Should Children Receive Fluoride Supplementation
By Arnold Solof, MD
Following comments I received about fluoride supplements for children on the interview published in the Times Journal, I went back and reviewed the current guidelines and recommendations and research available on the subject. Very little of the science has changed over the past 30 years, but more recently since about 2008, the wording, interpretation, and application of the available knowledge has changed.
As before 2008, the evidence continues to clearly show that fluoride supplementation reduces the incidence of caries in children. However, years ago, the statistics quoted were a 75% reduction in the number of cavities. Now, they are quoting numbers in the range of 33% reduction in cavities.
In 2010, the American Dental Association published a statement “Evidence-Based Clinical Recommendations on the Prescription of Dietary Fluoride Supplements for Caries Prevention: A report of the American Dental Association Council on Scientific Affairs“. The CDC (Center for Disease Control & Prevention) and AAP (American Academy of Pediatrics) and other expert recognized medical organizations followed their lead coming out with recommendations & guidelines consistent with the ADA statement.
In my opinion, there are serious problems with the new guidelines and I expect they will be revised at some point to deal with these problems.
Currently, more attention is being paid to the problem of fluorosis; a problem resulting from too high an intake of fluoride. In its mild form it results in barely detectable speckling of the teeth. In more severe forms, it can cause cosmetically noticable speckles and spots on the teeth and even weaken the tooth structure.
Total fluoride intake is the sum of one’s intake from all sources; water supply, supplements, fluoride rinses, fluoride toothpaste, food & beverages. One can accurately control the intake from all of these sources except food & beverages. The fluoride content from food and beverages is variable, unknown, and unlabeled.
In the past it was assumed that cases of fluorosis that appeared were the result of the excessive intake of fluoride from the unknown, unmeasured sources. Now, there is a suggestion that “minimal” and “mild” cases are more common in recipients of fluoride supplements. On the other hand, there is a general consensus, that the minimal and mild fluorosis cases are not clinically significant problems.
The ADA continues to strongly recommend that our community water supplies be fluoridated to prevent cavities. They used to recommend that all children, 6 months through 16 years receive fluoride supplements if their water supplies were not optimally fluoridated. Now, instead, they recommend that only children “at high risk for caries” whose water supply is sub-optimally fluoridated receive supplements. Carrying out that recommendation requires accurate, quick, and easily and regularly administered screening tests to separate out the “high risk” from the “low risk” groups. Good luck with all that. The accuracy of these tests are debatable, their results will vary over time with changing habits, lifestyle, environments, they take time to administer, and the definition of what constitutes sufficient risk to indicate the use of supplements remains undefined. When you analyze the “Evidence Based” statement, you see that these changes to the prior recommendations were classified as level “D”, meaning they had the weakest evidence for their basis. The class “D” evidence consisted only of expert “opinion” and their indirect extrapolation of conclusions from better evidence, not the evidence itself. So, in other words, there is no direct research based evidence for the recommendation to “screen” and only supplement the “high risk” group; just opinion.
The new approach appears to me to be inconsistent with itself. How do you on one hand recommend fluoridating the water supply which supplements everybody from birth through death, and on the other hand require a screening test to determining if it is safe and acceptable to give the equivalent amount of fluoride to those who happen to live in a community that decided not to fluoridate its water?
Now, playing the Devil’s advocate, the ADA had a reason for this change in the guidelines. They are trying to strike a balance between preventing cavities using supplementation with fluoride and avoidance of fluorosis by attempting to use only as much fluoride as needed in as few individuals as possible to achieve this end. But, for the reasons stated, I think they are fooling themselves if they think this approach is going to work. In the past, the guidelines were straightforward and clear. Even with clear guidelines it has been difficult to get parents to consistently give fluoride supplements day after day, year after year. What do you think is going to happen to the level of compliance with guidelines that are confusing, inconsistent and equivocal?
I am going to make a prediction. The application of the new guidelines will result in fewer children receiving the supplements. The result of that will be a big jump in the incidence of caries in communities with unfluoridated water supplies. 10 – 15 years from now when that becomes apparent, they will reword the guidelines so that all children in unfluoridated communities can again enjoy the benefit of this prevention strategy.
- ADA Fluoridation Policy & Statements – American Dental Association – ADA.org
- CDC – National Academy of Sciences – Safety – Community Water Fluoridation – Oral Health
- Summary chart of ADA guidelines
- Fluoridation I Like My Teeth
- Preventive Oral Health Intervention for Pediatricians
- pact Fluoride – Recommendations
- Caries risk screening test – under 6 years
- Caries risk screen test – over 6 years