DOI: 10.1542/Peds.2014-1699 ; Originally Published Online August

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/134/3/626.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org by guest on September 13, 2014 Guidance for the Clinician in Rendering Pediatric Care

CLINICAL REPORT Fluoride Use in Caries Prevention in the Primary Care Setting

Melinda B. Clark, MD, FAAP, Rebecca L. Slayton, DDS, PhD, abstract and SECTION ON ORAL HEALTH Dental caries remains the most common chronic disease of childhood KEY WORDS fl fl fl in the United States. Caries is a largely preventable condition, and fluo- enamel uorosis, uoride, uoride varnish, formula mixing, systemic fluoride supplements, toothpaste, water fluoridation ride has proven effectiveness in the prevention of caries. The goals of ABBREVIATIONS fl this clinical report are to clarify the use of available uoride modalities AAP—American Academy of Pediatrics for caries prevention in the primary care setting and to assist pediatri- ADA—American Dental Association cians in using fluoride to achieve maximum protection against dental CDC—Centers for Disease Control and Prevention EPA—Environmental Protection Agency caries while minimizing the likelihood of enamel fluorosis. Pediatrics 2014;134:626–633 This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Dental caries (ie, tooth decay) is an infectious disease in which acid Academy of Pediatrics has neither solicited nor accepted any produced by bacteria dissolves tooth enamel. If not halted, this process commercial involvement in the development of the content of will continue through the tooth and into the pulp, resulting in pain and this publication. tooth loss. This activity can further progress to local infections (ie, The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. dental alveolar abscess or facial cellulitis), systemic infection, and, in Variations, taking into account individual circumstances, may be rare cases, death. Dental caries in the United States is responsible for appropriate. many of the 51 million school hours lost per year as a result of dental- related illness, which translates into lost work hours for the parent or adult caregiver.1 Early childhood caries is the single greatest risk factor for caries in the permanent dentition. Good oral health is a necessary part of overall health, and recent studies have demonstrated the adverse effects of poor oral health on multiple other chronic conditions, including diabetes control.2 Therefore, the failure to prevent caries has health, educational, and financial consequences at both the individual and societal level. Dental caries is the most common chronic disease of childhood,1 with www.pediatrics.org/cgi/doi/10.1542/peds.2014-1699 59% of 12- to 19-year-olds having at least 1 documented cavity.3 Caries doi:10.1542/peds.2014-1699 is the “silent epidemic” that disproportionately affects poor, young, and Accepted for publication Jun 9, 2014 minority populations.1 The prevalence of dental caries in very young All clinical reports from the American Academy of Pediatrics children increased during the period between the last 2 national sur- automatically expire 5 years after publication unless reaffirmed, veys, despite improvements for older children.4 Because many children revised, or retired at or before that time. do not receive dental care at young ages, and risk factors for dental PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). caries are influenced by parenting practices, pediatricians have a Copyright © 2014 by the American Academy of Pediatrics unique opportunity to participate in the primary prevention of dental caries. Studies show that simple home and primary care setting prevention measures would save health care dollars.5 Development of dental caries requires 4 components: teeth, bacteria, carbohydrate exposure, and time. Once teeth emerge, they may become colonized with cariogenic bacteria. The bacteria metabolize carbohydrates

626 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from pediatrics.aappublications.org by guest on September 13, 2014 FROM THE AMERICAN ACADEMY OF PEDIATRICS and create acid as a byproduct. The acid reduces enamel demineralization; and white striations or opaque areas dissolves the mineral content of enamel (3) it inhibits bacterial metabolism and that are not readily noticeable to (demineralization) and, over time with acid production.9 The mechanisms of the casual observer. Although this repeated acid attacks, the enamel sur- fluoride are both topical and systemic, type of fluorosis is of no clinical face collapses and results in a cavity in but the topical effect is the most im- consequence, enamel fluorosis has the tooth. Protective factors that help to portant, especially over the life span.10 been increasing in frequency over remineralize enamel include exposing the last 2 decades to a rate of the teeth to fluoride, limiting the fre- RISK OF FLUOROSIS approximately 41% among adoles- quency of carbohydrate consumption, cents because fluoride sources are The only scientifically proven risk of more widely available in varied choosing less cariogenic foods, prac- fluoride use is the development of forms.17 Moderate and severe forms ticing good oral hygiene, receiving reg- fluorosis, which may occur with fluo- of enamel fluorosis are uncommon ular dental care, and delaying bacterial ride ingestion during tooth and bone in the United States but have both colonization. If carious lesions are iden- development. Fluorosis of permanent fi an aesthetic concern and potentially ti ed early, the process can be halted or teeth occurs when fluoride of sufficient ’ reversed by modifying the patientsin- quantity for a sufficient period of time is a structural concern, with pitting, dividual risk and protective factors. ingested during the time that tooth brittle incisal edges, and weakened Certain American Academy of Pediatrics enamel is being mineralized. Fluorosis groove anatomy in the permanent (AAP) publications (Oral Health Risk As- is the result of subsurface hypomin- 6-year molars. sessment Timing and Establishment of eralization and porosity between In 2001, the AAP endorsed the guidelines the Dental Home6 and Bright Futures: the developing enamel rods.11 This from the Centers for Disease Control Guidelines for Health Supervision of risk exists in children younger than and Prevention (CDC), “Recommen- Infants, Children, and Adolescents7)dis- 8 years, and the most susceptible dations for Using Fluoride to Prevent cuss these concepts in greater depth period for permanent maxillary in- and Control Dental Caries in the United and provide targeted preventive an- cisor fluorosis is between 15 and States.”15 Dental and governmental ticipatory guidance. The Medical Ex- 30 months of age.12–14 The risk of organizations (American Dental Associ- penditure Panel Survey demonstrated fluorosis is influenced by both the ation [ADA], American Academy of Pe- that 89% of infants and 1-year-olds dose and frequency of exposure to diatric Dentistry, the Department of have office-based physician visits an- fluoride during tooth development.15 Health and Human Services, and the nually, compared with only 1.5% who Recent evidence also suggests that CDC) have more recently published have dental visits.8 For primary pre- individual susceptibility or resis- guidelines on the use of fluoride, but vention to be effective, it is imperative tance to fluorosis includes a ge- current AAP publications do not reflect that pediatricians be knowledgeable netic component.16 these newer evidence-based guidelines. about the process of dental caries, After 8 years of age, there is no further Table 1 provides a simple explanation prevention of the disease, and avail- risk of fluorosis (except for the third of fluoride use for patients at low and able interventions, including fluoride. molars) because the permanent tooth high risk of caries. Fluoride is available from many sources enamel is fully mineralized. The vast The present report has 2 goals: (1) to and is divided into 3 major categories: majority of enamel fluorosisismildor assist pediatricians in using fluoride to tap water (and foods and beverages very mild and characterized by small achieve maximum protection against processed with fluoridated water), home administered, and professionally applied. There has been substantial public and TABLE 1 Summary of Fluoride Modalities for Low- and High-Risk Patients professional debate about fluoride, and Fluoride Modality Low Caries Risk High Caries Risk myriad information is available, often Toothpaste Starting at tooth emergence (smear of Starting at tooth emergence (smear of with confusing or conflicting messages. paste until age 3 y, then pea-sized) paste until age 3 y, then pea-sized) Fluoride varnish Every 3–6 mo starting at tooth Every 3–6 mo starting at tooth The widespread decline in dental caries emergence emergence in many developed countries, including Over-the-counter Not applicable Starting at age 6 y if the child can the United States, has been largely at- mouth rinse reliably swish and spit fl Community water Yes Yes tributable to the use of uoride. Fluoride fluoridation has 3 main mechanisms of action: (1) it Dietary fluoride Yes, if drinking water supply is not Yes, if drinking water supply is not promotes enamel remineralization; (2) it supplements fluoridated fluoridated

PEDIATRICS Volume 134, Number 3, September 2014 627 Downloaded from pediatrics.aappublications.org by guest on September 13, 2014 dental caries while minimizing the used. Ingestion of excessive amounts of dental health professionals in a variety likelihood of enamel fluorosis; and (2) fluoride can increase the risk of fluoro- of settings.23 The concentration of fluo- to clarify the advice that should be sis. This excess can be minimized by ride varnish is 22 600 ppm (2.26%), and given by pediatricians regarding fluo- limiting the amount of toothpaste used theactiveingredientissodiumfluoride. ride in the primary care setting. and by storing toothpaste where young The unit dose packaging from most children cannot access it without pa- manufacturers provides a specificmea- CURRENT INFORMATION rental help. sured amount (0.25 mg, providing 5 mg REGARDING FLUORIDE USE IN Use of fluoride toothpaste should begin of fluoride ion). The application of fluo- CARIES PREVENTION with the eruption of the first tooth. ride varnish during an oral screening is fl of benefit to children, especially those The following information aims to as- When uoride toothpaste is used for who may have limited access to dental sist pediatricians in achieving maxi- children younger than 3 years, it is care. Current American Academy of Pe- mum protection against dental caries recommended that the amount be diatric Dentistry recommendations for for their patients while minimizing the limited to a smear or grain of rice size children at high risk of caries is that likelihood of enamel fluorosis. Sources (about one-half of a pea). Once the child fluoride varnish be applied to their teeth of ingested fluoride include drinking has turned 3 years of age, a pea-sized 20,21 every 3 to 6 months.24 The2013ADA water, infant formula, fluoride tooth- amount of toothpaste should be used. guideline recommends application of paste, prescription fluoride supplements, Young children should not be given fluoride varnish at least every 6 months fluoride mouth rinses, professionally water to rinse after brushing because to both primary and permanent teeth in applied topical fluoride, and some their instinct is to swallow. Expec- those subjects at elevated caries risk.25 foods and beverages.18 torating without rinsing will both reduce the amount of fluoride swal- TheUSPreventiveServicesTaskForce fl recently published a new recommenda- Fluoride Toothpaste lowed and leave some uoride in the saliva, where it is available for uptake tion that primary care clinicians apply Fluoride toothpaste has consistently been by the dental plaque. Parents should fluoride varnish to the primary teeth of proven to provide a caries-preventive be strongly advised to supervise their all infants and children starting at the effect for individuals of all ages.15,19 In child’s use of fluoride toothpaste to age of primary tooth eruption (B rec- the United States, the fluoride concen- avoid overuse or ingestion. ommendation).26 tration of over-the-counter toothpaste High-concentration toothpaste (5000 In most states, Medicaid will pay phy- ranges from 1000 to 1100 ppm. In some ppm) is available by prescription only. sicians for the application of fluoride other countries, toothpastes containing The active ingredient in this toothpaste varnish. Information regarding fluoride 1500 ppm of fluoride are available. A is sodium fluoride. This agent can be varnish application reimbursement and 1-inch (1-g) strip of toothpaste translates recommended for children 6 years and which states currently provide payment to 1 or 1.5 mg of fluoride, respectively. older and adolescents who are at high can be found on the AAP Web site A pea-sized amount of toothpaste is risk of caries and who are able to (http://www2.aap.org/oralhealth/docs/ approximately one-quarter of an inch. expectorate after brushing. Dentists OHReimbursementChart.pdf) and the Therefore, a pea-sized amount of tooth- may also prescribe this agent for Pew Charitable Trusts Web site (http:// paste containing 1000/1100 ppm of adolescents who are undergoing or- www.pewstates.org/research/analysis/ fluoride would have approximately 0.25 thodontic treatment, as they are at reimbursing-physicians-for-fluoride- mg of fluoride, and the same amount of increased risk of caries during this varnish-85899377335). Because state reg- toothpaste containing 1500 ppm of fluo- time.22 ulations vary regarding whether fluoride ride would have approximately 0.38 mg varnish must be applied within the of fluoride. Most fluoride toothpaste in Fluoride Varnish context of a preventive care code, this the United States contains sodium fluo- information should be determined ride, sodium monofluorophosphate, or Fluoride varnish is a concentrated before billing. stannous fluorideastheactiveingre- topical fluoride that is applied to the dient. Parents should supervise children teeth by using a small brush and sets Indications for Use younger than 8 years to ensure the on contact with saliva. Advantages of In the primary care setting, fluoride proper amount of toothpaste and effec- this modality are that it is well tolerated varnish should be applied to the teeth tive brushing technique. Children youn- by infants and young children, has of all infants and children at least once ger than 6 years are more likely to a prolonged therapeutic effect, and can every 6 months and preferably every 3 ingest some or all of the toothpaste be applied by both dental and non- months, starting when the first tooth

628 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from pediatrics.aappublications.org by guest on September 13, 2014 FROM THE AMERICAN ACADEMY OF PEDIATRICS erupts and until establishment of a den- beyond daily use of fluoridated toothpaste Guidelines for Use tal home. for children at low risk of caries.28,29 CDC recommendations regarding fluoride supplementation are provided in Instructions for Use Dietary Fluoride Supplements Table 2. Supplements can be prescribed Fluoride varnish must be applied by Dietary fluoride supplements should be in liquid or tablet form. Tablets are a dentist, dental auxiliary professional, considered for children living in com- preferable for children old enough to physician, nurse, or other health care munities in which the community water chew, because they gain an additional professional, depending on the prac- is not fluoridated or who drink well topical benefit to the teeth during the tice regulations in each state. It should water that does not contain fluoride.26 chewing process. Liquid supplements not be dispensed to families to apply at Because there are many sources of are recommended for younger children home. Application of fluoride varnish is fluoride in the water supply and in and should ideally be added to water most commonly performed at the time processed food, it is essential that all or put directly into the child’s mouth. of a well-child visit. Teeth are dried with potential sources of fluoride be as- Addition of the fluoride supplement to a 2-inch gauze square, and the varnish sessed before prescribing a dietary milk or formula is not recommended is then painted onto all surfaces of the supplement, including consideration of because of the reduced absorption of teeth with a brush provided with the differing environmental exposures (eg, fluoride in the presence of calcium.31 varnish. Children are instructed to eat dual homes, child care). As a general Theriskofmildfluorosis can be mini- soft foods and not to brush their teeth guideline, if the primary source of water mized by health care providers verify- on the evening after the varnish ap- is fluoridated tap or well water, the child ingthattherearenoothersourcesof plication to maximize the contact time will not require fluoride supplementa- fluoride exposure before prescribing of the varnish to the tooth. The following tion, even if he or she primarily drinks systemic fluoride supplements. day, they should resume brushing twice bottled water, because the teeth are fl daily with uoridated toothpaste. exposed to fluoride through cooking and Other Sources of Fluoride brushing. The risk of fluorosis is high if Fluoride is present in processed foods fluoride supplements are given to Over-the-Counter Fluoride Rinse and beverages and may be naturally a child consuming fluoridated water.30 occurring in some areas of the coun- Over-the-counter fluoride rinse pro- Information about the fluoridation levels try. The presence of fluoride in juices vides a lower concentration of sodium in many community water systems can and carbonated beverages does not fluoride than toothpaste or varnish. be found on the CDC Web site entitled counteract the cariogenic nature of The concentration is most commonly My Water’s Fluoride (http://apps.nccd. these beverages. 230 ppm (0.05% sodium fluoride). Ex- cdc.gov/MWF/Index.asp). Not all commu- pert panels on this topic have con- nities report this information to the CDC; Reconstitution of Infant Formula cluded that over-the-counter fluoride therefore, it may be necessary to con- rinses should not be recommended for tact the local water department to de- In a study of infant feeding practices, children younger than 6 years because termine the level of fluoride in the 70% to 75% of mothers who fed their of their limited ability to rinse and spit community water. Well water must be infants formula used tap water to and the risk of swallowing higher-than- tested for fluoride content before pre- reconstitute the powdered formula.32 recommended levels of fluoride.27 A scribing supplements; such testing is According to CDC data from 2012, teaspoon (5 mL) of over-the-counter available in most states through the approximately 67% of US households fluoride rinse contains approximately state or county public health laboratory. using public water supplies received 1mgoffluoride. For children younger than 6 years, this type of rinse provides an additional, low-dose topical fluoride TABLE 2 Fluoride Supplementation Schedule for Children application that may assist in the pre- Age Fluoride Ion Level in Drinking Watera vention of enamel demineralization. <0.3 ppm 0.3–0.6 ppm >0.6 ppm However, the evidence for an anticaries Birth–6 mo None None None effect is limited. The daily use of a 6mo–3 y 0.25 mg/db None None 0.05% sodium fluoride rinse may be of 3–6 y 0.50 mg/d 0.25 mg/d None benefit for children older than 6 years 6–16 y 1.0 mg/d 0.50 mg/d None Source: Centers for Disease Control and Prevention.43 who are at high risk of dental caries; a 1.0 ppm = 1 mg/L. however, there is no additional benefit b 2.2 mg of sodium fluoride contains 1 mg of fluoride ion.

PEDIATRICS Volume 134, Number 3, September 2014 629 Downloaded from pediatrics.aappublications.org by guest on September 13, 2014 optimally fluoridated water (between or accessing the Web site My Water’s call the ethics of community water 0.7 and 1.2 ppm).33 Fluoride (http://apps.nccd.cdc.gov/MWF/ fluoridation into question, but courts Index.asp). have consistently held that it is legal and ADA Evidenced-Based Clinical appropriate for a community to adopt Recommendations Recommended Concentration a fluoridation program.37 Opponents In 2011, the ADA Council on Scientific Water fluoridation was initiated in the also express concern about the quality Affairs examined the existing evidence United States in the 1940s. In January and source of fluoride, claiming that and made 2 recommendations. The 2011, the US Department of Health and the additives (fluorosilicic acid, sodium first recommendation supported the Human Services proposed a change to fluoride, or sodium fluorosilicate), in continued use of optimally fluoridated lower the optimal fluoride level in their concentrated form, are highly toxic water to reconstitute powdered and drinking water. The proposed new rec- and are byproducts of the production of liquid infant formula, being cognizant ommendation is 0.7 mg of fluoride per phosphate fertilizer and may include of the small risk of fluorosis in per- liter of water to replace the previous other contaminants, such as arsenic. The manent teeth. The second recom- recommendation, which was based on quality and safety of fluoride additives mendation stated that if there was climate and ranged from 0.7 mg/L in the are ensured by Standard 60 of the Na- concern about the risk of mild fluo- warmest climates to 1.2 mg/L in the tional Sanitation Foundation/American rosis, the formula could be recon- coldest climates.36 The change was National Standards Institute, a program stituted with bottled (nonfluoridated) recommended because recent studies commissioned by the Environmental water.18 It should be noted that most showed no variation in water con- Protection Agency (EPA), and testing has bottled water has suboptimal levels of sumption by young children based on been conducted to confirm that arsenic fluoride and that fluoride content is climate and to adjust for an overall in- or other substances are below the levels not listed unless it is added. crease in sources of fluoride (foods and allowed by the EPA.38 Finally, there have beverages processed with fluoridated been many unsubstantiated or disproven water and fluoridated mouth rinses claims that fluoride leads to kidney dis- Community Water Fluoridation and toothpastes) in the American diet. ease, bone cancer, and compromised IQ. Community water fluoridation is the More than 3000 studies or research practice of adding a small amount of Evidence Supporting Community papers have been published on the fluoride to the water supply. It has been Water Fluoridation subject of fluoride or fluoridation.39 Few heralded as 1 of the top 10 public health Despite overwhelming evidence sup- topics have been as thoroughly re- achievements of the 20th century by the porting the safety and preventive bene- searched, and the overwhelming weight CDC.34 Community water fluoridation is fits of fluoridated water, community of the evidence—in addition to 68 years a safe, efficient, and cost-effective way water fluoridation continues to be a of experience—supports the safety to prevent tooth decay and has been controversial and highly emotional issue. and effectiveness of this public health shown to reduce tooth decay by 29%.35 Opponents express a number of con- practice. It prevents tooth decay through the cerns, all of which have been addressed provision of low levels of fluoride ex- or disproven by validated research. The Naturally Occurring Fluoride in posure to the teeth over time and only scientifically documented adverse Drinking Water provides both topical and systemic effect of excess (nontoxic) exposure to The optimal fluoride level in drinking exposure. It is estimated that every fluoride is fluorosis. An increase in the water is 0.7 to 1.2 ppm, an amount that dollar invested in water fluoridation incidence of mild enamel fluorosis has been proven beneficial in reducing saves $38 in dental treatment costs among teenagers has been cited as tooth decay. Naturally occurring fluo- (http://www.cdc.gov/fluoridation/bene- a reason to discontinue fluoridation, ride may be below or above these levels fits/). Currently, although more than even though this condition is cosmetic in some areas. Under the Safe Drinking 210 million Americans live in commu- with no detrimental health outcomes. Water Act (Pub L No. 93-523 [1974]), the nities with optimally fluoridated water, Recent opposition has sometimes cen- EPA requires notification by the water there are more than 70 million others tered on the question of who decides supplier if the fluoride level exceeds 2 with public water systems who do not whether to fluoridate (elected/public ppm. In areas where naturally occur- have access to fluoridated water.33 The officials or the voters), possibly reflect- ring fluoride levels in drinking water fluoridation status of a community ing a recent trend of distrust of the US exceed 2 ppm, people should consider water supply can be determined by government. Many opponents believe an alternative water source or home contacting the local water department fluoridation to be mass medication and water treatments to reduce the risk of

630 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from pediatrics.aappublications.org by guest on September 13, 2014 FROM THE AMERICAN ACADEMY OF PEDIATRICS

fluorosis in young children.40 Well wa- SUGGESTIONS FOR PEDIATRICIANS is a resource for oral health practice ter should be tested for the level of tools (http://www2.aap.org/oralhealth/ 1. Know how to assess caries risk. As fluoride; this testing is most commonly PracticeTools.html). recommended by the AAP’s Oral performed through the health de- Health Risk Assessment Timing and 4. Advocate for water fluoridation in partment. Establishment of the Dental Home6 the local community. Public water and Bright Futures: Guidelines for fluoridation is an effective and safe Fluoride Toxicity Health Supervision of Infants, Chil- method of protecting the most vul- fl Toxic levels of uoride are possible, dren, and Adolescents,7 pediatri- nerable members of our population particularly in children, as a result of cians should perform oral health from dental caries. Pediatricians are fl ingesting large quantities of uoride risk assessments on all children at encouraged to advocate on behalf fl supplements. The toxic dose of ele- preventive visits beginning at 6 of public water uoridation in their fl fl mental uoride is 5 to 10 mg of uoride months of age. An oral health risk communities and states. For addi- 41 fl per kilogram of body weight. Lethal assessment tool has been developed tional information and water uori- doses in children have been calculated by the AAP/Bright Futures and en- dation facts and detailed questions to be between 8 and 16 mg/kg. When dorsed by the National Interprofes- and answers, see http://www.ada. prescribing sodium fluoride supple- sional Initiative on Oral Health. This org/sections/newsAndEvents/pdfs/ ments, it is recommended to limit the fl tool can be accessed at http://www2. uoridation_facts.pdf, http://www. quantity prescribed at one time to no fl aap.org/oralhealth/RiskAssessment- cdc.gov/ uoridation/, and http:// more than a 4-month supply. Parents Tool.html. There are currently no www.ilikemyteeth.org. should be advised to keep fluoride validated early childhood caries risk products out of the reach of young LEAD AUTHORS assessment tools. The aforemen- children and to supervise their use. Melinda B. Clark, MD, FAAP tioned tool is a guide to help clini- Rebecca L. Slayton, DDS, PhD Fluoride Removal Systems cians counsel patients about oral health and best identify risk. SECTION ON ORAL HEALTH EXECUTIVE There are a number of water treatment COMMITTEE, 2011–2012 2. Know how to assess a child’sexpo- systems that are effective in the removal Adriana Segura, DDS, MS, Chairperson sure to fluoride and determine the of fluoride from water,42 including re- Suzanne Boulter, MD, FAAP verse osmosis and distillation. Parents need for topical or systemic supple- Melinda B. Clark, MD, FAAP 43 Rani Gereige, MD, FAAP should be counseled on the use of these ments. fl David Krol, MD, MPH, FAAP and activated alumina filters in the 3. Understand indications for uoride Wendy Mouradian, MD, FAAP home and, should they choose to use varnish and how to provide it. Fluo- Rocio Quinonez, DMD, MPH one that removes fluoride, the potential ride varnish can be a useful tool in Francisco Ramos-Gomez, DDS effect on their family’soralhealth. the prevention of early childhood car- Rebecca L. Slayton, DDS, PhD Martha Ann Keels, DDS, PhD, Immediate Past Commonly used home carbon filters ies. Additional training on oral Chairperson (eg, Brita [Brita LP, Oakland, California], screenings, fluoride varnish indica- PUR [Kaz USA, Incorporated, South- tions and application, and office LIAISONS borough, MA]) do not remove fluoride. implementation can be found in the Joseph Castellano, DDS – American Academy of These can be recommended for families Smiles for Life Curriculum Course 6: Pediatric Dentistry Sheila Strock, DMD, MPH – American Dental who are concerned about heavy metals Caries Risk Assessment, Fluoride Var- Association Liaison or other impurities in their home water nish and Counseling44 at www.smiles- supply but who wish to retain the forlifeoralhealth.org. In addition, the STAFF benefits of fluoridated water. AAP Children’s Oral Health Web site Lauren Barone, MPH

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Fluoride Use in Caries Prevention in the Primary Care Setting Melinda B. Clark, Rebecca L. Slayton and SECTION ON ORAL HEALTH Pediatrics 2014;134;626; originally published online August 25, 2014; DOI: 10.1542/peds.2014-1699 Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/134/3/626.full.ht ml References This article cites 31 articles, 13 of which can be accessed free at: http://pediatrics.aappublications.org/content/134/3/626.full.ht ml#ref-list-1 Citations This article has been cited by 1 HighWire-hosted articles: http://pediatrics.aappublications.org/content/134/3/626.full.ht ml#related-urls Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pediatrics.aappublications.org/site/misc/Permissions.xh tml Reprints Information about ordering reprints can be found online: http://pediatrics.aappublications.org/site/misc/reprints.xhtml

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