International Dental Journal (2000) 50, 119-128

Role of fluoride in oral health

promotion
John J. Clarkson and Jacinta McLoughlin
School of Dental Science, Trinity College, Dublin, Ireland

Fluoride has played a pivotal role in oral health promotion over the past The purpose of this paper is to
50 years. This paper reviews key issues currently impactingon the role of consider the key issues influencing
fluoride in preventing dental caries. The understanding of the process of the role of fluoride in oral health
dental caries and the mode of action of fluoride has changed in recent promotion. Background information
years. Dental caries is a continuous process of demineralisation and on the role of fluoride will be
remineralisation of the enamel and fluoride plays a key role in this proc- presented fast and following this,
ess through its action at the plaque enamel interface. It is now accepted four areas will be addressed: mode
that the primary mode of action of fluoride is post-eruptive. The post- of action of fluoride; fluoride intake/
eruptive action of fluoride has resulted in new methods of delivering exposure; dental fluorosis; and the
fluoride. The paper discusses the impact of these new methods of deliv- role of various fluoride delivery
ering fluoride on total fluoride intake in children and on the prevalence of systems in promoting oral health.
dental fluorosis. The role of different methods of delivering fluoride both The pioneering investigations
on a community and individual basis is presented and recommendations early in the 20* century by Frederick
are outlined. McKay and G. V. Black’ into stain-
ing of teeth/mottled enamel initiated
a process which ultimately led to the
dlscovery in 1931 that fluoride was
the cause of thls mottling2. In the
classical epidemiological studles of
Trendy Dean in the 1930s, includ-
ing the famous ‘shoe-leather study’,
the geographic distribution of
mottled enamel was mapped and
with it the inverse relationship
between caries and this condition3.
These studies demonstrated that one
part per million fluoride in water
resulted in minimum mottling of
teeth and a maximum reduction in
dental caries. Because the causative
factor of mottled enamel was now
known the term ‘mottling’ was
changed to dental fluorosis. These
studes also provided the impetus for
the initiation of community water
fluoridation in the prevention of
dental caries.
Community fluoridation pro-
grammes were introduced in
Grand-Rapids, Michigan and
Newburg, New York in 1945 with
control cities in Muskegon and
Ktngston. The studies that monitored
Correspondence to: Professor John J Clarkson, School of Dental Science, Trinity College,
Dublin, Ireland. those particular programmes in the

0 2000 FDlMlorld Dental Press

0020-6539/00/03119-10
120
1940s and early 1950s confirmed
that a reduction in dental caries of
approximately 50 per cent occurred
when one ppm fluoride was added
to the water s ~ p p l i e s ~As
, ~ .a result
of these investigations in the United
States, water fluoridation was intro-
duced in a number of countries
throughout the world, for example,
Australia, New Zealand, Singapore,
and Ireland. An example of the
success of this initiative can be seen
in Ireland, where legislation was
introduced in 1960 to allow for the
introduction of water fluoridation.
Following High Court and Supreme
Court challenges, fluoridation was
introduced in 1964. Currently 74 per
cent of the public in Ireland receive
fluoridated water. Baseline studies
were carried out prior to the
introduction of fluoridation6 and
post-fluoridation studies have since
been carried out7x8. These studles
confirmed the effectiveness of water
fluoridation. For example, in 1961,
before water fluoridation, the DMFT
in 12-year-olds in Ireland was 4.7,
and in 1993 this was reduced to 1.2,
a dramatic reduction in dental caries.
Fluoride toothpaste, introduced
during this period, would have
contributed to these changes. How-
ever, comparisons between two
regions on the island of Ireland, the
Republic of Ireland (fluoridated) and
Northern Ireland, (non-fluoridated),
both of which had access to fluoride
toothpaste, confirm the substantial
difference in the levels of dental
caries between fluoridated and
non-fluoridated areas over a 25 year
period (Table 1)"".
Reductions in the prevalence of
dental caries in Established Market
Economics (EME) over the past 30-
40 years have been dramatic and the
use of fluoride in its many forms has
played a vital role in this". However
dental caries still remains a major
public health problem and it is
essential that fluoride continues to
be available to tackle this situation.
There continues to be many chal-
lenges to the use of fluoride, both as
a public health measure and for indi-
vidual use, including allegations on
safety. The safety and effectiveness
of water fluoridation has been
endorsed by international and
International Dental Journal (2000) Vol. 50INo.3
Table 1 Mean DMFT values for 12-year-oldsin Northern Ireland and its northern
region (NB) and the Republic of Ireland and its eastern region (EHB)"".
Northern Ireland (non fluoridated)
1963 1983 1996R (NB)
5.5 4.4 3.3
national agencies such as WHOI3,
United States Public Health Servi~e'~,
National Research Council US'5,
Medical Research Council Australia"
and international dental associations
throughout the world.
Mode of action of fluoride
When fluoride was first introduced,
and for many years afterwards, it was
believed that the mode of action was
pre-eruptive (systemic), in that it was
incorporated into the tooth during
its development, resulting in a less
soluble enamel appatitel7JS.However,
research over the last 30 years into
the processes involved in dental
caries and the role of fluoride has
changed our understanding of this
concept. It is now understood that
the primary mode of action of
fluoride in reducing dental caries is
post-eruptive (topical), in that it
promotes remineralisation, and inhi-
bits demineralisation of dental
enamel during the caries p r o c e s ~ ' ~ ~ ~ ~ .
Other effects of fluoride include
the inhibition of glycolosis, and a
reduction in the production of
extra-cellular polysaccharides. Fluo-
ride may also have an effect on the
cariogenic potential of Streptococczls
mzltans and of course fluoride is also
bactericidal at high concentrations.
The implications of our current
understandmg of the post-eruptive
effect of fluoride, is that frequent
low concentration exposure to fluo-
ride in the oral cavity is the most
important factor in its use in
preventing and controlling dental
caries. T h s understanding of the
mode of action of fluoride has
resulted in the development of
post-eruptive (topical) methods of
delivering fluoride.
Fluoride intake from different
sources
Prior to the 1960s, diet was the main
Republic of Ireland (fluoridated)
1961-63 1984 1993 (EHB)
4.7 2.6 1.4
source of fluoride. Following the
introduction of water fluoridation in
the 1950/60s and of dental products
containing fluoride in the 1970s this
situation changed. The main sources
of fluoride in Established Market
Economies (EME) are; drinking
water, fluoridated salt, foods and
beverages, baby cereals and formulas,
fluoride supplements, toothpastes,
rinses, and topical fluorides. In addi-
tion fluoride in water also has a
'diffusion' or 'halo' effect, in that
drinks and foods manufactured in
fluoridated areas are also available
throughout the whole population,
including non-fluoridated areas. The
introduction of all of these different
fluoride delivery methods resulted in
an uncoordinated approach to the
delivery of fluoride. It is now clear
that more co-ordinated and efficient
systems for the delivery of fluoride
would result in cost savings, maxi-
mum reduction in caries and less
dental fluorosis.
Optimum exposure to fluoride
Optimum exposure to fluoride is
expressed in rmlligrams per kilogram
body weight. Estimates in the 1940s
put the appropriate exposure at 1.0
to 1.5 milligrams per day which is
the equivalent of 0.05mg F/kg body
weight per d a y . Current estimates
put optimal exposure at 0.05 to 0.07
milligrams per kilogram body weight
per dayzz. Some investigators have
suggested an even lower level of 0.03
to 0.0423.These various estimates are
based on the appropriate exposure
to fluoride necessary to obtain a
maximum reduction in caries with a
minimum occurrence of dental
fluorosis.
When considering exposure to
fluoride it is important to take into
account the various sources of
fluoride available, both from dental
products and from other sources, as
well as the impact of fluoride on

~~
dfferent age groups. The concen-
tration of fluoride used in water
fluoridation is based on a formula
which related the annual average
maximum daily air temperature in a
particular regon to water intakez4.
This formula resulted in the recom-
mendation that the concentration of
fluoride in water in the US should be
0.7 to 1.2 ppm fluoride. In children
aged 1 to 12 years of age this results
in an estimated intake of 0.05 d- enamel. The original studies by Dean
grams of fluoride per kilogram body
weight21.This is important informa-
tion when considering exposure to
other sources of fluoride in fluori-
dated areas or in situations when
foods are prepared with fluoridated
water.
Fluoride exposure in young chil-
dren is important, in preventing
caries but this may also result in
dental fluorosis if intake is excessive. delivery methods, other than water
Breast fed infants have a low intake
of fluoride. If infants are fed infant
formulas that are constituted with
water containing low lev& of fluo-
ride, then intake is low. However if
formulas are prepared with fluori-
dated water, intake can reach 0.08
milligrams F per kilogram body
weight per day2j.
In children in the age group from
6 months to 3 years, who are on a
mixed dlet, living in a non-fluoridated and this is primarily due to the halo
area, whose only source of fluoride
is from toothpaste, intake is relatively avadability of fluoride from sources
low. However, as stated earlier, if
chddren are living in a fluoridated
area, their expected intake from
water would be 0.05 d g r a m s per
kdo per day. If these children are
also using a fluoride toothpaste once
a day, and swallow some paste,
intake can increase to 0.06 to 0.08
miulgrams per kilo per day2.For chil-
dren aged 3 to 7 years of age dietary
intake is sirmlar to that for younger
children. However there may be
some reduction in fluoride exposure,
as these older children may not
swallow as much toothpaste.
In summary; there has been little
change since the 1950s in the dietary
component of fluoride. However
with the introduction of fluoridated
water in some countries and in
addition dental products containing
fluoride in most countries, there has
been an increase in exposure to fluo-
ride in clddren and also increased
risk of dental fluorosis.
Dental fluorosis
Background
Dental fluorosis is a dose response
effect caused by fluoride ingestion,
during the pre-eruptive development
of teeth. This results in increased
surface and sub-surface porosity in
showed that at a level of 1 part per
d o n fluoride the presence of defi-
nite fluorosis in the population was
10 to 12 per cent, with most of the
fluorosis being of a very mild
nature3. At levels of 2 parts per
million the prevalence of fluorosis
was 50 per cent and 5 per cent of
this was moderate fluorosis.
The introduction of fluoride
fluoridation has increased the preva-
lence of fluorosis in the community.
Most studies now show that in
fluoridated areas the prevalence of
fluorosis is twice as high as in the
original studiesz6.Currently, estimates
show that the prevalence of fluoro-
sis in EME is 20 to 25 per cent in
children aged 7 to 1727.In addition
the prevalence of fluorosis has
increased in non-fluoridated areas,
effect of water fluoridation and the
other than water fluoridation. How-
ever most of the fluorosis is of a
very mild nature and is generally not
noticed by the p ~ b l i c ~ ~although
-~O,
as the severity of dental fluorosis
increases it does become an aesthetic
iss~e~’,~~.
The severity of dental fluorosis is
dependent on the dose of fluoride,
duration of exposure and the timing
of fluoride exposure”. It is now
understood that teeth are most
vulnerable to fluorosis during the
transitional or early maturation stages
of the development of enamel. For
maxdlary incisors the critical age is
understood to be 15 to 30 months,
with a slightly lower age for males
and a higher age range for
After the age of 6 years, the risk of
dental fluorosis is negligible as the
majority of teeth have minerahsed at
t h s stage. The main risk factors for
Clarkson and McLoughlin: Role of fluoride in oral health promotion
121
dental fluorosis in EME are; fluori-
dated water, fluoride supplements,
fluoride toothpaste, and infant
formulas. Each of these factors will
now be dscussed.
Fluorosis and fluoridated water
Levels of fluorosis of up to 25 per
cent can occur within fluoridated
water areas2‘. Current concentrations
of fluoride in water are based on the
original formula of Galagan2’. In
1962 the US Public Health Service34
recommended that the level of fluo-
ride in water should be 0.07 to 1.2
parts per d o n ,based on average
annual temperatures and water
intake. However the World Health
Organization in 1994 gave a differ-
ent range of 0.5 to 1 part per
The studies of Galagan on
the relationship between annual air
temperature and water intake showed
a 60 per cent difference in intake of
water between warmer regons and
cooler regions in the US35.In a more
recent study, differences of less than
20 per cent were reported, and they
related primarily to particular geo-
graphc regons and times of the yea?‘.
In addition, patterns of consump-
tion of beverages have also changed
in the past 25 years. There is no
doubt that the level of fluorosis in
fluoridated areas has increased since
the 1940s, however there has been
very little change in water consump-
tion in that time3‘. Therefore the
presumption is that sources other
than fluoridated water are the main
contributors to the increase in fluoro-
sis in fluoridated areas. So, any case
to re-evaluate the concentrations of
fluoride recommended for water
fluoridation needs to be carefully
researched and take into account
other sources of fluoride.
Fluorosis and fluoride
supplements
Fluoride supplements were intro-
duced in order to provide fluoride to
communities where water fluorida-
tion was not possible. A number of
studles have shown a clear associa-
tion between fluoride supplements
and the risk of f l ~ o r o s i s ~ One
~ ~ ~ of
’.
the key issues is over prescribing of
122

Table 2 Methods to control fluorosis

Water Fluoridation Use appropriate concentration of fluoride. Monitor fluoride levels on a regular basis.
Supplements Use recommended dosage schedule. Advise patients of risk if schedule not followed. Use in high risk children.
Toothpaste Supervise brushing and amount of paste in children younger than 6 years of age. Consider paediatric paste
(min. 500 ppm F) in children younger than 3 years of age.
Rinses Use in high risk patients over 6 years of age.
Infant Formulas Prepare with non-fluoridatedwater.
Overall Monitor fluorosis and total fluoride exposure in community.

fluoride supplements, especially in
fluoridated areas. A number of
changes in the dosage schedule for
fluoride supplements have been
recommended over recent year^'^,^^
and it wlll take time to evaluate any
dfference in fluorosis resulting from
these changes.
Fluorosis and fluoride
toothpaste
Some recent studies have shown a
link between the use of fluoride
toothpaste and dental f l u o r o s i ~ ~ ~ ,ments.
However the risk from toothpastes
is not as high as from fluoride
supplements41.The risk factors for
fluorosis from toothpaste usage are:
the amount of paste used, the inges-
tion of paste, the age of brushing,
whether rinsing takes place after
brushing, and the frequency of brush-
ing. There is no doubt that the risk
of fluorosis is hgher if fluoride tooth-
paste is used in children less than 3
years of age as opposed to later use
and the amount of toothpaste used
is the most important f a ~ t o P , ~ * ~ ~under
Fluorosis and infant formulas
The risk of fluorosis resulting from
the use of infant formulas has been
reduced considerably as a result of
the action of manufacturers in
reducing the amount of fluoride in
these products42. However, infant
formulas should sull be prepared
using non-fluoridated water.
Reducing the risk of fluorosis
It is important to emphasise that
dental fluorosis can only occur if
fluoride is ingested prior to the erup-
tion of teeth. Reasonable precautions
when using fluoride in children less
than 6 years of age will therefore
reduce any risk considerably. There
are a number of actions that can be
taken to reduce the risk of fluorosis
from the use of fluoride in different
delivery systems (Table 2). Concen-
trations of fluoride in water should
be monitored on a regular basis. The
correct dosage of fluoride supple-
ments should be used and their use
in children younger than 3 years of
age should be restricted. The avail-
ability of fluoride from other sources,
especially water fluoridation should
be ascertained when using supple-
~ ~ ~ ~Prescription
. of supplements
to children less than 6 years of age
should include advice on the risk of
fluorosis if the dosage schedule is
not followed. When using fluoride
toothpaste, children under 6 years of
age should be supervised and only
a pea sized amount of paste should
be used on the toothbrush. Paediat-
ric pastes with a minimum of
concentration of 500ppmF may be
considered for children less than 3
years of age. Children less than 6
years should use fluoride rinses only
. supervision and if they are of
high risk of caries. Infant formulas
should be prepared using non-fluori-
dated water. There is also a need for
regular monitoring of fluoride
exposure in the community.
These general recommendations
do not entail any major change in
the current methods of delivering
fluoride. If they are followed then
dental fluorosis will not become a
public health or aesthetic problem
and fluoride, through its various
delivery methods, will continue to
play its vital role in oral health
promotion.
Fluoride delivery methods
Delivery methods for general and
community use will be considered
first, that is, water fluoridation, salt
fluoridation, milk fluoridation,
fluoride supplements and fluoride
toothpaste. Following this, fluoride
delivery systems primarily aimed at
individuals using topical methods will
be discussed.
Water fluoridation
The benefits of water fluoridation
have been clearly demon~trated',~~?~.
Some of its major advantages include:
fluoride occurs naturally in most
water sources so that water fluori-
dation merely adjusts the natural
environment to maximise caries
prevention; no active participation or
role is required by individuals or a
community; it reaches all sectors of
the community including those in
greatest need, such as those in lower
economic groups; it has a benefit
both to children and to adults; it
has the advantage of providing a
continuous low dosage; it has both a
pre and post eruptive effect; and
finally it is cost effective.
The World Health Organization
has laid down certain requirements
for the appropriate use of water
fl~oridation'~:
it should be used in areas where
there is moderate or high risk of
dental caries
where the economy can support
it and the technology is available
where the water supplies are well
organised, are used by the public
and are appropriately funded
equipment in the water plants
should be of a high standard
fluoride chemicals should be avatl-
able and there should be trained
personnel avadable to manage the
system.
The following are general recom-
mendations for the future use of
water fluoridation:

International Dental Journal (2000) Vol. 50/No.3


it should be maintained and
expanded where feasible
the levels in the water should be
continuously monitored
further research is needed to
examine the appropriate fluoride
levels in water, tahng account of
other sources of fluoride and
changing patterns of water
consumption.
There has been an expansion in
the use of bottled water in recent
years”. These products have a wide
range of fluoride content. In the
United States most bottled waters
contain less than 0 . 3 ~ p m F It
~ ~is.
recommended that the manufactur-
ers of bottled water should provide
appropriate labelling stating fluoride
content.
Salt fluoridation
Salt fluoridation is the most impor-
tant community delivery system,
other than water fluoridation. It has
been used extensively with excellent
results in countries, such as Switzer-
land, France, Germany, and many
South American countries“. The
recommended concentration of
fluoride is 400 mdligrams per kilo-
gram of salt. For domestic salt the
dosage is 200 &grams of fluoride
per hlogram of salt. The WHOI3 has
also laid down certain criteria for use
of salt fluoridation:
it should be used where water
fluoridation is not possible
where there are low levels of fluo-
ride in water
where there is not the political
wdl to introduce water fluorida-
tion
where there is a centralised salt
production system with strong
technical support
appropriate labehng of the salt
packages is essential.
Fluoridated milk
Fluoridated milk schemes have been
used in countries such as Bulgaria,
Chile, China, Russia and in some
cities in the UK. The normal dosage
is 5 d g r a m s of fluoride per litre
of milk. Milk fluoridation is mainly
used in schools’ programmes but
Table 3 Recommended dosage levels of supplemental
fluoride (mg F/day). American Dental Association 1 99438.
Concentration of fluoride in water (ppm)
Aae ~ 0 . 30.3-0.6 20.6
Birth-6 months 0 0
6 months-3years 0.25
3-6 years 0.50
6 + years 1.00
although there have been some
encouraging r e s ~ l t s ~ ’it, ~has
~ a
limited public health role.
Fluoride supplements
Fluoride supplements have been used
as public health measures as well
as for indwidual use. The dosage
schedule recommended varies from
region to regon. A dosage schedule
whch is generally accepted in the
United States38 can be seen in
Table 3. The WHO has suggested a
simpler and more conservative
approach, recommending 0.5mgF
per day for children over 3 years
of age, who are at risk and reside
in areas with low water fluoride
levelsI3.When using fluoride supple-
ments one has to balance issues of
effectiveness and a definite risk
of fluorosis against the accepted
effectiveness of systems such as
water fluoridation and the relatively
lower risk of fluorosis. Some of the
key factors to be taken into account
when using fluoride supplements
are:
they should only be used in a non-
fluoridated area
in children with high risk of
caries and greater than 3 years of
age
the prescription must be in
accordance with the dosage
schedule for the region in which
the person is residing
tablets should be chewed slowly
to gain benefit from the topical
effect
parents should be informed of
the possible risk of fluorosis, if
the dosage schedule is not fol-
lowed in children less than 6 years
of age
the role of supplements in adults
at high risk of caries should be
evaluated.
Clarkson and McLoughlin: Role of fluoride in oral health promotion
123
0
0 0
0.25 0
0.5 0
Fluoride toothpaste
There is h g h quality evidence avail-
able as to the benefit of fluoride
toothpaste in caries reduction. Well
controlled clinical trials have been
carried out on fluoride toothpastes
and have demonstrated caries reduc-
tions in the region of 30 per cent49.
The concentration of fluoride in
toothpastes varies. The standard,
most frequently used toothpaste
contains 1,000 to 1,100ppm of fluo-
ride. High concentration toothpastes
of 1,500 ppm may have a slight ad&-
tional benefit but are not used as
freq~ently~”’~. Low concentration
toothpastes such as 250ppm fluo-
ride, have shown poor results51.
Toothpaste containing 500 to
550ppm fluoride has been shown to
produce reductions in caries but less
than that achieved with standard
concentration toothpaste5*.However
when using these low concentration
toothpastes, less fluorosis occurs53.
Recommendations for the use of
fluoride toothpaste include:
containers khould be labelled with
the concentration of fluoride in
PPm
containers should be designed to
limit the amount of paste
dspensed
individuals should brush twice
daily
in chddren younger than 6 years
of age, brushing should be
supervised and only a pea-sized
portion of toothpaste used
it is also recommended that a full
rinse should not take place after
brushng, but a gentle rinse to
ensure that fluoride still remains
in the oral environment.
Further research is required on
low concentration fluoride tooth-
paste in chddren and also on high
concentration toothpaste for use by
adults at h g h risk of dental caries.
124
Fluoride gels and varnishes
High concentration gels containing
12,300ppm fluoride (1.23 per cent
APF gels) are used in children to
prevent caries. The procedures
include a four minute application and
steps in this process should mini-
mise ingestion of fluoride. Fluoride
gels are not intended for community
or public health programmes but for
high risk individual patients o n l y .
In more recent years fluoride
varnish has become available. Again
a high concentration, 22,OOOppm
fluoride sodium fluoride (5 per cent),
is normally used. Varnishes have
been shown to be effective at these
concentrations and are also used to
treat patients with hyper~ensitivity5~.
Fluoride varnishes are recommended
for:
patients with initial carious lesions
for nervous patients, because the
varnish is easy to apply
the medically and physically disa-
bled
for early childhood caries, root
caries and patients with ortho-
dontic appliances.
Slow release fluorides
A number of devices to allow fluo-
ride to be slowly released into the
oral cavity have been designed. These
include copolymer membrane devices
which release fluoride for up to 180
days and fluoride glass devices which
can allow slow release for up to one
year. They have a great potential for
special needs patients and disabled
patients, however the products are
not readily available.
Fluoride mouthrinses
Fluoride mouthrinses have been used
and shown to be effective both on a
community and on an individual
, ~ ’ . are two main meth-
b a ~ i s ~ ~There
ods of delivering rinses, low potency
sodium fluoride at 0.05 per cent and
high potency 0.2 per cent sodium
fluoride. The former is delivered on
a daily basis and the latter on a
fortnightly basis. Again, as with any
fluoride delivery system, care has to
be taken in children younger than 6
years of age. Recommendations for
International Dental Journal (2000) Vol. 50/No.3
the use of fluoride mouthrinses
include, that they should not be used
in children younger than 6 years of
age, and they should only be used in
high risk chldren. They are also
appropriate for patients with ortho-
dontic appliances or those receiving
radiotherapy treatment. Their use as
a school based system is question-
able because of the other sources
of fluoride which are now ready
a~ailable~’*’~.
Cost effectiveness
A number of studies have been
carried out to examine the cost
effectiveness of various fluoride
systemsG0. For water fluoridation, the
cost ranges from 12 US cents per
person per year to 5 US dollars with
an average of 51 US cents per
person per year. Studies have shown
benefits of 49 per cent in savings in
treatment costs as a result of the use
of water fluoridation6’.Rinsing has
been estimated to cost 1 US dollar
per child per year. However, this
may be an under-estimation because
of the relatively low caries levels in
many countries currently62.Fluoride
gels and varnishes are expensive to
use because of the high labour costs
involved. In comparison, fluoride
toothpaste is a very cost-effective
method of delivering fluoride“.
Research
A vast amount of research has been
carried out on fluoride over the past
50 years. However there are still
important areas that need further
investigation. Some of these have
been mentioned in this paper. A
number of recent reports and
workshops have examined some of
these issues and made research
recommendation^^^,^^. It is important
that resources be made available to
carry out h s research.
Conclusions
Fluoride is a key component of oral
health promotion and is the corner-
stone in the prevention of dental
caries, both in children and adults.
Its safety and effectiveness has been
accepted by international health
agencies. A co-ordinated approach
to the delivery of fluoride on a
community and individual basis is
necessary to ensure the efficient use
of resources and a maximum reduc-
tion in dental caries. This approach
will also ensure that the prevalence
of dental fluorosis will remain at an
acceptable level. The use of -fluoride
as a public health measure, such as
through water or salt fluoridation,
combined with the use of fluoride
toothpastes, needs to be maintained
and indeed expanded into new
regions. Using other fluoride deliv-
ery products has an important role
to play in reducing the prevalence of
caries in high risk groups. Continued
support from government funding
agencies and the corporate sector is
required so that ongoing research is
carried out on fluoride to ensure its
vital role in oral health promotion.
References
1. Black G V, McKay F S. Mottled teeth
- an endemic developmental imper-
fection of the teeth heretofore
unknown in the literature of dentistry.
Dent Cosmos 1916 58: 129-156.
2. Churchill H V. Occurrence of fluo-
rides in some waters of the United
States. J Ind Eng Chem 1931 23: 996-
998.
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Fluoride Working Groups Consensus Statement on Fluorides and Dental Caries
J Robert Bausch Netherlands
Introduction
Bosse Bjerner Sweden
Elias Casals Spain Over 50 years of extensive research
Ralph Duckworth UK throughout the world has consist-
Bill Landrigan USA ently demonstrated the safety and
Christopher Okunseri UK efficacy of fluoride in preventing
Egita Senakola Latvia dental decay. The scientific basis for
Francoise Spatz France the use of fluoride and its safety has
Erica Amir Israel been accepted by numerous scien-
Anda Brinkmane Latvia tific bodies, expert groups and
Robin Davies u I< government agencies. The use of
Guy Goffin Belgmm fluoride has resulted in a substantial
Kevin Hardwick USA decline in the incidence and preva-
Hans The0 Leinen Germ any lence of dental decay and has
Dan Meyer USA improved the quality of life for
Rachel O’Halloran u I< d o n s of people.
Jim Page UK
Thomas Schindler Germany
How fluoride inhibits caries
Eli Schwarz USA
The original investigations into the
role of fluoride in the prevention of
Workshopissues dental decay linked its mode of
In the light of the presented up- action to its presence and concen-
date on the issues of fluoride, in tration in the water supply. It was
which ways should the FDI’s assumed that the beneficial effect of
‘Position Statement on Fluorides fluoride related to its systemic effect
and Dental Caries’ be amended, in strengthening tooth enamel
molfied and/or expanded? during development.
The sigmficance of fluorosis. Rec- It has now become clear that the
ommendations to be issued and constant supply of appropriate
actions undertaken to reduce the levels of fluoride in the mouth is the
risk for incidence and gravity of most important factor, as the
fluorosis. presence of low levels of fluoride
inhibits demineralisation and encour-
ages remineralisation of the tooth
enamel during the dental decay
process.
These findngs are of profound
importance with regard to the use
of fluoride as a preventive or thera-
peutic measure. They have confirmed
that the topical application of fluo-
ride, or indeed any means of
maintaining an adequate concentra-
tion of fluoride in the mouth, is of
central importance in preventing
dental decay.
Delivery systems for fluoride
Fluoridation of water supplies
Fluoridation of water supplies, where
possible, remains the most effective
public health measure for the
prevention and treatment of dental
decay. This is attributable to the fact
that water is a dietary component
Clarkson and McLoughlin: Role of fluoride in oral health promotion
127
required and used by everyone and
therefore benefits all sectors of the
community. The only limitations to
its use are a reliable and controllable
water supply, whch almost invari-
ably means a centralised piped source
of water.
The availability of fluoride from
other sources needs to be known
in order to determine the most
appropriate water fluoride levels.
Recommendations for the concen-
tration of fluoride in water depend
primarily on water consumption,
which may be effected by climate. In
addition, local cultural or dietary
practices should also be taken into
account.
Fluoridated salt
Administration of fluoride via salt
intake is an alternative where the
local situation is not suitable for
water fluoridation. Studies have
produced consistent data indcating
its effectiveness in reducing dental
decay. The production of fluoridated
salt should be centralised with strong
technical support to ensure control-
led production. Concentration of
fluoride in salt must be based on
studies of salt intake and the a v d -
abihty of fluoride from other sources.
Fluoride concentration should appear
on the salt packagmg.
Fluoridated milk
Fluoridated milk has been used as a
fluoride source, especially for young
children through school pro-
’grammes. A number of studes have
shown it to be effective. However it
has had limited exposure as a public
health measure.
Fluoride-containingtoothpastes
Of all the delivery systems in use at
the present time, fluoride dentifrices
have been the subject of the most
comprehensive testing. A wide range
of well controlled studies has been
carried out and almost all of these
have demonstrated considerable
reductions in dental decay resulting
128
in greatly improved oral health.
Excessive swallowing of tooth-
paste by young children has been of
some concern with regard to the oc-
currence of mild enamel opacities
(dental fluorosis). In order to reduce
this possibllity the ingestion of tooth-
paste should be minimised. In some
regions of the world, low concentra-
tion fluoride-containing dentifrices,
especially for children, are available.
Dentifrices with concentrations of
550 ppm or less are manufactured
but there is conflicting evidence of
their effectiveness in reducing dental
decay.
Fluoride dentifrices are a most
important public health measure and
efforts should be made to extend
their use.
Dentifrices should be used at least
twice per day with a minimum
amount of water used to rinse the
mouth after brushing.
Dentifrice containers must display
the fluoride concentration and a
notice that children younger than 6
years of age should be supervised
during brushing, and only use a small
amount (e.g. a pea-sized portion) of
toothpaste.
Fluoride supplements
Fluoride tablets may be recom-
mended for at-risk individual patients
and can also be considered for
general use in,at-risk groups in the
community when other fluoride
sources are not available. The effec-
tiveness of fluoride tablets is not as
clearly documented as other delivery
systems. In view of the recognition
of the importance of the topical
effect of fluoride it is recommended
that supplements should be sucked,
chewed or dissolved in the mouth
International Dental Journal (2000) Vol. 50/No.3
before being swallowed.There is also
the possibility of an increased risk of
opacities/fluorosis if supplements are
used inappropriately.
Dosage must take into account
local fluoride availability particularly
in the water supply. Dosage sched-
ules should, where available, be
consulted. There are several national
dosage schedules available which
differ somewhat in their recommen-
dations. These must be monitored
carefully and updated regularly in the
light of other sources of fluoride.
Fluoride mouthrinses
In at risk populations, fluoride
mouthrinses may be an effective
public health measure. Mouthrinses
can be used on a daily basis or at
other intervals as dictated by local
needs. Fluoride mouthrinsing is not
recommended for chddren under six
years of age.
Commercially available fluoride
mouthrinses intended for indwidual
use have been demonstrated to be
effective and should be used accord-
ing to the specific needs of the
individual.
Professionally applied gels
Professionally applied gels are indi-
cated for indviduals at-risk of dental
decay. Concentrations are usually
high. In view of this they must be
handled with care.
Fluoride varnishes
Fluoride varnishes are indicated for
individuals at-risk of dental decay or
for patients at-risk due to dental or
medical treatment.
Fluoride exposure from multiple
sources
Fluorides are found naturally
throughout the world. They are
present to some extent in all foods
and waters so that all humans ingest
some fluoride. Fluoride has become
more avadable via food and drink,
fluoridated water, dentifrices, mouth-
washes and so forth. This can be
extremely beneficial in terms of the
prevention of dental decay. It can
also increase the risk of the rmlder
forms of dental opacities/fluorosis.
Because of this there should be a
co-ordinated approach to fluoride
delivery. It is imperative that fluo-
ride availabhty from all sources is
taken into account before embark-
ing on a specific course of fluoride
treatment.
Health risk assessment
It is clear from a vast amount of
scientific evidence that, if used
properly, and at the concentrations
appropriate for the prevention of
dental decay, fluoride is safe and
effective. However enamel opacities/
fluorosis can be caused by excessive
fluoride ingestion during the
pre-eruptive development of teeth.
At the fluoride levels used to
prevent decay these opacities are of
the mildest form and are primarily
of aesthetic interest. Recent studies
have shown that the public generally
do not notice or find objectionable
these minor changes on teeth.
Provided that levels of intake are
carefully monitored, fluoride is
considered to be a most important
public health measure in maintain-
ing oral health.