study. The 2 samples were similar in terms of geographic location, racial and ethnic backgrounds, and socioeconomic status. To further enhance the comparison and to match the 2 groups, the 2 samples were restricted to white children with a normal overjet (<4 mm) and normal anteroposterior molar relationship, no anterior open bite, and no crossbite. In addition, individuals were excluded if any permanent teeth were erupted. Measurements of maxillary and mandibular arch lengths and intercanine and intermolar arch widths were made, with measurements of overjet and overbite. The results indicated that maxillary and mandibular arch lengths in both sexes were significantly shorter in the contemporary sample; all arch widths were significantly smaller in contemporary boys, but not in girls. These findings suggest that average arch dimensions may be smaller in contemporary children than in past generations. Further research is needed to determine whether smaller arch dimensions are associated with more crowding in the primary, mixed, and permanent dentitions.

Oral health in the United States: the post-fluoride generation

Tremendous strides have been made in reducing the incidence of tooth decay, periodontal diseases, and associated loss of teeth in adults and children since the inception of community water fluoridation programs. Yet the disadvantaged and poor have not fully shared in the benefits. Other challenges to oral health remain. Oral cancer and related smoking and smokeless tobacco use remain major public health problems. Access to preventive and therapeutic dental care is far from universal. Public health programs similar in commitment to the approach of community water fluoridation programs initiated in the 1950s and 1960s are needed to address neglected oral health needs of underserved and high-risk populations in the United States.

Risk of enamel fluorosis in nonfluoridated and optimally fluoridated populations: considerations for the dental professional

BACKGROUND

Few studies have evaluated the impact of specific fluoride sources on the prevalence of enamel fluorosis in the population. The author conducted research to determine attributable risk percent estimates for mild-to-moderate enamel fluorosis in two populations of middle-school-aged children.

METHODS

The author recruited two groups of children 10 to 14 years of age. One group of 429 had grown up in nonfluoridated communities; the other group of 234 had grown up in optimally fluoridated communities. Trained examiners measured enamel fluorosis using the Fluorosis Risk Index and measured early childhood fluoride exposure using a questionnaire completed by the parent. The author then calculated attributable risk percent estimates, or the proportion of cases of mild-to-moderate enamel fluorosis associated with exposure to specific early fluoride sources, based on logistic regression models.

RESULTS

In the nonfluoridated study sample, sixty-five percent of the enamel fluorosis cases were attributed to fluoride supplementation under the pre-1994 protocol. An additional 34 percent were explained by the children having brushed more than once per day during the first two years of life. In the optimally fluoridated study sample, 68 percent of the enamel fluorosis cases were explained by the children using more than a pea-sized amount of toothpaste during the first year of life, 13 percent by having been inappropriately given a fluoride supplement, and 9 percent by the use of infant formula in the form of a powdered concentrate.

CONCLUSIONS

Enamel fluorosis in the nonfluoridated study sample was attributed to fluoride supplementation under the pre-1994 protocol and early toothbrushing behaviors. Enamel fluorosis in the optimally fluoridated study sample was attributed to early toothbrushing behaviors, inappropriate fluoride supplementation and the use of infant formula in the form of a powdered concentrate.

CLINICAL IMPLICATIONS

By advising parents about the best early use of fluoride agents, health professionals play an important role in reducing the prevalence of clinically noticeable enamel fluorosis.

Professionally applied topical fluoride and restorative care in insured children

OBJECTIVES

This study evaluates the association between use of professionally applied topical fluoride and use of interproximal restorations in primary and permanent teeth of children.

METHODS

Insurance claims from 15,190 children, for treatment provided by 1,556 different dentists, were analyzed to look for associations between frequency of use of professionally applied topical fluoride and use of interproximal restorations. The average follow-up period for the children included in the analysis was 5.3 years, with the range from 3.0 to 7.9 years.

RESULTS

Both tabular and regression results failed to demonstrate an association between frequency of use of professionally applied topical fluoride and use of interproximal restorations in either the primary or permanent dentition. The most powerful predictor of restorative care for these children was the overall propensity of the dentist to place restorations in children.

CONCLUSIONS

In this group of insured children, we were unable to find an association between the frequency of use of professionally applied topical fluoride and restorative care. Further, despite numerous recommendations that professionally applied topical fluorides should be used only in moderate- and high-caries children, approximately two-thirds of these children received topical fluoride at every recall visit, nearly two times per year.

Assessing fluoride levels of carbonated soft drinks

BACKGROUND

Dental fluorosis occurs as a result of excessive total fluoride intake during tooth development. Some children may receive substantial intake from soft drinks, but few studies have reported fluoride levels in soft drinks. The authors examined the fluoride concentrations of 332 soft drinks.

METHODS

Soft drinks were purchased from Iowa grocery stores. To identify production sites, the authors recorded product details and batch numbers. After decarbonating the drinks, the authors assayed samples for fluoride content using a fluoride ion-specific electrode, and reported the results in parts per million, or ppm, using appropriate standards and duplicate assessments. Descriptive statistics were used to summarize the findings.

RESULTS

The fluoride levels of the products ranged from 0.02 to 1.28 ppm, with a mean level of 0.72 ppm. Fluoride levels exceeded 0.60 ppm for 71 percent of the products. Results varied substantially by production site, even within the same company and for the same product. There were no substantial differences between flavors or between diet and regular soft drinks.

CONCLUSIONS

The majority of soft drinks had fluoride levels exceeding 0.60 ppm. Variation in fluoride levels probably is due largely to the different water sources used in production.

CLINICAL IMPLICATIONS

With no fluoride levels marked on the soft drink products or easily available from the manufacturers, it is not possible for clinicians or consumers to directly estimate fluoride ingestion from carbonated beverages. Therefore, to reduce the risk of dental fluorosis, dental and medical practitioners should be cautious about prescribing dietary fluoride supplements to preschool-aged children in nonfluoridated areas who consume large quantities of carbonated soft drinks.

Estimation of the fraction of an ingested dose of fluoride excreted through urine in pre-school children

OBJECTIVE

To determine the fraction of an ingested fluoride dose of 1 mg in 50 mL orange juice that is excreted through the urine (FUEF) of children aged 3-5 years.

METHODS

Eighty-eight controlled determinations involving 24-hour urinary collections from a total of 48 children were carried out during consecutive control and test days. Net fluoride urinary excretion due to the ingested dose was calculated as the difference between the total amount of fluoride excreted by each child on test and control days.

RESULTS

Excretion of the fluoride ingested from the single fluoride dose presented an average value of 30.7% (95% CI: 28.9-32.5%). No significant associations were found between individual FUEF values with either anthropometrical variables or urinary pH values. The average FUEF value found in the present study lies between previously reported values for infants and young adults. The epidemiological usefulness of the FUEF values in estimating daily fluoride dose in pre-school children is discussed.

Fluoride ingestion from toothpaste by young children

OBJECTIVE

To investigate the reported and observed brushing habits of young children and their ingestion of fluoride from toothpaste.

DESIGN

In 1997, a random sample of 50 children, aged 30 months, from three districts in the North West region of England, were visited at home.

METHODS

The reported and observed toothbrushing behaviour was determined and the weight of toothpaste applied to the toothbrush was measured. The amount of fluoride retained in the mouth after brushing with either a 400 ppm F or 1,450 ppm F toothpaste was determined.

RESULTS

All parents claimed that their children's teeth were being brushed with a fluoride toothpaste at least once daily. The mean amount of toothpaste applied on the brush was 0.36 g of which 0.27 g (72%) was retained in the mouth. The mean amount of fluoride ingested per brushing was 0.42 mg when using the 1,450 ppm F toothpaste and 0.10 mg when using the 400 ppm F toothpaste. Although most parents applied a small amount of toothpaste a small minority applied a large amount. If using the 400 ppm F toothpaste twice daily no children of average weight would have exceeded ingestion of 0.05 mgF/kg body weight whereas 14 average weight children would have exceeded this value if using the 1450 ppm F toothpaste.

CONCLUSIONS

It is essential that parents of children aged less than 7 years apply a small (pea-sized) amount of fluoride toothpaste on the toothbrush and discourage swallowing.

Patterns of dietary fluoride supplement use during infancy

OBJECTIVES

This paper reports on patterns of dietary fluoride supplement use during infancy.

METHODS

Data were collected by mail for a birth cohort (n = 1,072) studied at 6 weeks and 3, 6, 9, and 12 months of age.

RESULTS

Percentages using supplements were 13.7 at 6 weeks, 13.4 at 3 months, 16.5 at 6 months, 13.0 at 9 months, and 12.1 at 12 months. Among those receiving supplements, mean proportions of weeks that supplements were received during the different time periods varied from 0.59 to 0.80. Number of days per week receiving supplements averaged 4.8 to 5.0. Mean fluoride dosages when supplements were received were 0.22 mg to 0.24 mg. Estimated average daily fluoride ingestion per day (among those receiving supplements during that time period and factoring in those days and weeks that supplements were not received) was 0.11 mg at 6 weeks, 0.15 mg at 3 months, 0.12 mg at 6 months, 0.11 mg at 9 months, and 0.14 mg at 12 months. Among the subset of 129 children with complete data at all time points who used supplements sometime during their first year of life, mean annual daily supplement dosage was 0.07 mg fluoride, with 75 percent having less than or equal to 0.10 mg. Those infants with mothers and fathers with more education were more likely to receive supplements.

CONCLUSIONS

Group average use of fluoride supplements was fairly consistent over the 12 months; however, individual patterns varied substantially. Estimated actual mean daily fluoride intake when including days that supplements were not received was substantially less than the recommended 0.25 mg per day.

Fluorosis risk in grade 2 students residing in a rural area with widely varying natural fluoride

OBJECTIVES

This pilot study was performed to determine the prevalence of dental fluorosis and the association between fluorosis and a number of risk factors in a group of second grade students in a rural, non-fluoridated area of Ontario, Canada.

METHODS

Of 1739 students screened during routine health surveillance, 1367 had erupted maxillary central incisors. Fluorosis was scored on these children using the Tooth Surface Index of Fluorosis (TSIF). A fluoride exposure questionnaire and water sample vial was sent home from school with each child.

RESULTS

Valid responses were obtained for 752 children (55%). The prevalence of fluorosis in respondents was 23.3%, with 4.9% scoring TSIF of 2 or more. In bivariate analysis, several variables were significantly associated with the prevalence and/or severity of fluorosis. These included: water fluoride concentration, breast-feeding duration, professionally applied topical fluoride, fluoride supplement use, bottle-feeding, fluoridated mouthwash use, and early parental toothbrushing with toothpaste. In logistic regression analysis limited to children living at the current residence for 4 years or more, only four variables had significant independent effects. These were water fluoride concentration, breast-feeding duration, fluoride supplement use, and fluoridated mouthwash use.

CONCLUSIONS

These findings indicate that fluorosis is an important concern in non-fluoridated areas. Fluoride supplements should not be recommended unless an independent home water test is performed. Breast-feeding for 6 months or more may protect children from developing dental fluorosis in the permanent incisors.

Changes in dental fluorosis and dental caries in Newburgh and Kingston, New York

OBJECTIVES

This study sought to determine whether the prevalence of dental fluorosis and dental caries had changed in a fluoridated community and a nonfluoridated community since an earlier study conducted in 1986.

METHODS

Dental fluorosis and dental caries data were collected on 7- to 14-year-old lifelong residents (n = 1493) of Newburgh and Kingston, NY.

RESULTS

Estimated dental fluorosis prevalence rates were 19.6% in Newburgh and 11.7% in Kingston. The greatest disparity in caries scores was observed between poor and nonpoor children in nonfluoridated Kingston.

CONCLUSIONS

The prevalence of dental fluorosis has not declined in Newburgh and Kingston, whereas the prevalence of dental caries has continued to decline.

Severe dental fluorosis in a Tanzanian population consuming water with negligible fluoride concentration

OBJECTIVES

To identify risk factors for dental fluorosis that cannot be explained by drinking water fluoride concentration alone.

METHODS

Two hundred eighty-four Tanzanian children ages 9 to 19 (mean 14.0+/-SD 1.69), who were lifetime residents at differing altitudes (Chanika, 100 m; Rundugai, 840 m; and Kibosho, 1,463 m; Sites 1, 2, and 3 respectively) were examined for dental fluorosis and caries. They were interviewed about their food habits, environmental characteristics and use of a fluoride-containing food tenderizer known locally as magadi. Meal, urine, water and magadi samples supplied by the participants were analyzed for fluoride content. Urine samples were also analyzed for creatinine concentration. Four magadi samples from Sites 1 and 3 were analyzed for complete element composition.

RESULTS

Of the 13 water samples from Site 2, 10 contained > or =4 mg/L F, ranging from 1.26 to 12.36 mg/L with a mean+/-SD of 5.72+/-4.71 mg/L. Sites 1 and 3 had negligible water fluoride of 0.05+/-0.05 and 0.18+/-0.32 mg/L respectively. Mean TFI fluorosis scores (range 0-9) for Site 2 were high: 4.44+/-1.68. In Sites 1 and 3, which both had negligible water fluoride, fluorosis scores varied dramatically: Site 1 mean maximum TFI was 0.01+/-0.07 and Site 3 TFI was 4.39+/-1.52. Mean DMFS was 1.39+/-2.45, 0.15+/-0.73 and 0.19+/-0.61 at Sites 1, 2, and 3, respectively. There were no restorations present. Urinary fluoride values were 0.52+/-0.70, 4.34+/-7.62, and 1.43+/-1.80 mg/L F at Sites 1, 2, and 3, respectively. Mean urinary fluoride values at Site 3 were within the normal urinary fluoride reference value range in spite of pervasive severe pitting fluorosis. Meal and magadi analyses revealed widely varied fluoride concentrations. Concentrations ranged from 0.01 to 22.04 mg/L F for meals and from 189 to 83211 mg/L F for magadi. Complete element analysis revealed the presence of aluminum, iron, magnesium, manganese, strontium and titanium in four magadi samples. There were much higher concentrations of these elements in samples from Site 3, which was at the highest altitude and had severe enamel disturbances in spite of negligible water fluoride concentration. An analysis of covariance model supported the research hypothesis that the three communities differed significantly in mean fluorosis scores (P<0.0001). Controlling for urinary fluoride concentration and urinary fluoride:urinary creatinine ratio, location appeared to significantly affect fluorosis severity. Urinary fluoride:urinary creatinine ratio had a stronger correlation than urinary fluoride concentration with mean TFI fluorosis scores (r=0.43 vs r= 0.25).

CONCLUSIONS

The severity of enamel disturbances at Site 3 (1463 m) was not consistent with the low fluoride concentration in drinking water, and was more severe than would be expected from the subjects' normal urinary fluoride values. Location, fluoride in magadi, other elements found in magadi, and malnutrition are variables which may be contributing to the severity of dental enamel disturbances occurring in Site 3. Altitude was a variable which differentiated the locations.

Nutrition and oral health guidelines for pregnant women, infants, and children

Good oral health care and nutrition during pregnancy, infancy, and childhood are essential but often overlooked factors in the growth and development of the teeth and oral cavity. Pregnant women and parents and caregivers of infants and children often receive little guidance about proper preventive dental and oral health care, including fluoride and dietary measures. Pregnant women can maintain their health through proper diet, good oral hygiene, and appropriate use of fluoride. An adequate diet during gestation is important for optimal oral development of the fetus. To promote good oral health in infancy, caregivers need to provide the infant with appropriate amounts of fluoride in addition to a healthful diet. As the teeth erupt into the mouth, the caregiver needs to clean the teeth thoroughly on a daily basis. When solid foods are introduced in later infancy, it is also important to limit the frequency of caries-promoting fermentable carbohydrates between meals. Good oral hygiene habits and dietary practices that emphasize minimum exposure to retentive, fermentable carbohydrates; use of fluoridated water; and a varied, balanced diet should continue throughout childhood to set the stage for optimal oral health for a lifetime.

Fluoride concentrations of infant foods

Infants who ingest high amounts of fluoride can be at risk of dental fluorosis. The authors analyzed the fluoride concentration of 238 commercially available infant foods. Fluoride concentrations ranged from 0.01 to 8.38 micrograms of fluoride per gram, with the highest fluoride concentrations found in infant foods containing chicken. Infant foods, especially those containing chicken, should be considered when determining total fluoride intake.

[Evaluation of fluoride content of bottled drinking waters in Brazil]

The utilization of a systemic fluoride method must be controlled in terms of risks and benefits. The reason for this is that while a small dose will not be effective in preventing dental caries, a larger dose may cause dental fluorosis. Therefore the knowledge of the fluoride concentration found in the bottled mineral waters sold throughout the Brazilian market the consumption of which has increased lately, is of great concern. The objective of the study was the analysis of the concentration of fluoride found in the bottled mineral waters. A hundred and four brands coming from different regions of Brazil were analysed using an Orion 96-09 ion specific electrode and an Orion EA 940 ionanalyser. previously calibrated with standard fluoride solutions. Different concentrations of fluoride ranging from 0.0 to 4.4 were found. It was discovered that specific bottled waters contained: 1) Significant concentrations of fluoride not reported by the producer; 2) Fluoride concentrations of no preventive effect, although the producer had advertised the water as a Fluoridated Mineral Water; 3) Fluoride concentrations high enough to cause dental fluorosis, although the producer did not alert the consumer to this fact. It is to be concluded, therefore, that a sanitary regulatory system for the control of the level of fluoride in the bottled mineral waters marketed is necessary. Such reputation should be formulated in terms of benefits as well as in terms of risks.

Assessing fluoride concentrations of juices and juice-flavored drinks

Few studies have investigated fluoride exposures from juices and juice-flavored drinks manufactured with water. In this study, the authors analyzed 532 juices and juice drinks for fluoride. Fluoride ion concentrations ranged from 0.02 to 2.80 parts per million, in part because of variations in fluoride concentrations of water used in production. Children's ingestion of fluoride from juices and juice-flavored drinks can be substantial and a factor in the development of fluorosis.

The effectiveness of community water fluoridation in the United States

Grand Rapids, the first city in the world to implement controlled water fluoridation, has served as a model for thousands of other communities. Fluoridation is one of the greatest public health and disease-preventive measures of all time. Its advantages include effectiveness for all, ease of delivery, safety, equity, and low cost. Today, nearly 56 percent of the US population lives in fluoridated communities (62% of those on central water supplies). Previously observed caries reductions of one-half to two-thirds are no longer attainable in the United States because other fluoride methods and products have reduced the caries prevalence in all areas, thus diluting the measurement of effectiveness, and because benefits of fluoridation are dispersed in many ways to persons in nonfluoridated areas. Water fluoridation itself, however, remains as effective as it ever was among groups at high risk to dental caries. Contrary to early beliefs that stressed the importance of preeruptive fluoride exposure, fluoridation also provides an important source of topical fluoride and facilitates remineralization. Although data on effectiveness and safety are compelling, future progress of water fluoridation will be affected by economic, political, and public perception factors.

Infants' fluoride ingestion from water, supplements and dentifrice

Concerns about dental fluorosis and the paucity of detailed fluoride intake data prompted this longitudinal study of fluoride intake in infants from birth to 9 months of age. On average, water fluoride intake greatly exceeded that from dietary fluoride supplements or fluoride dentifrice. However, fluoride supplements and dentifrice contributed substantial proportions of fluoride intake among children using them. Some children had estimated fluoride intake from water, supplements and dentifrice that exceeded the recommended "optimal" intake (a level that has yet to be determined scientifically). Practitioners should estimate fluoride ingestion from all these sources if considering systemic fluoride supplementation.

Infants' fluoride intake from drinking water alone, and from water added to formula, beverages, and food

In infants, the majority of total ingested fluoride is obtained from water, formula and beverages prepared with water, baby foods, and dietary fluoride supplements. Few studies have investigated the distribution of fluoride intake from these sources among young children at risk for dental fluorosis. The purpose of this study was to assess estimated water fluoride intake from different sources of water among a birth cohort studied longitudinally from birth until age 9 months. Parental reports were collected at 6 weeks, 3 months, 6 months, and 9 months of age for water, formula, beverage, and other dietary intake during the preceding week. Fluoride levels of home and child-care tap and bottled water sources were determined. This report estimates daily quantities of fluoride ingested only from water--both by itself and used to reconstitute formula, beverages, and food. Daily fluoride intake from water by itself ranged to 0.43 mg, with mean intakes < 0.05 mg. Water fluoride intake from reconstitution of concentrated infant formula ranged to 1.57 mg, with mean intakes by age from 0.18 to 0.31 mg. Fluoride intake from water added to juices and other beverages ranged to 0.67 mg, with means < 0.05 mg. Estimated total daily water fluoride intake ranged to 1.73 mg fluoride, with means from 0.29 to 0.38 mg.

Commentary on and recommendations for the proper uses of fluoride

Fluorosis has been associated with the fluoride concentration of drinking water, use of dietary fluoride supplements, early use of dentifrices, and prolonged use of infant formula. The literature, however, does not show associations between fluorosis and use of fluoride mouthrinses, professionally applied fluorides, bottled waters, carbonated beverages, and juices. It is unwise to issue laundry lists of items that may be implicated as problem-causing when, in fact, they may not be. Although usually classified without fluorosis, children in Dean's "questionable" category would be classified with the condition if the TFI or TSIF were used. Accordingly, Dean, in 1942, really reported only 52.8 percent of children without fluorosis in Kewanee, a community with 0.9 ppm fluoride in drinking water. Because the morbidity and sequelae of dental caries have declined, undue emphasis has been placed recently on the risks of using fluoride rather than on its profound beneficial effects. Although of paramount importance, conclusions cannot be drawn on whether fluoride protects against, contributes to, or has no effect on bone fractures or is valuable in treating osteoporosis. Careful thought is required before making recommendations that may reduce health benefits because of unfounded concerns about perceived risks. There should be greater regulation of extraneous fluoride sources, rather than reliance on educational efforts or recommendations to eliminate use of highly effective preventive regimens.