Fluoride intake by infants

Factors associated with dental fluorosis among Malaysian children exposed to different fluoride concentrations in the public water supply

OBJECTIVES

To determine the prevalence of dental fluorosis, and factors associated with its occurrence in two cohorts of children exposed to different fluoride concentrations in the Malaysian water supply.

METHODS

A cross-sectional study was conducted among lifelong residents (n = 1,155) aged 9 and 12 years old living in fluoridated and nonfluoridated areas. Malaysian children aged 12 years were born when the level of fluoride in the public water supply was 0.7 ppm while those aged 9 years were born after the level was reduced to 0.5 ppm. Fluorosis was blind scored using standardized photographs of maxillary central incisors using Dean's criteria. Fluoride exposures and other factors were assessed by parental questionnaire. Data were analyzed using descriptive statistics, Chi-squared analyses, and logistic regression.

RESULTS

Fluorosis prevalence was lower (31.9 percent) among the younger children born after the reduction of fluoride concentration in the water, compared to a prevalence of 38.4 percent in the older cohort. Early tooth brushing practices and fluoridated toothpaste were not statistically associated with fluorosis status. However, the prevalence of fluorosis was significantly associated with parents' education level, parents' income, fluoridated water, type of infant feeding method, age breast feeding ceased, use of formula milk, duration of formula milk intake, and type of water used to reconstitute formula milk via simple logistic regression. Fluoridated water remained a significant risk factor for fluorosis in multiple logistic regression.

CONCLUSIONS

Fluorosis was lower among children born after the adjustment of fluoride concentration in the water. Fluoridated water remained as a strong risk factor for fluorosis after downward adjustment of its fluoride concentration.

Developmental fluoride neurotoxicity: an updated review

BACKGROUND

After the discovery of fluoride as a caries-preventing agent in the mid-twentieth century, fluoridation of community water has become a widespread intervention, sometimes hailed as a mainstay of modern public health. However, this practice results in elevated fluoride intake and has become controversial for two reasons. First, topical fluoride application in the oral cavity appears to be a more direct and appropriate means of preventing caries. Second, systemic fluoride uptake is suspected of causing adverse effects, in particular neurotoxicity during early development. The latter is supported by experimental neurotoxicity findings and toxicokinetic evidence of fluoride passing into the brain.

METHOD

An integrated literature review was conducted on fluoride exposure and intellectual disability, with a main focus on studies on children published subsequent to a meta-analysis from 2012.

RESULTS

Fourteen recent cross-sectional studies from endemic areas with naturally high fluoride concentrations in groundwater supported the previous findings of cognitive deficits in children with elevated fluoride exposures. Three recent prospective studies from Mexico and Canada with individual exposure data showed that early-life exposures were negatively associated with children's performance on cognitive tests. Neurotoxicity appeared to be dose-dependent, and tentative benchmark dose calculations suggest that safe exposures are likely to be below currently accepted or recommended fluoride concentrations in drinking water.

CONCLUSION

The recent epidemiological results support the notion that elevated fluoride intake during early development can result in IQ deficits that may be considerable. Recognition of neurotoxic risks is necessary when determining the safety of fluoride-contaminated drinking water and fluoride uses for preventive dentistry purposes.

Fluoride Exposure Induces Inhibition of Sodium-and Potassium-Activated Adenosine Triphosphatase (Na+, K+-ATPase) Enzyme Activity: Molecular Mechanisms and Implications for Public Health

In this study, several lines of evidence are provided to show that Na + , K + -ATPase activity exerts vital roles in normal brain development and function and that loss of enzyme activity is implicated in neurodevelopmental, neuropsychiatric and neurodegenerative disorders, as well as increased risk of cancer, metabolic, pulmonary and cardiovascular disease. Evidence is presented to show that fluoride (F) inhibits Na + , K + -ATPase activity by altering biological pathways through modifying the expression of genes and the activity of glycolytic enzymes, metalloenzymes, hormones, proteins, neuropeptides and cytokines, as well as biological interface interactions that rely on the bioavailability of chemical elements magnesium and manganese to modulate ATP and Na + , K + -ATPase enzyme activity. Taken together, the findings of this study provide unprecedented insights into the molecular mechanisms and biological pathways by which F inhibits Na + , K + -ATPase activity and contributes to the etiology and pathophysiology of diseases associated with impairment of this essential enzyme. Moreover, the findings of this study further suggest that there are windows of susceptibility over the life course where chronic F exposure in pregnancy and early infancy may impair Na + , K + -ATPase activity with both short- and long-term implications for disease and inequalities in health. These findings would warrant considerable attention and potential intervention, not to mention additional research on the potential effects of F intake in contributing to chronic disease.

Determination of fluoride concentration in powdered milk in Iran 2010

High concentrations of fluoride (F) in powdered milk (formula milk) can have adverse health effects on the body. The F concentration in powdered milk was analysed in Iran in 2010. A total of twelve commercial brands of highly consumed powdered milk were selected to analyse the F content through the standard F ion-selective electrode method. From each brand, three samples with different production dates were selected. The means and standard deviation for F concentration in all the samples was 1·73 (sd 0·3) μg F/g. The minimum and maximum F content in powdered milk brands Humana2 and Humana3 was 1·32 (sd 0·1) and 2·36 (sd 0·3) μg F/g, respectively. The study revealed that there was no significant difference in F concentration in the samples that belonged to various dates. Humana3 had a high F concentration (with an average of 2·36 (sd 0·3) μg F/g), which can be a risk factor for increased dental fluorosis, especially when being prepared using water with a high content of F.

Effect of discontinuation of fluoride intake from water and toothpaste on urinary excretion in young children

As there is no homeostatic mechanism for maintaining circulating fluoride (F) in the human body, the concentration may decrease and increase again when intake is interrupted and re-started. The present study prospectively evaluated this process in children exposed to F intake from water and toothpaste, using F in urine as a biomarker. Eleven children from Ibiá, Brazil (with sub-optimally fluoridated water supply) aged two to four years who regularly used fluoridated toothpaste (1,100 ppm F) took part in the study. Twenty-four-hour urine was collected at baseline (Day 0, F exposure from water and toothpaste) as well as after the interruption of fluoride intake from water and dentifrice (Days 1 to 28) (F interruption) and after fluoride intake from these sources had been re-established (Days 29 to 34) (F re-exposure). Urinary volume was measured, fluoride concentration was determined and the amount of fluoride excreted was calculated and expressed in mg F/day. Urinary fluoride excretion (UFE) during the periods of fluoride exposure, interruption and re-exposure was analyzed using the Wilcoxon test. Mean UFE was 0.25 mg F/day (SD: 0.15) at baseline, dropped to a mean of 0.14 mg F/day during F interruption (SD: 0.07; range: 0.11 to 0.17 mg F/day) and rose to 0.21 (SD: 0.09) and 0.19 (SD: 0.08) following F re-exposure. The difference between baseline UFE and the period of F interruption was statistically significant (p<0.05), while the difference between baseline and the period of F re-exposure was non-significant (p>0.05). The findings suggest that circulating F in the body of young children rapidly decreases in the first 24 hours and again increases very fast after discontinuation and re-exposure of F from water and toothpaste.

Fluoride in the environment and its metabolism in humans

The presence of environmental fluoride and its impact on human health is well documented. When consumed in adequate quantity, fluoride prevents dental caries, assists in the formation of dental enamels, and prevents deficiencies in bone mineralization. At excessive exposure levels, ingestion of fluoride causes dental fluorosis skeletal fluorosis, and manifestations such as gastrointestinal, neurological, and urinary problems. The distribution of fluoride in the environment is uneven and largely is believed to derive from geogenic causes. The natural sources of fluoride are fluorite, fluorapatite, and cryolite, whereas anthropogenic sources include coal burning, oil refining, steel production, brick-making industries, and phosphatic fertilizer plants, among others. Among the various sources of fluoride in the environment, those of anthropogenic origin have occasionally been considered to be major ones. The gourndwater is more susceptible to fluoride accumulation and contamination than are other environmental media, primarily because of its contact with geological substrates underneath. The high fluoride concentration in water usually reflects the solubility of fluoride (CaF₂). High concentrations are also often associated with soft, alkaline, and calcium-deficient waters. The fluoride compounds that occur naturally in drinking water are almost totally bioavailable (90%) and are completely absorbed from the gastrointestinal tract. As a result, drinking water is considered to be the potential source of fluoride that causes fluorosis. Because the bioavailability of fluoride is generally reduced in humans when consumed with milk or a calcium-rich diet, it is highly recommended that the inhabitants of fluoride-contaminated areas should incorporate calcium-rich foods in their routine diet. Guidelines for limiting the fluoride intake from drinking water have been postulated by various authorities. Such limits are designed to protect public health and should reflect all fluoride intake sources, including dietary fluoride. The toxicological risks posed by fluoride could be better understood if epidemiological surveillance for dental and skeletal fluorosis would be systematically conducted in fluoride-affected areas. Such input would greatly improve understanding of the human dose-response relationship. Such surveillance of potentially high fluoride areas is also important because it would help to delineate, much earlier, the remedial measures that are appropriate for those areas.

Assessment of water contribution on total fluoride intake of various age groups of people in fluoride endemic and non-endemic areas of Dindigul District, Tamil Nadu, South India

The prevalence of fluorosis is mainly due to the intake of large quantities of fluoride through water. It is necessary to determine the contribution of water used for drinking and food processing and other diet sources on daily fluoride intake for finding the ways to reduce the excess fluoride intake than the minimum safe level intake of 0.05 mg/kg/day. The main objectives of this study are to determine the quantitative impact of water through drinking and cooking of food and beverages on total fluoride intake as well as to estimate the contribution of commonly consumed diet sources on total fluoride intake. Contribution of water on daily fluoride intake and estimation of total fluoride intake through the diet sources were accomplished through analysis of fluoride in drinking water, solid and liquid food items, Infant formulae, tea and coffee infusions using fluoride ion selective electrode. Determination of incidence of fluorosis in different fluoride endemic areas in Dindigul District of Tamil Nadu, South India is achieved through clinical survey. The percentage of daily fluoride intake through water is significantly higher for infants than children, adults and old age groups of people. The percentile scores of fluoride intake through water from drinking and cooking increases with increase of water fluoride level. The rate of prevalence of fluorosis is higher in adolescent girls and females than adolescent boys and males residing in high fluoride endemic areas. More than 60% of the total fluoride intake per day derived from water used for drinking and food processing. Hence the people residing in the fluoride endemic areas in Dindigul District of Tamil Nadu, South India are advised to take serious concern about the fluoride level of water used for drinking and cooking to avoid further fluorosis risks.

Fluoride content of UHT milks commercially available in Bauru, Brazil

OBJECTIVES

The aims of the present study were to evaluate the fluoride (F) concentrations in whole, defatted and chocolate milks commercially available in Brazil and to estimate the daily F intake from these sources.

MATERIAL AND METHODS

F concentrations were determined for 23 brands of milks, after HMDS-facilitated diffusion, using a F ion-specific electrode. Possible F ingestion per kg body weight was estimated, based on suggested volumes of formula consumption, for infants aging 1 to 12 months.

RESULTS

F concentrations ranged from 0.02 to 1.6 microg/mL F for all brands analyzed. Whole and defatted milks had the lowest F concentrations, ranging from 0.02 to 0.07 microg/mL. With respect to chocolate milks, three brands had F concentrations above 0.5 microg/mL. Some brands of chocolate milks exceeded the dose regarded as the threshold level for the development of dental fluorosis, without taking into account other sources of fluoride intake.

CONCLUSION

The high fluoride concentrations found in some brands of chocolate milks in the present study indicate that many products may be important contributors to the total fluoride intake, reinforcing the need of assaying fluoride content of foods and beverages consumed by small children.

Fluoride content of several breakfast cereals and snacks found in Brazil

Breakfast cereals and snacks are foodstuffs highly appreciated by children, and the possibility that they contain substantial amounts of fluoride, associated with their widespread consume, may make them important contributors to the total daily fluoride intake. The aim of this study was to analyze the fluoride content on several breakfast cereals (A) and snacks (B) purchased in Brazil. The analysis were made after HMDS-facilitated diffusion (Taves) using the ion-specific electrode (9609). Mean fluoride concentrations ± SD (range, unit mg F/g) were: A= 0.76 ± 0.60 (0.08-1.86, n=15) and B= 0.32 ± 0.09 (0.22-0.55, n=18). Our results suggest that the total amount of fluoride available in some products may contribute to the total daily fluoride intake. The product labels should provide information on their fluoride content to prevent fluorosis at the age of risk.

The case for reducing the current Council on Dental Therapeutics fluoride supplementation schedule

The milder forms of dental fluorosis have increased in prevalence since the original epidemiologic surveys of the 1930s. Most studies of fluorosis have identified the use of supplements as a major risk factor. Fluorosis could be prevented, in part, by stopping the improper prescription of fluoride supplements in optimally fluoridated areas and by lowering the dosage currently recommended by the Council on Dental Therapeutics supplemental fluoride schedule. At a 1991 workshop at the University of North Carolina, five alternatives to the present ADA Council on Dental Therapeutics schedule were suggested; however, no consensus on dosage was reached. Recently, the Fédération Dentaire International adopted a dosage schedule of 0.25 mg F from birth to 3 years of age, 0.5 mg F from 3 to 5 years, and 1 mg F thereafter. At a 1992 Canadian workshop it was proposed that supplements should not be started until age 3, should be given only to those "at high risk" of caries, and only 0.25 mg F should be prescribed from 3 to 5 years of age. Similarly, in some European countries supplements are not recommended until 3 years, at which time 0.5 mg F is prescribed, but only "for children at risk." Australia is considering a dosage schedule starting with 0.25 mg F at 6 months, again only for those "particularly at risk of caries." Serious problems exist in limiting fluoride supplementation only to high-caries-risk children because they are not easily identifiable at a young age. Ideally, a dosage schedule should be based on body surface area or weight rather than simply age, and supplements should be in the form of lozenges for children over 2 years of age. A reduced fluoride supplement dosage schedule is proposed.