CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Fluoride Use in Caries Prevention in the Primary Care Setting Melinda B. Clark, MD, FAAP,a Martha Ann Keels, DDS, PhD,b,c Rebecca L. Slayton, DDS, PhD,d SECTION ON ORAL HEALTH

Dental caries remains the most common chronic disease of childhood in the abstract United States. Caries is a largely preventable condition, and fluoride has aDepartment of Pediatrics, Albany Medical Center, Albany, New York; proven effectiveness in caries prevention. This clinical report aims to clarify bDepartment of Surgery and Pediatrics, Duke University, Durham, the use of available fluoride modalities for caries prevention in the primary North Carolina; cThe Adams School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and dDepartment of care setting and to assist pediatricians in using fluoride to achieve maximum Pediatric Dentistry, School of Dentistry, University of Washington, protection against dental caries, while minimizing the likelihood of enamel Seattle, Washington

fluorosis. varnish application is now considered the standard of care Clinical reports from the American Academy of Pediatrics benefit from in pediatric primary care. This report highlights administration, billing, and expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of payment information regarding the fluoride varnish procedure. Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

Drs Clark, Keels, and Slayton participated in the concept and design of the manuscript, analysis and interpretation of data, and drafting and revising of the manuscript; and all authors approved the final manuscript as submitted.This document is copyrighted and is Dental caries (ie, decay) is an infectious disease caused by property of the American Academy of Pediatrics and its Board of on the tooth surface metabolizing carbohydrates and producing acid, Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved which dissolves . If unchecked, this process continues through a process approved by the Board of Directors. The American through the tooth and into the pulp, resulting in pain and tooth loss. This Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this can further progress to local infections (ie, dental alveolar abscess or facial publication. cellulitis), systemic infection, and, in rare cases, death. Dental caries in the The guidance in this report does not indicate an exclusive course of United States is responsible for many of the 51 million school hours lost treatment or serve as a standard of medical care. Variations, taking per year as a result of dental-related illness, which translates into lost into account individual circumstances, may be appropriate. 1 work hours for the adult caregiver. Early childhood caries is the single All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, greatest risk factor for caries in the permanent dentition. Good oral health revised, or retired at or before that time. is a necessary part of overall health, and studies have demonstrated adverse effects of poor oral health on multiple chronic conditions, DOI: https://doi.org/10.1542/peds.2020-034637 including diabetes control.2 Therefore, failure to prevent caries has health, Address correspondence to Melinda B. Clark, MD. Email: ClarkM@ amc.edu educational, and financial consequences at both the individual and societal levels. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Dental caries is the most common chronic disease of childhood,1 with 59% Copyright © 2020 by the American Academy of Pediatrics of 12- to 19-year-olds having at least 1 documented cavity.3 Caries is FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. a “silent epidemic” that disproportionately affects poor, young, minority populations and children living below 100% of the poverty level.1 In the United States, 25% of 2- to 5-year-old children from low socioeconomic To cite: Clark MB, Slayton RL, AAP SECTION ON ORAL and minority groups experience 80% of dental disease.4 Among 3- to 5- HEALTH. Fluoride Use in Caries Prevention in the Primary Care Setting. Pediatrics. 2020;146(6):e2020034637 year-olds, untreated dental decay was significantly greater for non-

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 146, number 6, December 2020:e2020034637 FROM THE AMERICAN ACADEMY OF PEDIATRICS Hispanic Black and Hispanic children syndrome, the risk was close to that a day for 2 minutes and flossing (19.3% and 19.8%, respectively) than of controls and considerably lower between all teeth that touch), and for non-Hispanic white children than the other 3 groups of children receiving regular dental assessments (11.3%).4 This disparity persisted with special health care needs.7 and care. If carious lesions are among children 6 to 9 years and 13 to identified early, the process can be Unfortunately, dental caries 15 years of age.4 Dental caries is halted or reversed by modifying the prevalence in young children a global problem, with early patient’s individual risk and increased between the previous 2 childhood caries prevalence among protective factors. The AAP’s national surveys, despite socioeconomically disadvantaged publications “Maintaining and improvements among older children.9 groups reported to be as high as Improving the Oral Health of Young Many children do not receive dental 70%.5 It has been suggested that Children”11 and Bright Futures: care at young ages, and because the health beliefs, self‐efficacy, access to Guidelines for Health Supervision of risk of dental caries is heavily care, and parents’ attitudes and Infants, Children, and Adolescents12 influenced by parenting practices, practices related to dietary and oral discuss these concepts in greater pediatricians have a unique hygiene behaviors may contribute to depth and provide targeted opportunity to participate in the this disparity.6 anticipatory guidance. For primary primary prevention of dental caries. prevention to be effective, it is The 2007–2016 Medical Expenditure Children with special health care imperative that pediatricians be Panel Survey demonstrated that needs, including those with knowledgeable about the process of 88.8% of infants and 1-year-olds have developmental delay, complex dental caries, social determinants of office-based physician visits annually, neurodevelopmental disabilities, or oral health, prevention of the disease, compared with only 3.6% of infants congenital heart disease are also and available interventions, including and 1-year-olds having general dental affected disproportionately.7,8 In fluoride. visits (American Academy of a study of Head Start children, those Pediatrics [AAP], unpublished with developmental delays had Fluoride is available from many analysis of 2007–2016 Medical a caries prevalence ratio that was sources, divided into 3 major Expenditure Panel Survey, August 1.26 times higher than classmates categories: tap water (and foods and 2019). Studies show that health care fl without developmental delays.8 This beverages processed with uoridated dollars are saved with simple home difference may be attributable to water), home administered, and and primary care setting prevention challenges with home care routines professionally applied. The measures.10 such as toothbrushing and use of widespread decline in dental caries in medications with high sugar content, The development of dental caries many developed countries, including among other factors.8 Children with requires 4 components: teeth, the United States, has been largely fl special health care needs are bacteria, carbohydrate exposure, and attributable to the use of uoride. frequently considered as a group time. Once teeth emerge, they become Fluoride has 3 main mechanisms of 13 when determining caries risk. colonized with cariogenic bacteria. action : However, some diagnoses place The bacteria metabolize 1. Fluoride promotes enamel children at greater risk for caries, carbohydrates and create acid as remineralization. whereas other children are at a byproduct. The acid dissolves the 2. Fluoride reduces enamel decreased or similar risk as children mineral content of enamel demineralization. without special health care needs. In (demineralization) and, over time, 3. Fluoride inhibits bacterial a retrospective longitudinal study of with repeated acid attacks, the metabolism and acid production. children with autism spectrum enamel surface disintegrates and disorder, Down syndrome, congenital results in a cavity in the tooth. The mechanisms of fluoride are both heart disease, and cerebral palsy, Protective factors that help to 7 topical and systemic, but the topical Frank et al determined that the remineralize enamel include exposing effect is the most important, fl caries risk among the group of the teeth to uoride, limiting the especially over the life span.14 children with special health care frequency of carbohydrate needs was higher than among the consumption (to 3 meals and 2 There has been substantial public and control subjects but the risk differed healthy snacks per day), choosing less professional debate about fluoride, significantly by diagnosis. The caries cariogenic foods (selecting cheese or and a great deal of information is burden was greatest in children with raw carrots over candy or crackers; available, often with confusing or congenital heart disease, followed by selecting fresh fruit over dried fruit or conflicting messages. Excess fluoride those with autism spectrum processed fruit snacks), practicing ingestion during tooth development disorders.7 For children with Down good (brushing twice can result in subsurface

Downloaded from www.aappublications.org/news by guest on September 26, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS hypomineralization and porosity Moderate and severe forms of enamel Fluoride to Prevent and Control between the developing enamel rods, fluorosis are uncommon in the United Dental Caries in the United States.”21 termed enamel fluorosis.15 Fluorosis States but have both an aesthetic The 2 intents of this clinical report of permanent teeth occurs when concern and, potentially, a structural are as follows: excessive fluoride is ingested during concern with pitting, brittle incisal the time that tooth enamel is being edges and weakened groove anatomy 1. to assist pediatricians in using fl mineralized; therefore, the risk is in the permanent 6-year molars.20 uoride to achieve maximum influenced by both dose and After 8 years of age, there is no protection against dental caries, frequency of ingestion. Recent further risk of fluorosis except for the while minimizing the likelihood of fl evidence also suggests a genetic third molars because all other enamel uorosis; and susceptibility or resistance to the permanent tooth enamel is fully 2. to clarify what advice should be development of fluorosis.16 Fluorosis mineralized. given by pediatricians regarding develops in children younger than fluoride in the primary care 8 years, with the most susceptible Dental and governmental setting. period for permanent maxillary organizations (the American Dental incisor fluorosis (central teeth) Association [ADA], American between 15 and 30 months of Academy of Pediatric Dentistry CURRENT INFORMATION REGARDING age.17–19 The vast majority of enamel [AAPD], and Centers for Disease FLUORIDE USE IN CARIES PREVENTION fluorosis is mild or very mild and Control and Prevention [CDC]) have Sources of ingested fluoride include characterized by small white all published guidelines on the , infant formula, striations or opaque areas not readily use of fluoride. In 2001, the AAP fluoride , prescription noticeable to the casual observer and endorsed the CDC publication fluoride supplements, fluoride mouth is of minimal clinical consequence. “Recommendations for Using rinses, professionally applied topical

FIGURE 1 AAP Oral Health Risk Assessment Tool.

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 146, number 6, December 2020 3 fluoride, and some foods and Children younger than 6 years are sodium fluoride. This agent can be beverages.22 Preventive strategies for more likely to ingest toothpaste and recommended for children 6 years caries can be tailored by focusing on increase the risk of fluorosis. and older and adolescents who are at key risk factors for dental caries Fluorosis risk can be minimized by high risk of caries and who are able to associated with diet, bacteria, saliva, using the recommended amounts of expectorate after brushing. Examples and status of the teeth (both current toothpaste and storing toothpaste of children for whom high- and previous caries experience).11 where young children cannot access it concentration fluoride toothpaste The AAP Oral Health Risk Assessment without parental help. Parents should might be indicated are those with Tool (Fig 1) is recommended in supervise children younger than history of dental caries and new Bright Futures: Guidelines for Health 8 years to ensure the proper amount lesions, children with , and Supervision of Infants, Children, and of toothpaste and effective brushing those with gastroesophageal reflux Adolescents and endorsed by the technique. causing dental erosion. Dental health National Interprofessional Initiative professionals may also prescribe this on Oral Health. This tool can be found Recommendations and Dosing agent for adolescents who are at www.aap.org/en-us/Documents/ undergoing orthodontic treatment The use of fluoride toothpaste should oralhealth_RiskAssessmentTool.pdf. because they are at increased risk of begin with the eruption of the first caries during this time.26 Table 1 provides condensed tooth. For children younger than recommendations for use of fluoride 3 years, the recommended amount is modalities in patients at low and high a smear or grain of rice size Fluoride varnish is a concentrated risk of caries as described in the (approximately 0.1 mg of fluoride). topical fluoride applied to the teeth following sections. Once the child has turned 3 years of that sets on contact with saliva. age and is more able to consistently Advantages of this modality are that it expectorate, a pea-sized amount of Fluoride Toothpaste is well tolerated by infants and young toothpaste (approximately 0.25 mg of Fluoride toothpaste has consistently children, has a prolonged therapeutic fluoride) should be used.24,25 It is been proven to provide a caries- effect, and can be applied by both preferable to spit, but not rinse, after preventive effect for individuals of all dental and nondental health brushing. Expectorating without ages.21,23 In the United States, the professionals in a variety of rinsing reduces the amount of fluoride concentration of over-the- settings.27 The concentration of fluoride swallowed and leaves some counter (OTC) toothpaste ranges fluoride varnish is 22 600 ppm fluoride available in the saliva for from 1000 to 1100 ppm. This (2.26% fluoride ion), and the active uptake by the . Parents translates into 1 mg of fluoride in a ingredient is sodium fluoride. The should be strongly advised to 1-inch (1 g) strip of paste. A unit dose packaging from most supervise their child’s use of fluoride pea-sized amount of toothpaste is manufacturers provides a specific toothpaste to avoid overuse or approximately one-quarter of an inch. measured amount (0.25 mL, ingestion, especially with children Therefore, a pea-sized amount of providing 5 mg of fluoride ion). The who have complex toothpaste containing 1000 to 1100 application of fluoride varnish during neurodevelopmental disabilities and ppm fluoride would have an oral screening is of benefitto cannot consistently expectorate. approximately 0.25 mg of fluoride. children, especially those with limited Most fluoride in High-concentration toothpaste (5000 access to dental care. The current the United States contain ppm) is available by prescription AAPD recommendation for children sodium fluoride, sodium only, and this decision is usually made at high risk of caries is that fluoride monofluorophosphate, or stannous by a dental health professional. The varnish be applied to the teeth every fluoride as the active ingredient. active ingredient in this toothpaste is 3 to 6 months.28 The 2013 ADA

TABLE 1 Summary of Fluoride Modalities for Low- and High-Risk Patients Fluoride Modality Low Caries Risk High Caries Risk Toothpaste Starting at tooth emergence (smear of paste until age 3, then Starting at tooth emergence (smear of paste until age 3, then pea-sized) pea-sized) Fluoride varnish Every 3–6 mo starting at tooth emergence Every 3 mo starting at tooth emergence Mouth rinse OTC Do not use Starting at age 6 y if the child can reliably swish and spit Community water Yes Yes fluoridation Dietary fluoride Yes, if drinking water supply is not fluoridated Yes, if drinking water supply is not fluoridated supplements

Downloaded from www.aappublications.org/news by guest on September 26, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS guideline recommends application of information for these chapter oral recommended for children younger fluoride varnish at least every health advocates can be found at than 6 years because of their limited 6 months to both primary and www.aap.org/en-us/advocacy-and- ability to rinse and spit and increased permanent teeth of those at elevated policy/aap-health-initiatives/Oral- risk of swallowing higher than caries risk.29 Medicaid pays both Health/Pages/Chapter-Oral-Health- recommended amounts of fluoride.32 physicians and for the Advocates.aspx. A teaspoon (5 mL) of OTC fluoride application of fluoride varnish in all rinse contains approximately 1 mg of 50 states. Indications for Use fluoride. For children older than In the primary care setting, fluoride 6 years, OTC rinses provide additional Under the Patient Protection and varnish should be applied at least topical fluoride that may assist in the Affordable Care Act,30 payers are once every 6 months for all children prevention of enamel required to cover, without cost- and every 3 months for children at demineralization. However, the sharing, preventive services high risk for caries, starting when the evidence for an anticaries effect is recommended by the US Preventive first tooth erupts and until the limited, and decisions to recommend Services Task Force (USPSTF) and establishment of a dental home. OTC fluoride rinses should be made Bright Futures guidelines. The Medical and dental professionals are in consultation with the child’s dental USPSTF recommended in 2014 that encouraged to work in collaboration health care provider.33,34 primary care clinicians apply fluoride to ensure that fluoride varnish is varnish to the primary teeth of all being applied. Dietary Fluoride Supplements infants and children starting at the The USPSTF recommended in 2014 age of primary tooth eruption (B Instructions for Use that primary care clinicians prescribe recommendation).31 All children Fluoride varnish must be applied by dietary fluoride supplements for 5 years and younger deserve to have a , dental auxiliary children living in communities with application of fluoride varnish fully professional, physician, nurse, or nonfluoridated water or who drink covered, as per USPSTF other health care professional on the well water that does not contain recommendations, as part of health basis of individual state practice acts. fluoride.31 Because there are many maintenance and preventive care and It should not be dispensed to families sources of fluoride in water supplies for fluoride varnish application to be to apply at home. Application of and processed food and drinks, it is a covered benefit and separately paid fluoride varnish is most commonly essential that all potential sources of service (ie, not considered incidental performed in the context of a well- fluoride be assessed before to the office visit). All practices child visit. Teeth are dried with a 2- prescribing a dietary supplement, should be paid separately and inch gauze square, and then the including consideration of differing appropriately according to the varnish is painted onto all surfaces of environmental exposures (dual definition of the Current Procedural the teeth with a brush. The dose homes and child care). As a general Terminology (CPT) code, which recommended for young children is guideline, if the source of drinking defines fluoride application as 0.25 mL, which is available in single- water in the primary home is a separately identifiable procedure. dose applicator kits. Children can eat fluoridated tap or well water, children Fluoride varnish payment should not and drink immediately after will not require fluoride be bundled with routine preventive application and are instructed to eat supplementation, even if they evaluation and management services soft foods and not to brush their teeth primarily drink bottled water because because definitions of preventive care on the evening after the varnish the teeth are exposed to fluoride under those specific CPT codes do not application to maximize the contact through food preparation and include fluoride varnish application. time of varnish on the teeth. Children brushing. The risk of fluorosis is high Information regarding coding, billing, should resume brushing twice daily if fluoride supplements are given to and payment for fluoride varnish with fluoridated toothpaste the a child consuming fluoridated application can be found on the AAP following morning. water.35 Information about the Web site (www.aap.org/oralhealth) fluoridation levels in many and the Pew Center on the States Web OTC Fluoride Rinse community water systems can be site (www.pewstates.org/research/ OTC fluoride rinse provides a lower found on the CDC Web site “My analysis/reimbursing-physicians-for- concentration of sodium fluoride than Water’s Fluoride” (https://nccd.cdc. fluoride-varnish-85899377335). toothpaste or varnish. The gov/doh_mwf/default/default.aspx). Many AAP Chapters have chapter oral concentration is most commonly 230 Not all communities report this health advocates who promote and ppm (0.05% sodium fluoride). Expert information to the CDC, so it may be advocate for pediatric oral health panels on this topic have concluded necessary to contact the local water within their community. Contact that OTC fluoride rinses should not be department to determine the level of

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 146, number 6, December 2020 5 fluoride in the community water. Well TABLE 2 Fluoride Supplementation Schedule appropriate to buy water with no water must be tested for fluoride for Children added fluoride before tooth content before prescribing Age Fluoride Ion Level in Drinking emergence. After tooth emergence, supplements, and this testing is Water, ppma formula should be mixed with available in most areas through the ,0.3 0.3–0.6 .0.6 optimally fluoridated tap water or fl state or county Birth to 6 mo None None None nursery water with uoride, or laboratory. Challenges with dietary 6 mo to 3 y 0.25 mg/db None None fluoride supplements should be fluoride supplementation include 3–6 y 0.50 mg/d 0.25 mg/d None prescribed. It should be noted that determining the child’s fluoride 6–16 y 1.0 mg/d 0.50 mg/d None most bottled water has suboptimal exposures and proper administration Source: Centers for Disease Control and Prevention.21 concentrations of fluoride and that a of the medication. 1.0 ppm = 1 mg/L. fluoride content is not listed unless b 2.2 mg of sodium fluoride contains 1 mg of fluoride ion. fluoride is added by the It is important to note that the manufacturer. Fluoride is often added USPSTF recommendations vary from to milk or formula is not to “nursery” water, and this must be the ADA and AAPD guidelines, which recommended because absorption of declared on the packaging. Dietary both recommend fluoride fluoride is reduced in the presence of fluoride supplements should not be supplementation only be considered calcium.38 The risk of fluorosis can be prescribed for children drinking for children who drink fluoride- minimized by health care providers infant formula reconstituted with deficient water and are also at high verifying that there are no other fluoridated water. risk for dental caries.36,37 No caries sources of fluoride exposure before risk assessment tool has been prescribing systemic fluoride Community validated for pediatricians to use, but supplements. Community water fluoridation is the the AAP Oral Health Risk Assessment practice of adding a small amount of Tool was piloted through the Quality Other Sources of Fluoride fluoride to the water supply to Improvement Innovation Network, Fluoride is present in processed foods achieve a fluoride concentration of and more than 80% of practices and beverages and may be naturally 0.7 ppm. Community water found the tool easy to implement occurring in some areas of the fluoridation was heralded by the CDC because clinicians did not need to country. The presence of fluoride in as 1 of the top 10 public health significantly alter current practice to juices and carbonated beverages does achievements of the 20th century.42 incorporate risk assessment. not counteract the cariogenic nature Community water fluoridation is Identification of high-risk patients for of these beverages. a safe, efficient, and cost-effective way oral health referral increased from to prevent and has been 11% to more than 87% with the use Breastfeeding and Reconstitution of shown to reduce tooth decay by of this tool (Brightening Oral Health Infant Formula 25%.43 It prevents tooth decay by Workgroup and Quality Improvement The AAP recommends exclusive providing both topical and systemic Innovation Networks, AAP, breastfeeding for the first 6 months of exposure of low levels of fluoride to Brightening Oral Health: Teaching life, and there is no need during this the teeth over time. Although more and Implementing Oral Health Risk period of time to supplement with than 210 million Americans live in Assessments in Pediatric Care project, fluoride or water that is fluoridated. A communities with optimally unpublished data, 2009). study of infant feeding practices fluoridated water, more than 70 revealed that 70% to 75% of mothers million others do not have access to Guidelines for Use who fed their infants formula used fluoridated water in their public The CDC-recommended fluoride tap water to reconstitute the water system.41 The fluoridation supplementation dosage schedule is powdered formula.39 According to status of a community water supply provided in Table 2. Supplements can 2014 CDC data,40 approximately 74% can be determined by contacting the be prescribed in liquid, tablet, or of US households using a community local water department or accessing lozenge form. Tablets are preferable public water supply received the CDC Web site “My Water’s for children who can chew because optimally fluoridated water.41 Before Fluoride” (https://nccd.cdc.gov/doh_ they gain an additional topical benefit the emergence of the primary teeth, mwf/default/default.aspx). to the teeth during the chewing tap water can be used to reconstitute process. Liquid supplements are formula. There is a small risk of Recommended Concentration recommended for younger children fluorosis in the permanent dentition Community water fluoridation was and should ideally be added to water if a fluoridated water source is used initiated in the United States in the or put directly into the child’s mouth. to reconstitute formula.22 If families 1940s. In 2015, the US Department of Addition of the fluoride supplement elect to purchase water, it is Health and Human Services finalized

Downloaded from www.aappublications.org/news by guest on September 26, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS a recommendation to lower the production of phosphate fertilizer from ingesting large quantities of optimal fluoride concentration in and may include other fluoride supplements, fluoridated drinking water to 0.7 mg/L.44 This contaminants, such as arsenic. toothpaste, or fluoride mouth rinse. fluoride concentration replaced the The quality and safety of fluoride The toxic dose of elemental fluoride is previous recommendation, which was additives are ensured by Standard 5to10mgoffluoride/kg of body based on climate and ranged from 60 of the National Sanitation weight.50 Lethal doses in children 0.7 mg/L in warmest climates to Foundation/American National have been calculated to be between 1.2 mg/L in coldest climates.44 The Standards Institute, a program 8 and 16 mg/kg. When prescribing change was recommended because commissioned by the US sodium fluoride supplements, it recent studies revealed no variation Environmental Protection Agency is recommended to limit the in water consumption by young (EPA), and testing is conducted to quantity prescribed at one time to children on the basis of climate and to confirm that the concentrations of no more than a 4-month supply. adjust for an overall increase in arsenic or other substances are Parents should be advised to keep fluoride intake through foods and below those allowed by the EPA.46 fluoride products out of the reach beverages processed with fluoridated Finally,therehavebeenmany of young children and to supervise water, fluoridated mouth rinses, and unsubstantiated or disproven claims their use. fluoride toothpastes. that fluoride leads to kidney disease, bone cancer, and compromised IQ. Fluoride-Removal Systems Evidence Supporting Community Water More than 3000 studies or research A number of water treatment systems Fluoridation articles have been published on the are effective in removing fluoride Despite overwhelming evidence subject of fluoride or fluoridation.47 from water,51 including reverse supporting the safety and preventive Few topics have been as thoroughly osmosis and distillation. Parents benefits of fluoridated water, researched as community water should be counseled on the use of community water fluoridation fluoridation, and the overwhelming these and activated alumina filters in continues to be a controversial and weight of the evidence (along with the home and, should they choose to highly emotional issue. Opponents over 75 years of experience) supports use one that removes fluoride, the express a number of concerns that the safety and effectiveness of this potential adverse effects on the have been addressed or disproven by public health practice. family’s oral health. Commonly used validated research. The only home carbon filters (eg, Brita or PUR) scientifically documented adverse Naturally Occurring Fluoride in Drinking do not remove fluoride.51 Families Water effect of excess (nontoxic) exposure concerned about heavy metals or to fluoride is fluorosis. An increase in The optimal fluoride concentration in other impurities in their home water the incidence of mild enamel fluorosis drinking water is 0.7 ppm, an amount supply can use an activated carbon among teenagers has been cited as proven beneficial in reducing tooth filter and still retain the benefits of a reason to discontinue fluoridation, decay.44 Naturally occurring fluoride fluoridated water. although this is a cosmetic condition may be below or above these levels in with no detrimental health outcomes. some areas. Under the Safe Drinking Silver Diamine Fluoride Recent opposition has sometimes Water Act,48 the EPA requires Silver diamine fluoride (SDF) is centered on the question of who notification by the water supplier if a minimally invasive, low-cost liquid decides whether to fluoridate: elected the fluoride concentration exceeds 2 solution that is painted on cavitated and/or public officials or the voters. ppm. In areas where naturally lesions. In young children, SDF Some opponents believe occurring fluoride concentrations in provides a nonsurgical technique to fluoridation to be mass medication drinking water exceed 2 ppm, people manage carious lesions until the child and call into question the ethics of should consider an alternative water can cope with traditional restorative community water fluoridation, but source or home water treatments to dental care and, potentially, avoid courts have consistently upheld that reduce the risk of fluorosis in young sedation or a general anesthetic.52 it is legal and appropriate for children.49 Well water should be SDF has been used in Japan for more a community to adopt a fluoridation tested for the concentration of than 40 years and was cleared by the program.45 Opponents express fluoride, and this testing is most US Food and Drug Administration in concern about the quality and commonly performed through the 2014 to treat tooth sensitivity in source of fluoride, claiming that the local health department. adults.53,54 Similar to fluoride additives (fluorosilicic acid, sodium varnish, SDF (38% solution) has been fluoride, or sodium fluorosilicate), used off-label in children and adults in their concentrated form, are Toxic levels of fluoride are possible, to stabilize dental caries and reduce highly toxic byproducts of the particularly in children, resulting dental sensitivity. At present, the use

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 146, number 6, December 2020 7 of SDF in the United States is largely of the first tooth. A smear or grain limited to the dental profession of rice sized amount is because there are no formal recommended for children professional guidelines for use younger than 3 years, and a pea- outside of dentistry. SDF is indicated sized amount of toothpaste is for the arrest of cavitated carious appropriate for most children lesions in primary teeth as part of starting at 3 years of age (see a comprehensive caries management Fig 4). 52 program. Information about SDF is 3. Apply fluoride varnish according included in this report in expectation FIGURE 3 to the periodicity schedule and bill of questions to pediatricians about Three-year stabilization of a carious lesion on 1 using the CPT code 99188. this increasingly publicized primary molar after SDF application. Photo- Fluoride varnish is a proven tool in intervention and increasing numbers graph courtesy of Martha Ann Keels, DDS, PhD. early childhood caries prevention. of SDF-treated teeth seen in pediatric Additional training on oral practices. The mechanism of SDF screenings, fluoride varnish action is poorly understood, but silver SUGGESTIONS FOR PEDIATRICIANS indications and application, and ions are known to be antimicrobial, 1. Know how to assess caries risk. As office implementation can be and the fluoride prevents further recommended by the AAP in found in the Smiles for Life enamel demineralization. After SDF “Maintaining and Improving the Curriculum Course: Caries Risk application, the lesions must be Oral Health of Young Children” and Assessment, Fluoride Varnish and followed to assess their hardness the fourth edition of Bright Counseling55 at www. state. Additional treatments can be Futures, pediatricians should smilesforlifeoralhealth.org. applied to obtain sufficient hardness. perform oral health risk Additionally, the AAP Children’s The only known contraindication to assessments on all children at oral health Web site is a resource SDF is silver allergy, but SDF is not every routine well-child visit for oral health practice tools at indicated for carious lesions involving beginning at 6 months of age. The the pulp. The only significant adverse https://www.aap.org/en-us/ Oral Health Risk Assessment Tool advocacy-and-policy/aap-health- effect of SDF is that the carious lesion has been developed by the AAP turns black (Figs 2 and 3), which can initiatives/Oral-Health/Pages/ and Bright Futures and endorsed Oral-Health-Practice-Tools.aspx. be esthetically problematic for some. by the National Interprofessional 4. Know how to determine the SDF can also temporarily stain the Initiative on Oral Health. This tool concentration of fluoride in skin black if it accidentally comes into can be accessed at www.aap.org/ a child’s primary drinking water contact with the epithelium, and SDF en-us/Documents/oralhealth_ can cause mucosal irritation for and determine the need for RiskAssessmentTool.pdf. The tool 21 approximately 48 hours after mucosal is a guide to help clinicians systemic supplements. contact. Care must be taken when counsel patients about oral health 5. Advocate for water fluoridation in applying SDF to a cavitated lesion to and counsel in reducing risk. your local community. Public avoid contact with the child’s mucosa fl water fluoridation is an effective or skin. Details of SDF application 2. Recommend use of uoridated toothpaste starting at the eruption and safe method of protecting the technique for dental health most vulnerable members of our professionals are delineated in the population from dental caries. 54 AAPD Chairside Guide. Pediatricians are encouraged to advocate on behalf of public water fluoridation in their communities and states. For additional information and water fluoridation facts and detailed questions and answers, see the following: o http://www.ilikemyteeth.org; o www.ada.org/en/public- programs/advocating-for-the- FIGURE 2 fl Permanent staining of carious lesions after FIGURE 4 public/ uoride-and- SDF application. Photograph courtesy of Mar- Diagram of smear versus pea-sized amount of fluoridation/fluoridation-facts; tha Ann Keels, DDS, PhD. fluoride toothpaste. and

Downloaded from www.aappublications.org/news by guest on September 26, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS o http://www.cdc.gov/ Qadira Ali Huff, MD, MPH, FAAP ABBREVIATIONS fluoridation/. Jeffrey M. Karp, DMD Anupama Rao Tate, DMD AAP: American Academy of 6. Understand indications for SDF John H. Unkel, DDS, MD, MPA, FAAP and be able to recognize the David Krol, MD, MPH, FAAP, Immediate Past Pediatrics clinical appearance of SDF- Chairperson AAPD: American Academy of treated teeth. Pediatric Dentistry ADA: American Dental Association LIAISONS CDC: Centers for Disease Control LEAD AUTHORS Tooka Zokaie, MPH, CLSSGB – American and Prevention Melinda B. Clark, MD, FAAP Dental Association CPT: Current Procedural – Martha Ann Keels, DDS, PhD Matt Crespin, MPH, RDH American Dental Terminology Hygienists’ Association Rebecca L. Slayton, DDS, PhD EPA: US Environmental Protection John Fales, DDS, MS – American Academy of Pediatric Dentistry Agency SECTION ON ORAL HEALTH EXECUTIVE OTC: over-the-counter COMMITTEE, 2018–2019 SDF: silver diamine fluoride STAFF Patricia A. Braun, MD, MPH, FAAP, USPSTF: US Preventive Services Chairperson Ngozi Onyema-Melton, MPH, CHES Task Force Susan A. Fisher-Owens, MD, MPH, FAAP Lauren Barone, MPH

FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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