FROM THE ACADEMY Position Paper

Position of the Academy of Nutrition and Dietetics: The Impact of on Health

ABSTRACT POSITION STATEMENT It is the position of the Academy of Nutrition and Dietetics to support optimal systemic It is the position of the Academy of Nutrition and topical fluoride as an important measure to promote oral health and and Dietetics to support optimal systemic and topical fluoride as an important public overall health throughout life. Fluoride is an important element in the mineralization of health measure to promote oral health and bone and teeth. The proper use of topical and systemic fluoride has resulted in major overall health throughout life. reductions in dental caries and its associated disability. Dental caries remains the most prevalent chronic disease in children and affects all age groups of the population. The Centers for Disease Control and Prevention has named fluoridation of water as one of the 10 most important public health measures of the 21st century. Currently, Ͼ72% of the US population that is served by community water systems benefits from water fluoridation. However, only 27 states provide fluoridated water to more than three quarters of the state’s residents on public water systems. Fluoride also plays a role in bone health. However, at this time, use of high doses of fluoride for prevention is con- sidered experimental only. Dietetics practitioners should routinely monitor and pro- mote the use of fluorides for all age groups. J Acad Nutr Diet. 2012;112:1443-1453.

LUORIDE IS A NATURAL promote optimum fluoride use as they tain or increase plasma concentrations, element that is considered a would other nutrients essential for negative fluoride balance can occur due beneficial nutrient at optimal health. to mobilization from calcified tissues.1 F levels1 and is important to the integrity of bone and teeth. About 99% Role of Fluoride in Bone Health of the fluoride in the body is in the hard PHYSIOLOGY OF FLUORIDE IN tissues.2 When consumed in optimal THE BODY Research has shown that in large amounts in water and food and used Typically, about 80% of dietary calcium enough doses, fluoride can stimulate topically in fluoridated dentifrices, oral is absorbed. Body tissue and fluid con- bone cell (osteoblast) proliferation and rinses, gels, foams, and professionally centrations are directly related to in- increase new mineral deposition in applied office treatments, fluoride in- take and are not homeostatically regu- cancellous bone. These effects are me- creases mineralization, helps re- lated. About 99% of body fluoride is in diated by fluoride ions’ incorporation duce dental enamel demineralization calcified tissues in both rapidly and into bone crystals, which increases the and promote dental enamel remineral- slowly exchangeable pools. Fluoride size and, thus, decreases the solubility ization, and helps reduce dentin hyper- elimination is almost totally via the of the bone () crystals. Larger sensitivity. kidneys through unrestricted filtration crystals are more resistant to osteoclas- The use of fluorides for the preven- through the glomeruli. The degree of tic attack (osteoclasts are cells involved tion of dental caries is recognized as the tubular resorption is inversely related in bone resorption). However, the most effective dental public health to tubular fluid pH. Fluoride balance at amount of fluoride in the water supply measure in existence.3,4 Fluoride is any age is dependent on absorption and considered optimal to promote oral beneficial to all age groups throughout excretion. About half of absorbed fluo- health (1 ppm or 1 mg/L), is not consid- the life cycle. Recent statistics show ride is retained by uptake into calcified ered sufficient to stimulate osteoblast that adults are just as likely to experi- tissues and half excreted in the urine in activity or prevent osteoporotic frac- ence new dental caries as children.5,6 healthy young or middle-aged adults. tures.7 Studies suggest concentrations Fluoride is important for bone health as As much as 80% can be retained by of sodium fluoride in the water supply well, through its role in mineralization. young children as a result of increased would need to reach a threshold of 4 The Dietary Reference Intakes establish uptake by the developing bone and ppm to promote osteoblast activity.8 recommendations for fluoride intake1 teeth. In older individuals, it is likely Meta-analysis of the efficacy of fluoride (see the Table for these recommenda- that more is excreted than retained. therapy (at fluoride levels much higher tions). Dietetics practitioners should Fluoride balance is determined by the than from water fluoridation) on bone blood-bone-fluoride steady state. Fluo- loss and fractures9 and other compre- 2212-2672/$36.00 ride balance is generally positive, but if hensive reviews10,11 have determined doi: 10.1016/j.jand.2012.07.012 chronic intake is not sufficient to main- that although fluoride has an ability to

© 2012 by the Academy of Nutrition and Dietetics. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 1443 FROM THE ACADEMY

This Academy position paper includes the Table. Dietary Reference Intakes for fluoridea authors’ independent review of the liter- ature in addition to a systematic review Dietary Reference Intakes for Fluoride conducted using the Academy’s Evidence Analysis Process and information from Reference Adequate intake Tolerable upper the Academy’s Evidence Analysis Library. Topics from the Evidence Analysis Library Age group weights g (lb) (mg/day) limit (mg/day) are clearly delineated. The use of an evi- dence-based approach provides impor- Infants 0-6 mo 7 (16) 0.01 0.7 tant added benefits to earlier review Infants 6-12 mo 9 (20) 0.5 0.9 methods. The major advantage of the ap- proach is the more rigorous standardiza- Children 1-3 y 13 (29) 0.7 1.3 tion of review criteria, which minimizes Children 4-8 y 22 (48) 1.0 2.0 the likelihood of reviewer bias and in- creases the ease with which disparate ar- Children 9-13 y 40 (88) 2.0 10 ticles can be compared. For a detailed description of the methods used in the Boys 14-18 y 64 (142) 3.0 10 evidence analysis process, access the Girls 14-18 y 57 (125) 3.0 10 Academy’s Evidence Analysis Process at www.andevidencelibrary.com/eaprocess. Males 19 y and older 76 (166) 4.0 10 Conclusion Statements are assigned a Females 19 y and older 61 (133) 3.0 10 grade by an expert work group based on the systematic analysis and evaluation of aThe Dietary Reference Intakes (DRI) are guidelines set by the Institute of Medicine of the US National Academy of Sciences the supporting research evidence. Grade detailing the known nutrient requirements for human males and females by age group. The DRI system is used by both IϭGood; Grade IIϭFair; Grade IIIϭLimited; the United States and Canada and is the basis for the information on Nutrition Facts labels. The strength of the science Grade IVϭExpert Opinion Only; and determines which of the following guidelines are set for a specific nutrient: Recommended Dietary Allowances (RDA), the Grade VϭNot Assignable (because there daily dietary intake level of a nutrient considered sufficient by the Food and Nutrition Board to meet the requirements of is no evidence to support or refute the nearly all (97% to 98%) healthy individuals in each life-stage and sex group; Adequate Intake, where no RDA has been conclusion). See grade definitions at established, but the amount established is somewhat less firmly believed to be adequate for everyone in the demographic www.andevidencelibrary.com. group; Estimated Average Requirements, expected to satisfy the needs of 50% of the people in that age group based on a Evidence-based information for this and review of the scientific literature; and, Tolerable Upper Intake Levels, to caution against excessive intake of nutrients that other topics can be found at www. can be harmful in large amounts. This is the highest level of daily consumption that current data have shown to cause no andevidencelibrary.com. side effects in humans when used indefinitely. ies in their primary teeth, and 59% of ing tooth development) (see later sec- adolescents aged 12 to 19 years had tion and Bone Health). increase bone mineral density in the dental caries in their permanent The later part of the 20th century saw lumbar spine, it does not cause a reduc- teeth.17 In addition, 91% of US adults a major decline in the prevalence and tion in vertebral fractures12 and can in- and 93% of Americans aged 60 years severity of dental caries in many devel- crease side effects. Evidence from ran- and older have experienced tooth de- oped nations, attributed in large part to domized clinical trials is insufficient to cay.18 Furthermore, great disparity ex- community water fluoridation and support a cause-and-effect relationship ists in the distribution of dental caries other fluoride sources.22,23 Still the between the amount of fluoride in in the United States, with the poor suf- worst affected are the underserved of and bone health sta- fering a disproportionately high share of all age groups who do not have access tus.13,14 This position is supported by the disease burden.19 Dental caries can to dental care and preventive services osteoporosis clinical practice guide- have serious health effects throughout such as fluoride. lines from Canada15 and the United life, including contributing to failure to As a result, in 2000 the Surgeon Gen- States.16 thrive in children, causing the oral pain eral proclaimed a crisis in oral health in that can interfere with desire and ability the United States and convened a con- Role of Fluoride in Dental Health to eat, and contributing to substantial ference to address the issues. The primary role of fluoride is in the loss of school and work days.20 prevention of (dental car- The relationship between fluoride Mechanisms of Fluoride Action on ies). Dental caries is a transmissible, and dental caries was first noted in the multifactorial disease that is the most early part of the 20th century, when it Teeth common chronic condition of child- was observed that residents living in Fluoride functions to enhance tooth hood (five times more common than areas of the country with naturally high mineralization and remineralization, childhood asthma and seven times levels of fluoride in the water had teeth decrease and reverse tooth demineral- more common than hay fever3). that were highly resistant to caries, al- ization, and inhibit the metabolism of Dental caries results when acido- though they were brown-stained.21 It the acid-producing responsi- genic bacteria colonized on tooth sur- was later determined that fluoride at ble for dental caries.24 faces metabolize fermentable carbohy- lower “optimal” concentrations of 0.7 Fluoride incorporated into the devel- drates to acids (eg, acetic, butyric, to 1.2 ppm in the water supply im- oping enamel of teeth pre-eruptively formic, lactic, and propionic acid), parted protection against development results in a crystalline tooth structure which demineralize . of dental caries and reduced the overall that has increased resistance to caries. From 1999 through 2004, 42% of chil- risk of developing fluorosis (tooth de- However, recent research has found dren aged 2 to 11 years had dental car- fects caused by excessive fluoride dur- that the primary action of fluoride oc-

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curs topically after tooth eruption with These bacteria secrete acids onto tooth available through the local department consistent application, and the benefits surfaces (the byproducts of carbohy- of public health. The fluoride content of continue throughout life.22,24 The max- drate fermentation), which initiate individual well water can vary consid- imum caries-prevention benefit is tooth demineralization. The entry of erably in fluoride content and should be achieved when both systemic and top- fluoride into the bacterial cell interferes tested by local or state public health de- ical sources of fluoride are utilized.25 with acid production, thus reducing po- partments or private laboratories for tential enamel destruction. People of all fluoride content. Home water purifica- Systemic Effects of Fluoride on ages benefit from the topical effects of tion and filter systems can also affect fluoride, whether or not they had pre- the fluoride content of the water. The Teeth (Pre- and Post-Eruptive) eruptive systemic fluoride as chil- fluoride in commercial bottled waters Fluoride is found in small amounts in dren.27,28 is also variable and might be listed on most soil, water, plants, and animals the package label. and, as such, is a normal component of SOURCES, INDICATIONS, AND all diets. Once absorbed into the blood- EFFICACY OF FLUORIDE Fluoridation of Community Water stream, fluoride is either deposited into Supplies. Fluoridation of public water bones and developing teeth or excreted Fluoride can be obtained from fluori- supplies continues to be the most cost- in the urine. Pre-eruptively, during dated drinking water; foods and bever- effective dental public health measure tooth development, fluoride is incorpo- ages made with fluoridated water; in existence.35 The latter part of the rated into the developing tooth’s min- other beverage sources, such as tea; 20th century saw a major decline in the eralizing structure and helps increase and from oral health products, such as prevalence and severity of dental caries resistance to acid demineralization. Af- fluoride oral rinses, fluoride-containing in many developed nations, attributed ter tooth eruption, ingested fluoride is dentifrices, topically applied gels and in large part to community water fluo- secreted in the saliva and contributes foams, and dietary fluoride supple- 29 ridation (beginning in the 1940s) and topically to tooth protection. Systemic ments. other fluoride sources.36 Community fluoride benefits developing teeth from water fluoridation is, by definition, the before birth until all teeth have erupted Determining Fluoride Intake adjustment of fluoride in a water sup- (typically through age 12 years). The Because of the wide availability of fluo- ply to a proposed optimal concentra- protective effects via saliva are life- ride sources, the varied fluoride levels tion of 0.7 ppm. This recommended long. Saliva contains water, protein, in foods and beverages, the effects of level of fluoride is considered optimal calcium, phosphates, fluoride, bicar- home water treatments and filtration for caries prevention and safety.1 Stud- bonates, and immunoglobulins. Conse- systems, and the variability of fluoride ies continue to show that water fluori- quently, saliva is important for enamel in bottled waters, total fluoride intake dation reduces enamel caries in chil- remineralization, acid dilution and 30,31 is difficult to determine. In addi- dren by Ն20% and helps prevent root neutralization, and oral clearance of tion, the diffusion of fluoride into non- surface caries and tooth loss in adults as food debris. However, pre-eruptive flu- fluoridated areas from bottled bever- well. Water fluoridation is particularly oride is no longer considered the major ages, processed foods, and other beneficial for individuals living in com- mechanism by which fluoride provides sources, can blur the effect of the water munities with fewer resources, who optimum protection against dental car- 32 supply alone. have a high burden of dental caries and ies.25,26 less access to oral health care and alter- Fluoridated Water native fluoride resources.37 Healthy Topical Effects of Fluoride on Water and water-based beverages are People 2020 objectives for the nation set Teeth (Post-Eruptive) the chief sources of dietary fluoride. It is a target goal of 79.6% of the population using piped water to have that water Topical mechanisms are now consid- estimated that, on average, about 80% 38 ered the primary means by which fluo- of dietary fluoride comes from tap and optimally fluoridated. By 2008, 72.4% ride imparts protection to teeth, and bottled water and water-based bever- of the US population served by public water supplies had access to fluori- the topical benefits of fluoride are now ages, such as teas, coffee, carbonated 39 considered independent of the sys- beverages, beers, and ready-to-drink dated water. The Healthy People 2010 33 target of 75% had been met by 27 states temic effects for preventing dental car- juices and drinks. The estimated 39 ies. The post-eruptive beneficial effect amount of fluoride consumed from flu- and the District of Colombia. How- of fluoride likely occurs primarily from oridated drinking water alone by adults ever, only 27 states provide fluoridated the presence of fluoride in the fluid ranges from 1.8 to 2.7 mg per day. The water to more than three quarters of the state’s residents on public water phase at the tooth enamel surface. The average child under age 6 years con- 40 frequency of fluoride exposure to the sumes Ͻ0.5 L water/day and would systems. tooth surface is of prime importance for consume Ͻ0.5 mg/day fluoride from maintaining high fluoride concentra- optimally fluoridated drinking water. Cost and Cost Savings of Commu- tion in the fluid phase of enamel sur- In recent years, there has been a trend nity . Water fluo- faces, which will prevent caries and en- toward consumption of less tap water ridation continues to be the most cost- hance the remineralization of early in the home and greater consumption effective community-based approach carious lesions.26 In addition to its di- of drinks processed elsewhere, includ- to dental caries prevention in the rect mineralizing effect on enamel, flu- ing bottled waters.34 The fluoride con- United States in terms of cost per saved oride also affects oral plaque bacteria. tent of community water supplies is tooth surface, and has the benefit of

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reaching all segments of a population, • difficulty navigating the political their community water supply or they regardless of socioeconomic status or processes needed for the adop- can have well water analyzed for fluo- age. In most communities, every $1 in- tion of water fluoridation; ride content.49,50 vested in fluoridation saves $38 or • unsubstantiated claims or fear more in treatment costs.41 In 2004, an tactics made by fluoridation op- Fluoride Dietary Supplements. The estimated $78 billion was spent on ponents that influence public prescription of dietary fluoride supple- dental services. This represented about opinion against fluoridation; and ments for children living in nonfluori- • 5% of all expenditures for personal an unsupportive political envi- dated areas has been an alternative to health care in the United States. The na- ronment from a fiscal standpoint. water fluoridation for caries prevention tional average cost to fill one cavity Because many of the public wa- since the 1940s. However, the in- ter systems that are not fluori- with dental amalgam is approximately creased risk to children of developing dated serve small populations, $65—the approximate cost of providing mild fluorosis (see the following sec- this increases the per capita cost fluoridation to an individual for a life- tion on fluorosis), often associated with of fluoridation.41 time.42 the inappropriate use of dietary supple- ments during the first 3 years of Fluoride in Foods and Beverages life,39,51 has resulted in a change in Antifluoridation Movements and In addition to drinking fluoridated wa- guidelines for the use of fluoride sup- Sentiment. Although the proportion ter, foods and beverages prepared with plements. of the US population having access to fluoridated water are also sources of An expert panel of the American fluoridated community water supplies fluoride.46 In general, however, the flu- Dental Association Council on Scien- continues to rise,42 decisions to fluori- oride content of branded, purchased tific Affairs, via an evidence-based date community water supplies are foods tends to be low. Some bottled wa- analysis process, now recommends made at the local level through public ters contain fluoride, but most do not. that fluoride supplements be pre- referenda, and can change with elec- The US Food and Drug Administration scribed only for children at high risk tion cycles. This public decision process does not require bottlers to list the flu- of developing dental caries and whose is used, often effectively, by those op- oride content of bottled water, but does primary source of drinking water is posing water fluoridation. require fluoride additives to be listed. deficient in fluoride. The value of flu- The charges raised by opponents In 2006, the US Food and Drug Adminis- oride in caries prevention is consid- tend to be more sophisticated varia- tration approved the labeling statement ered to outweigh concern about tions on themes used since the incep- “drinking fluoridated water may reduce enamel fluorosis in children at high 25,35,52-56 tion of water fluoridation, namely, un- the risk of tooth decay” if the bottled wa- risk for developing caries. proven adverse health consequences ter contains Ͼ0.6 mg/L up to 1 mg/L.31 Several factors should be assessed (eg, cancer, acquired immunodefi- The National Fluoride database from the before deciding whether or not fluoride ciency syndrome [AIDS]) and infringe- US Department of Agriculture Nutrient supplementation is indicated. First is a ment on freedom of choice. Their Data Laboratory provides a nationally determination of the fluoride level of strong appeals and messages associat- representative database of the fluoride the primary water source. The local ing fluoridation with cancer and AIDS, concentration in food and beverages con- health department can provide infor- 33 although disproven, can and have had a sumed in the United States. mation on the fluoride content of water powerful influence on the public.43-45 from public systems. Private water Although antifluoridationists have Fluoride and Infant Formulas. For sources, such as well water, can vary tremendously in fluoride content from gained much publicity in an attempt to infants from birth to age 12 months of location to location and should be create the illusion of scientific contro- age who consume reconstituted infant tested yearly for fluoride content at the versy over fluoridation, claims of health formula as the main source of nutrition, local department of public health labo- hazards from water fluoridation at the caregivers should use powdered or liq- ratory. appropriate level are unfounded. Fluo- uid concentrate infant formulas recon- stituted with optimally fluoridated wa- Because foods processed or reconsti- ridation is perhaps the most thoroughly ter (while being cognizant of the tuted with fluoridated water can add studied community health measure in potential for increasing children’s risk considerably to total fluoride consump- recent history. for fluorosis).47,48 For caregivers who tion (particularly in infants), potential Today, the challenges to increasing might be concerned about the potential sources of fluoride intake in children’s and maintaining community water flu- for increasing children’s risk of enamel diets should be identified before any oridation are many and include: fluorosis, ready-to-feed formula or fluoride supplementation is recom- • lack of awareness of the impor- powdered or liquid concentrate formu- mended.52,57 tance of fluoridation and lack of las can be reconstituted with fluoride- Children’s risk of caries should also recognition of the current oral free or low-fluorideϪcontaining water. be assessed. Several risk assessment problems of society by those who These are waters labeled “purified,” tools are available in the literature.58,59 vote on fluoridation legislation “demineralized,” “deionized,” “dis- Fluoride supplements can be in drops (eg, scientists, policymakers, and tilled,” or “produced through reverse- or tablet form. Tablets should be slowly the public); osmosis.” Caregivers can check with dissolved to enhance the topical effects • misperception that fluoridation their local department of public health of the fluoride. Because fluoride supple- is no longer needed or effective; to determine the fluoride content of ments can exert a topical effect on

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Figure. Clinical recommendations for the use of dietary fluoride supplements. Republished with permission of ADA Publishing Co, Inc, from Rozier and colleagues57; permission conveyed through Copyright Clearance Center, Inc. enamel when distributed to the oral Fluoride supplements are also not gen- tant topical fluoride sources that are cavity via saliva, the recommendation erally recommended for breastfed infants highly effective and can be easily ad- for supplement use when indicated is residing in fluoridated communities. Al- ministered in the school, home, or den- for children up to 16 years of age.51 though the concentration of fluoride in tal office setting.27,28,61-63 They are All fluoride supplementation should breast milk is very low, many mothers meant to provide a consistent source of be under the supervision of a physician combine breastfeeding with formula feed- fluoride to increase the resistance to or a dentist. See the Figure for fluoride ing and might be giving infants fluoridated acid of the outer layers of tooth enamel supplementation guidelines. water between feedings. throughout life, and are not meant to be Registered dietitians should consider it swallowed for systemic effects. Fluoride Supplements and part of their practice to inform pregnant For individuals at high risk of devel- women and parents of infants and young Breastfeeding oping dental caries (especially those children about the guidelines for the use with special health care needs), con- Providing prenatal systemic fluoride in of fluoride supplements and refer clients centrated fluoride solutions, gels, and amounts higher than obtained nor- to dental care providers when indicated. mally through water and food is not varnishes are also effective when ap- recommended because there is little in- plied by dental professionals. Fluoride dication that fluoride will confer mean- TOPICAL APPLICATION rinses also provided additional caries- ingful systemic benefits to the develop- Fluoride from mouth rinses, dentifrices, preventive benefits for individuals with ing fetus prenatally.60 gels, foams, and varnishes are impor- high caries levels and who also drank

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fluoridated water and used fluoride- patients into low, moderate, and high secondary carious le- containing dentifrices.64 The use of flu- caries risk.70 The risk categories are sions in the last 3 years; oride varnishes in school-based oral based on the number and timing of the X presence of multiple health programs for children as well as development of carious lesions and the factors that can in- in private practice is increasing, as flu- presence or absence of risk factors. crease caries risk; oride varnish is an effective and easily These risk factors include medication, X suboptimal fluoride ex- applied method for providing topical radiation, or disease-induced dry posure; fluoride therapy.65 mouth (xerostomia); poor X xerostomia. Fluoride products carrying the Amer- or inability to perform proper oral ican Dental Association seal of approval health care; high levels of cariogenic Preventive recommendations can then on the product label have undergone bacteria; poor family dental health; ge- be made by qualified health profession- extensive clinical testing to demon- netic, developmental, or acquired den- als for fluoride use based on risk cate- strate their effectiveness and safety.66 tal defects; chemotherapy or radiation gory. To reduce the risk of fluorosis in devel- therapy; eating disorders; drug or alco- Fluoride recommendations by level oping permanent teeth, children hol abuse; cariogenic diet; irregular of risk are as follows: Individuals of all should not swallow oral care products dental care; orthodontic treatment; or ages are encouraged to use fluoridated meant for topical use. For this reason, the presence of exposed root surfaces. water and to brush with a fluoride-con- taining dentifrice. Fluoride dietary sup- the American Dental Association does The risk categories are as follows: not recommend the use of fluoride plements should be used only when in- mouth rinses by children under the age 1. Low risk: All age groups—no in- dicated (see earlier discussion). of 6 years.67 They recommend that chil- cipient or cavitated primary or Individuals of any age who have teeth dren aged 2 to 6 years brush with a pea- secondary carious lesions within and are at low caries risk will probably sized amount of fluoride the past 3 years and no other risk not receive additional benefit from pro- only, and that children should be super- factors. fessional topical fluoride applications. vised while brushing and taught to spit 2. Moderate risk: For these individuals, fluoridated water out rather than swallow the toothpaste • Younger than age 6 and fluoride toothpaste can provide ade- rinse or gel. Parents should consult years—no incipient or cavi- quate caries prevention. The decision with the child’s dentist or physician be- tated primary or secondary whether or not to apply topical fluoride fore using fluoride toothpaste for chil- carious lesions within the in these cases should be made by the dren under 2 years. Parents and care- past 3 years, but the pres- practitioner and individual patient. givers should judiciously monitor the ence of at least one other use of all fluoride-containing products risk factor. Children younger than 6 years by children under the age of 6 years.68 • Older than 6 years—any of Moderate caries risk: Children under Fluoride modalities protect adults the following: the age of 6 years who have teeth and and people of all age groups. Older X one or two incipient or are at moderate caries risk, should have adults and other vulnerable popula- cavitated primary or professional fluoride varnish applica- tions are especially benefited when secondary carious le- tions twice a year. their ability to receive dental care or sions in the last 3 years; their ability to practice good oral hy- X no incipient or cavitated giene are not compromised. Because of primary or secondary High caries risk: The children at high the successes of the dental team and in- carious lesions within caries risk should have fluoride varnish creased oral health literacy, many more the past 3 years, but the applications twice a year. There is some adults keep their teeth. It is no longer a presence of at least one evidence that applications of fluoride foregone conclusion that dentures are a other risk factor. varnish more often than twice a year part of aging. Many of these older can be more effective in caries preven- adults have root surface exposure due 3. High risk: tion. • to gum recession, for example. These Younger than age 6 years— surfaces are particularly vulnerable to any of the following: Children and teens aged 6 to 18 X any incipient or cavi- decay and are a prime example of how years fluoride can benefit older adults.69 tated primary or sec- ondary carious lesions Moderate caries risk: Children older in the last 3 years; than age 6 years and teens should have Topical Fluoride Indications X presence of multiple either professional fluoride varnish or through the Life Cycle factors that can in- fluoride gel applications twice a year, at Indications for the use of fluorides are crease caries risk; the discretion of the dentist and pa- based primarily on levels of caries risk X suboptimal fluoride ex- tient. rather than age or other factors. An ex- posure; pert panel established by the American X xerostomia. High caries risk: Children older than Dental Association Council on Scientific • Older than 6 years—any of age 6 years and teens who are at high Affairs determined a system for caries the following: risk for developing caries should have risk assessment that is valid and reli- X three of more incipient professional fluoride varnish applica- able and that can be used to categorize or cavitated primary or tions two to four times a year or fluo-

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ride gel applications twice a year, at the ride products should be kept out of lence of severe enamel fluorosis is very discretion of the dentist and patient. reach of small children.78 low (near zero) at fluoride concentra- Again, there is some evidence that ap- The Environmental Protection Agency tions Ͻ2 mg/L. Any increase in moderate plications of fluoride varnish more of- (EPA) has jurisdiction over the amount enamel fluorosis at this level would only ten than twice a year can be more effec- of fluoride allowed in drinking water. be a cosmetic effect, with no evidence of tive in caries prevention. The EPA has set an enforceable regula- any other adverse health effects. It was tion for fluoride (called the maximum recommended that studies of the preva- Adults and older adults (aged 65 contaminant level [MCL]) at 4.0 mg/L or lence and severity of enamel fluorosis should be done in US communities with years and older) 4.0 ppm, a level at which no adverse health effects are likely to occur over a fluoride concentrations Ͼ1 mg/L. Cur- Moderate and high caries risk: For lifetime. The MCL is set in consideration rently, the US Department of Health and people older than age 18 years, al- of health goals, cost, benefits, and the Human Services and the EPA are in ac- though there are no clinical trials to ability of public water systems to detect cord that the recommended level of flu- support recommending professionally and remove contaminants using suit- oride in drinking water should be set at applied topical fluoride varnish or gel, able treatment technologies. The EPA the lowest end of the current optimal there is reason to believe that these has also set a secondary (nonenforce- range of 0.7 to 1.2 mg/L water to attain products, applied two to four times a able) standard (secondary maximum the benefits of tooth decay prevention year, can be effective in preventing car- contaminant level) for fluoride at 2.0 while limiting unwanted health ef- 79,80 ies. mg/L or 2.0 ppm to protect against cos- fects. metic effects (such as the moderate These suggested changes in regula- FLUORIDE SAFETY tooth discoloration of fluorosis). Al- tions are also currently undergoing a Dental Fluorosis and Bone Health though not required to comply with review process and have not been ap- secondary maximum contaminant lev- proved at this point. Once the EPA has Fluoride research of more than 65 years els, states can choose to adopt them as established their guidelines, further has shown that fluoride is safe and ef- enforceable standards and must inform recommendations can be made. fective at the levels used for water flu- customers of the risk for dental fluoro- oridation (0.7 to 1.2 mg/L). However, sis in children if the secondary maxi- ACADEMY EVIDENCE ANALYSIS naturally fluoridated areas at a level Ն2 mum contaminant level is exceeded.79 mg/L can put children 8 years old and LIBRARY SYSTEMATIC REVIEW younger at increased risk for dental flu- As a result of a review of new health and OF FLUORIDE QUESTIONS orosis, and consumption of water with exposure data available on orally in- This section summarizes the results of a a fluoride content of 4 mg/L over a life- gested fluoride conducted by the Na- systematic review of the literature con- time can increase risk for bone frac- tional Research Council of the National ducted using the Academy’s Evidence tures.71 Academies of Science, in 2006 the Na- Analysis Process. In this process, an ex- Fluorosis is hypomineralization of tional Research Council recommended pert work group identified dietetics tooth enamel that results from exces- that the EPA update its fluoride risk as- practiceϪrelated questions about fluo- sive fluoride ingestion before tooth sessment to include new data on health ride and a systematic review of the lit- eruption in children (during enamel risks and better estimates of total expo- erature was performed. The level of ev- development).72-75 Clinically, the ap- sure. The report concluded that the idence provided the basis for a rating pearance of fluorosis can range from present MCL of 4 mg/L was not protec- for each statement and a conclusion hardly noticeable white spots to severe tive for severe dental fluorosis and statement. pitting and discoloration of teeth, de- might not be protective for skeletal The literature review was conducted pending on the dose, duration, and tim- fractures, and that the EPA’s MCL goal in March 2009. To identify and select 80 ing of fluoride intake. In recent years, of 4 mg/L should be lowered. Lower- articles for review, the National Library there has been an increase in the prev- ing the MCL goal will prevent children of Medicine’s PubMed database and the alence of mild fluorosis in the United from developing severe enamel fluoro- Cochrane Database of Systematic Re- States and many developed nations,7 sis and will reduce the lifetime accu- views were searched for information attributable to a variety of factors, such mulation of fluoride into bone that the on fluoride or sodium fluoride pub- as young children swallowing fluoride majority of the committee concluded is lished in peer-reviewed journals in the dentifrice, misuse of dietary fluoride likely to put individuals at increased past 10 years. The search was limited to supplements, use of powdered infant risk of bone fracture and possibly skel- English and included free living hu- formula reconstituted with fluoridated etal fluorosis, which are particular con- mans of all ages. All study designs ex- water, and diffusion (“halo”) effect of cerns for subpopulations that are prone cept case studies were included in the increased fluoride from foods and bev- to accumulating fluoride in their bone. search. Articles published from 1998 to erages processed in fluoridated ar- The EPA has begun the process of deter- 2009 with a sample size of at least 10 eas.50,76,77 According to the Centers for mining whether or not to lower the max- adults per study group and with a Ͻ20% Disease Control and Prevention, 32% of imum allowable level of fluoride in dropout rate were searched. Studies American children now have some drinking water from the current 4 ppm. were also identified by screening the form of dental fluorosis, with 2.45% of The review process is currently ongoing reference lists of the selected articles. children having the moderate to severe and has no definite time table for com- Identified articles were then excluded if stages.7 Because fluoride can be toxic if pletion. they did not provide an answer that consumed in excessive amounts, fluo- It was also reported that the preva- was directly related to the question.

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-fair, indicating only limited evi؍The detailed search plan and results • Fluoride levels are often con- III and information on the process and founded with levels of other dence for an association between fluo- how the conclusions of the Fluoride Ev- known neurotoxins (such as ar- ride intake renal system effects. idence Analysis Project were reported senic) in the studies, as fluoride In summary, there is very little evidence on the Evidence Analysis Library web- was naturally occurring. to support any of the concerns voiced in site.81 The Academy uses Grades I, II, • All populations studied were these questions. Registered dietitians and III, for strong, fair, and weak levels non-US settings (one Mexican should feel well supported in allaying fears of evidence. Grade IV designates expert and the rest Chinese); therefore, about harmful side effects of fluoride when opinion only; and Grade V indicates not exposure levels and confounding provided in recommended amounts. assignable (because there is no evi- factors can be quite different dence that directly supports or refutes than in a US setting. THE ROLE OF DIETETICS the question). • Although none of the studies PRACTITIONERS Questions about fluoride that were found an association between IQ analyzed through this evidence analy- and fluoride levels Ͻ1.0 mg/L, Fluoride provides important health sis process and the findings are as fol- this research cannot be used to benefits throughout the life cycle and lows81: identify a safe upper limit. should be promoted by dietetics practi- tioners throughout their practices. Di- What is the relation between As a result of these findings, the etetics practitioners work in a wide va- silicofluoride exposure and blood strength of the available supporting ev- riety of practice arenas (eg, inpatient, idence was determined to be Grade ambulatory, community, public health, fair, indicating only limited evi- media, industry) with clients of all ages؍lead levels in children? III Conclusion statement: Water fluori- dence for an association between fluo- and are therefore in a better position dation with silicofluoride (but not so- ride intake and IQ. than many other health professionals dium fluoride) can be associated with to advocate for the appropriate use of increased risk of elevated blood lead What are the effects of fluoride fluoride. Dietetics practitioners should levels in children, especially those al- become knowledgeable about fluo- ready at risk for lead exposure. exposure (intake) on the renal rides82 and routinely promote and The overall strength of the available system at different levels (among monitor the appropriate use of sys- supporting evidence was determined different age groups)? temic and topical fluorides in vulnera- ؍ to be Grade III fair, indicating only Conclusion statement: Research on ble groups, including older adults and limited evidence for a relationship be- the relationship between ingestion of especially children and adolescents. Di- tween silicofluoride exposure and fluoride and renal function is limited by etetics practitioners should recom- blood levels in children. several factors including: mend that children have their first den- The American Dental Association and • most of the studies were of neu- tal visit within 6 months of eruption of the Centers for Disease Control and Pre- tral or negative methodological the first tooth and no later than 12 83,84 vention indicate that all of the chemi- quality; months of age. They should also cals used in fluoridation meet safety • few studies report precise indi- monitor fluoride use by obtaining in- standards. vidual levels of fluoride inges- formation about the fluoridation of lo- tion; and cal water supplies from state depart- What is the relation between • none of the studies were of US ments of public health and referring exposure to high levels of populations. children to dental professionals when fluoride in drinking water and indicated. The Figure provides sug- The research suggests that ingestion of gested age-specific fluoride recom- intelligence quotient (IQ) in lower levels (conservatively Ͻ1to1.5 mendations. Dietetics practitioners children? ppm) of fluoride in healthy subjects is should also add their voices as strong Conclusion statement: All four pri- not associated with renal impairment. advocates for community water fluori- mary studies consistently found a neg- The very limited research does sug- dation legislation whenever it is a bal- ative relationship between chronic ex- gest an association between ingestion lot issue. Toward this end, alliances and posure to high levels of fluoride (Ͼ3.15 of higher levels (2.2 ppm in a single referral systems among dietetics prac- mg/L) and IQ in children when com- study, although there is no clear defini- titioners, dental hygienists, and den- pared with children who live in areas tion of higher levels obtainable from tists need to be strengthened in the with lower levels of fluoride in the the research) of fluoride in drinking pursuit of optimal oral health. drinking water (Ͻ1.0 mg/L). The meta- water and fluorotoxic effects in sub- When fluoride is provided in optimal analysis also reported the same rela- jects with impaired renal function. amounts, it can potentially convey ma- tionship in 12 of the 16 studies exam- However, the research suggests that jor dental health benefits to all age ined. One of the four primary studies this association might be the result of groups.68 Fluoridation of public water found a statistically significant increase impaired fluoride excretion by subjects supplies has been recognized as one of in proportion of children with IQ Ͻ80 who already have some form of renal the most effective dental public health when mean fluoride level in the water compromise. measure in existence.4,85 Still, approxi- was 2.46Ϯ0.25 mg/L. As a result of these findings, the mately one third of the US population Application to US populations is strength of the available supporting ev- on public water systems fails to receive hampered by several limitations: idence was determined to be Grade the maximum benefits possible from

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community water fluoridation for a va- teoporosis. IX: Summary of meta-analyses of 28. Marinho VC, Higgins JP, Logan S, Sheiham riety of reasons. Fluoridated water and therapies for postmenopausal osteoporosis. A. Topical fluoride (, mouth- Endocr Rev. 2002;23(4):570-578. rinses, gels or varnishes) for preventing dentifrices are the mainstays of fluoride dental caries in children and adolescents. 29 13. Sayegh R, Stubblefield P. Bone metabolism delivery for all age groups. Access to and the perimenopause overview, risk Cochrane Database Syst Rev. 2003(4): dental care is an ongoing concern. factors, screening, and osteoporosis pre- CD002782. Healthy People 2020 has a continued ventive measures. Obstet Gynecol Clin 29. Chu C, Mei ML, Lo ECM. Use of fluorides in North Am. 2002;29(3):495-510. dental caries management. Gen Dent. goal to promote interventions such as 2010;58(1):37-43. fluoride to reduce tooth decay.86 Di- 14. Phipps KR, Orwell ES, Mason JD, Cauley JA. Community water fluoridation, bone min- 30. Johnson SA, DeBiase C. Concentration lev- etetics practitioners can be strong ad- eral density, and fractures: Prospective els of fluoride in bottled drinking water. J vocates for the appropriate use of fluo- study of effects in older women. BMJ. Dent Hyg. 2003;77(3):161-167. ride as an integral component of total 2000;321(7265):860-864. 31. Centers for Disease Control and Prevention. health promotion. The Academy of Nu- 15. Brown JP, Josse RG, Scientific Advisory Commercially bottled water. http://www. Council of the Osteoporosis Society of cdc.gov/healthywater/drinking/bottled/. trition and Dietetics strongly reaffirms Canada. 2002 Clinical practice guidelines Reviewed February 6, 2012. Accessed its endorsement of the use of systemic for the diagnosis and management of os- April 12, 2012. and topical fluorides, including water etoporosis in Canada. CMAJ. 2002;167(10 32. Griffin SO, Gooch BF, Lockwood SA, Tomar suppl):S1-S34. fluoridation, as an important health- SL. Quantifying the diffused benefit from 16. Reginster J, Felsenberg D, Pavo I, et al. Ef- water fluoridation in the United States. promotion measure. fect of rallloxifene combined with mono- Community Dent Oral Epidemiol. 2001; fluorophosphate as compared with mono- 29(2):120-129. fluorophosphate alone in postmenopausal 33. US Department of Agriculture, National References women with low bone mass: A random- Agriculture Library. USDA national fluo- 1. Institute of Medicine, National Academy ized controlled trial. Osteoporos Int. 2003; ride database of selected beverages of Sciences, Food and Nutrition Board. Di- 14(9):741-749. and foods. http://www.nal.usda.gov/fnic/ etary Reference Intakes for Calcium, Phos- 17. Rozier R. The prevalence and severity of foodcomp/Data/Fluoride/fluoride.pdf. phorus, Magnesium, Vitamin. Washington, enamel fluorosis in North American chil- Published October 2004. Accessed April DC: National Academies Press; 1997. dren. J Public Health Dent. 1999;59(4):239- 12, 2012. 2. Levy SM. An update on fluorides and fluo- 246. 34. Bassin EB, Mittleman MA, Wypij D, Jo- rosis. J Can Dent Assoc. 2003;69(5):286- 18. National Center for Disease Pre- shipura K, Douglass CW. Problems in ex- 291. vention and Health Promotion, Division of posure assessment of fluoride in drinking 3. Department of Health and Human Ser- Oral Health. Oral health: Preventing cavi- water. J Public Health Dent. 2004;64(1): vices. US Public Health Service. Oral Health ties, gum disease, tooth loss, and oral can- 45-49. in America: A Report of the Surgeon General. cers. Centers for Disease Control and Pre- 35. Centers for Disease Control and Preven- Rockville, MD: Department of Health and vention website. http://www.cdc.gov/ tion. Surgeon General’s Statement on Human Services; 2000. chronicdisease/resources/publications/ Community Water Fluoridation, 2004. aag/pdf/2011/Oral-Health-AAG-PDF-508. 4. Centers for Disease Control and Preven- http://www.cdc.gov/fluoridation/fact_ pdf. Published 2011. Accessed May 15, tion. CDC honors 65 years of community sheets/sg04.htm. Reviewed August 3, 2012. water fluoridation. http://www.cdc.gov/ 2006. Accessed May 15, 2012. fluoridation/65_years.htm. Modified April 19. Dye B, Tan S, Smith V, et al. Trends in oral 36. American Dental Association. American 27, 2012. Accessed April 12, 2012. health status: United States, 1988-1994 Dental Association Statement on Water Flu- and 1999-2004. Vital Health Stat 11. 5. Griffin SO, Griffin PM, Swann JL, Zlobin N. oridation Efficacy and Safety. Chicago, IL: 2007(248):1-92. Estimating rates of new root caries in ADA Positions and Statements; 2002. older adults. J Dent Res. 2004;83(8):634- 20. Griffin SO, Gooch B, BeltrÂn ED. Dental ser- 37. 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Ac- prevent and control dental caries in the 39. Centers for Disease Control and Preven- cessed May 15, 2012. United States. MMWR Recommendations tion. Populations Receiving Optimally Flu- 8. Hillier S, Cooper C, Kellingray S, Russell G, and Reports. 2001;50(RR-14):1-42. oridated Public Drinking Water-United Hughes H, Coggon D. Fluoride in drinking 23. Horowitz HS. The 2001 CDC recommenda- States, 1992-2006. MMWR Morb Mortal water and risk of hip fracture in the UK: A tions for using fluoride to prevent and Wkly Rep. 2008;57(27):737-741. case-control study. Lancet. 2000; control dental caries in the United States. J 40. Centers for Disease Control and Preven- 355(9200):265-269. Public Health Dent. 2003;63(1):3-8; dis- tion. 2008 water fluoridation statistics. 9. Hauselmann H, Rizzoli R. A comprehen- cussion 9-10. http://www.cdc.gov/fluoridation/statistics/ sive review of treatments for postmeno- 24. Wynn R. Fluoride after 50 years, a clearer 2008stats.htm. Modified October 22, 2010. pausal osteoporosis. Osteoporos Int. 2003; picture of its mechanism. Gen Dent. 2002; Accessed June 26, 2012. 14(1):2-12. 50(2):118-122, 124, 126. 41. Centers for Disease Control and Preven- 10. Li Y, Liang C, Slemenda CW, et al. Effect of 25. Singh KA, Spencer AJ. Relative effects of tion. Cost savings of community water flu- long-term exposure to fluoride in drinking pre- and post-eruption water fluoride on oridation. http://www.cdc.gov/fluoridation/ water on risks of bone fractures. J Bone caries experience by surface type of per- fact_sheets/cost.htm. Updated September Miner Res. 2001;16(5):932-939. manent first molars. Community Dent Oral 1, 2009. Accessed June 26, 2012. 11. Haguenauer D, Welch V, Shea B, Tugwell P, Epidemiol. 2004;32(6):435-446. 42. Centers for Disease Control and Preven- Adachi JD, Wells G. Fluoride for the treat- 26. Glenn WD 3rd. Fluoride (F), an essential tion. Fluoridation growth, by population, ment of postmenopausal osteoporotic pre-eruptive nutrient. J Dent Res. 2002; United States 1940-2006. http://www. fractures: A meta-analysis. Osteoporos Int. 81(8):516; author reply 516. cdc.gov/nohss/FSGrowth_text.htm. Modi- 2001;11(9):727-738. 27. Marinho VCC. Evidence-based effective- fied October 30, 2008. Accessed June 26, 12. Cranney A, Guyatt G, Griffith L, et al. Meta- ness of topical fluorides. Adv Dent Res. 2012. analyses of therapies for postmenopausal os- 2008;20(1):3-7. 43. Neenan ME, Easley M, Ruiz M. Water fluo-

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ridation. In: Harris NO, Garcia-Godoy F, on Scientific Affairs. J Am Den Assoc. fluoridation/pdf/fall_2006.pdf. Published eds. Primary Preventive Dentistry. 6th ed. 2010;141(12):1480-1489. Fall 2006. Accessed May 15, 2012. Upper Saddle River, NJ: Prentice Hall; 58. American Dental Association. Caries risk 72. Aoba T, Fejerskov O. Dental fluorosis: 2004:181-239. assessment form (ages 0-6). http://www. Chemistry and biology. Crit Rev Oral Biol 44. Neenan ME. Obstacles to extending fluori- ada.org/sections/professionalResources/ Med. 2002;13(2):155-170. dation in the United States. Community pdfs/topics_caries_educational_under6. 73. Bowen WH. Fluorosis: Is it really a prob- Dent Health. 1996;13(suppl 2):10-20. pdf. Accessed April 12, 2012. lem? J Am Dent Assoc. 2002;133(10):1405- 45. Newbrun E. The fluoridation war: A scien- 59. American Academy of Pediatric Dentistry. 1407. tific dispute on a religious argument. J Policy on use of a caries risk assessment 74. 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The Academy of Nutrition and Dietetics Position adopted by the House of Delegates Leadership Team on April 23, 1989 and reaffirmed on September 11, 1993; September 28, 1998; June 19, 2003; and July 16, 2008. This position is in effect until December 31, 2017. The Academy authorizes republication of the position, in its entirety, provided full and proper credit is given. Readers can copy and distribute this paper, providing such distribution is not used to indicate an endorsement of product or service. Commercial distribution is not permitted without the permission of the Academy. Requests to use portions of the position must be directed to the Academy headquarters at 800/877-1600, ext. 4835, or [email protected]. Authors: Carole A. Palmer, EdD, RD, LDN, Tufts University School of Dental Medicine and Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA; Joyce Ann Gilbert, PhD, RD, The Marilyn Magaram Center, California State University, Northridge. Reviewers: Jeanne Blankenship, MS, RD, Academy Policy Initiatives and Advocacy, Washington, DC; Sharon Denny, MS, RD, Academy Knowledge Center, Chicago, IL; Public Health/Community Nutrition dietetic practice group (Katrina Holt, MPH, MS, RD, Georgetown University, Washington, DC); Dietitians in Integrative and Functional Medicine DPG (Erica Kasuli, MS, RD, CDN, Consultant, New York, NY); Catherine J. Klein, PhD, RD (Children’s National Medical Center, Washington, DC); Steven M. Levy, DDS, MPH (University of Iowa, Iowa City); Esther Myers, PhD, RD, FADA (Academy Research and Strategic Business Development, Chicago, IL); Pediatric Nutrition DPG (Beth Ogata, University of Washington, Seattle); Quality Management Committee (Marsha R. Stieber, MSA, RD, CNSC, Mesa, AZ); Gary M. Whitford, PhD, DMD, Medical College of Georgia, Augusta. Academy Positions Committee Workgroup: James H. Swain, PhD, RD, LD, chair; Dian O. Weddle, PhD, RD, FADA; Lisa F. Harper Mallonee, MPH, RD, LD, content advisor; Leon E. Stanislav, DDS, content advisor. We thank the reviewers for their many constructive comments and suggestions. The reviewers were not asked to endorse this position or the supporting paper.

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