Fluoride Supplementation in Kids

Episode 102: Fluoride supplementation in kids.

Steven and Dr. Cha explained the importance of fluoride recommendations to prevent dental decay in kids who live in areas where water fluoride is low.

A: When I moved to Bakersfield, my children were 3 and a 5 years old, we took them to a pediatrician, and they got a prescription for fluoride supplements, that was something I had never seen before, so I was curious, and for many years I wanted to know the fluoride content of my water. Recently, I discovered the page nccd.cdc.gov thanks to the American Family Physician article about the fluorination of water, and I found the content of Bakersfield.  Because in Family Medicine we see patients from the cradle to the tomb and from head to toe, today we will talk about dental health. 

This is the Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

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Fluoride Supplementation in Kids. 
Written by Steve Beebe, MS3, Ross University School of Medicine. Editions by Hector Arreaza, MD; and Gina Cha, MD.

G: Let’s start with the definition of fluoride, What is fluoride?

S: Fluoride is a mineral – a substance that occurs in nature in its well-defined crystalline form. Put another way, fluoride is the negatively charged form of the element fluorine -- one of the elements on the periodic table. Fluoride is considered one of the essential/beneficial trace elements that our body uses for a variety of purposes. Other common trace elements include copper, iodine, iron, and zinc.[1] Where can fluoride be found?

G: Fluoride is commonly found in groundwater. It can also be found in tea, bones, shells, medical supplements, and fluoridated toothpaste. The fluoride takes the place of hydroxyl groups in the tooth matrix thereby making teeth more resistant to acidic substances which reduces dental caries.

A: Why is fluoride a controversial topic?

S: Although fluoride and dental caries/cavities are inversely correlated, it has yet to be shown that fluoride is strictly essential.[2]

A: Also, fluoride is not innocuous, it can be detrimental if taken in excess. Why is the fluorination of water important?

G: Dental caries is the most common chronic disease in children. The National Health & Nutrition Examination Survey showed that over 23% of children between ages 2-5 had dental cavities.[3] Unfortunately, having dental caries is associated with localized pain, tooth loss, impaired growth, impaired weight gain, and poor school performance, and it carries a risk for dental caries in the future as an adult.[4]

A: Some parents think that having caries on your baby teeth does not matter because those teeth are going to fall anyways.

G: The American Academy of Pediatric Dentistry explains that fluorination of the water supply helps balance the risk of getting dental caries with the risk of fluorosis or tooth mottling from excessive fluoride intake.[5] How much fluoride is enough for human consumption?

S: The National Academic Press recommends a maximum of 2.5mg of fluoride each day to avoid fluorosis (mottling of teeth). The NAP recommends 0.1 to 1mg from birth to 1 year of age and 0.5 to 1.5mg from 1-3 years of age as safe and adequate.[6]

The United States Preventive Services Task Force (USPSTF) recommends starting an oral fluoride supplement at 6 months of age in areas where the water supply is deficient in fluoride. S: Topical application of fluoride is seen as safe as early as the eruption of primary teeth.[7] (A: dental varnishing we do in well-child exams). Unfortunately, the USPSTF mentions that there have been no studies done to adequately address the dosage of oral fluoride supplementation in children with poor water fluoridation. Is there such a thing as too much fluoride?

G: Yes. Symptoms are dose-dependent and range from generalized pain, nausea, vomiting, diarrhea, staining of the teeth (fluorosis), renal dysfunction, cardiac dysfunction, coma, and death. When do we start giving fluoride supplements to our patients if needed?

S: The American Dental Association (ADA) recommends cleaning the teeth of children under the age of 2 years old with water and a brush as soon as teeth protrude into the mouth – a grain of rice-sized smear of fluoridated toothpaste can be used. At 3-6 years of age, the ADA recommends children use a pea-sized amount of fluoride toothpaste when brushing with a toothbrush.[8] (A: we have an obsession with comparing staff to food)

G: The American Academy of Pediatric Dentistry (AAPD) recommends a community fluorination level of 0.7 ppm in the water supply. They recommend against supplementing children under 6 months of age. However, they recommend the following daily oral supplementation:

Average:              6 m-3 years: 0.25 mg.

3-6 years: 0.5.

6-16 y: 0.5 – 1 mg

The dose changes based on how much fluoride you have in your water:

0.25 mg of Fluoride in areas with <0.3ppm Fluoride in children aged 6 months to 3 years0.5 mg of Fluoride in areas <0.3ppm Fluoride for children aged 3-6 years0.25mg of Fluoride in areas 0. 3 to 0.6ppm Fluoride for children aged 3-6 years1mg of Fluoride in areas <0.03 ppm Fluoride for children aged 6-16 years0.5 mg of Fluoride in areas 0.3 to 0.6ppm Fluoride for children aged 6-16 years [9]

A: In Bakersfield, the fluoride concentration 0.14 mg/L. What does this mean?

This water system has fluoride from natural sources, but at a level below what is recommended for the prevention of tooth decay. So, counsel your patients about the prevention of decay during clinic and prescribe as needed. The U.S. Department of Health and Human Services recommends a level of 0.7 mg/L of fluoride in your drinking water. This is the level that prevents tooth decay and promotes good oral health. For additional information on fluoride in drinking water please visit the CDC Water Fluoridation Page.

G: The American Academy of Family Physicians agrees with these guidelines provided by the AAPD.[10] When should we stop giving fluoride supplements to our patients? 

Oral supplementation does not seem to be recommended past 16 years of age.

A piece of advice from a dentist: “Only brush and floss the teeth you want to keep.”

Conclusion: Now we conclude our episode number 102 “Fluoride supplementation in kids.” Dr. Cha and future doctor Steven explained the importance of dental decay prevention. Fluorination of water varies in different areas of the US. Remember to check the fluoride in your city water, and if it is below 0.7 milligrams per liter, kids in your area may need fluoride supplementation to prevent caries. Adjust the dose accordingly to prescribe the right amount. Visit “My water’s fluoride” website at nccd.cdc.gov for more information. Even without trying, every night you go to bed being a little wiser.

This week we thank Hector Arreaza, Gina Cha, and Steve Beebee.

Audio edition: Suraj Amrutia. Thanks for listening to Rio Bravo qWeek Podcast. If you have any feedback, contact us by email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week!

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References:

[1] S. Pazirandeh, MD, D. L. Burns, MD, I. J. Griffin, MB ChB. Overview of Dietary Trace Elements. UpToDate. Accessed 5/30/2022.

[2] Subcommittee on the Tenth Edition of the Recommended Dietary Allowances. Recommended Dietary Allowances, 10th Edition. Page #235. Available at: https://www.nap.edu/catalog/1349/recommended-dietary-allowances-10th-edition (Accessed on 5/30/2022).

[3] Centers for Disease Control and Prevention. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention, and Edentulism, United States, 1999–2004 to 2011–2016. Centers for Disease Control and Prevention; 2019.

[4] Chou R, Pappas M, Dana T, Selph S, Hart E, Schwarz E. Screening and Prevention of Dental Caries in Children Younger Than Five Years of Age: A Systematic Review for the U.S.Preventive Services Task Force. Evidence Synthesis No. 210. Agency for Healthcare Research and Quality; 2021. AHRQ publication No. 21-05279-EF-1.

[5] American Academy of Pediatric Dentistry. Fluoride therapy. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2021:302-5.

[6] Subcommittee on the Tenth Edition of the Recommended Dietary Allowances. Recommended Dietary Allowances, 10th Edition. Page #238. Available at: https://www.nap.edu/catalog/1349/recommended-dietary-allowances-10th-edition (Accessed on 5/30/2022).

[7] USPSTF. Prevention of Dental Caries in Children Younger than 4 years: Screening and interventions. December 7th, 2021.

[8] American Dental Association. Healthy habits. https://www.mouthhealthy.org/en/babies-and-kids/healthy-habits (Accessed on May 30, 2022).

[9] American Academy of Pediatric Dentistry. Fluoride therapy. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2021:302-5.

[10] H. Silk, MD, MPH. Fluoride: The Family Physician's Role. https://www.aafp.org/pubs/afp/issues/2015/0801/p174.html. Accessed 5/30/2022.