Reducing the Risks - Safety - Community Water Fluoridation

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Department of Health and Human Services
Centers for Disease Control and Prevention

Reducing the Risk for Enamel Fluorosis

CDC has developed recommendations to reduce the risk for enamel fluorosis. The use of fluorides in community water supplies and in other fluoride products can increase the risk of enamel fluorosis. Community water fluoridation is a safe, effective and inexpensive way to prevent tooth decay, and CDC recommends continuing and extending this practice. Steps can be taken to reduce the risk for enamel fluorosis associated with drinking water and other fluoride products.

Who should be aware of recommendations to reduce the risk for enamel fluorosis?

Parents and caregivers of children aged 8 or younger, as well as health care and public health providers, consumer product industries, and health agencies should know and follow these recommendations.

What can parents and caregivers do to reduce the risk?

Know the Fluoride Concentration in the Primary Source of Drinking Water
All persons should know whether the fluoride concentration in their primary source of drinking water is below optimal (less than 0.7 ppm), optimal (0.7–1.2 ppm), or above optimal (greater than 1.2 ppm). This knowledge is the basis for all individual and professional decisions regarding use of other fluoride modalities (e.g., fluoride toothpaste for children under 2 years of age, mouthrinse or supplements). It is recommended that parents and caregivers of children, especially children aged less than 6 years, know the fluoride concentration in their child's drinking water. For example, in nonfluoridated areas where the natural fluoride concentration is below optimal, fluoride supplements might be considered, whereas in areas where the natural fluoride concentration of more than 2 ppm, children should use alternative sources of drinking water.

Supervise Use of Fluoride Toothpaste Among Children Aged Less Than 6 Years
Children's teeth should be cleaned daily from the time the teeth erupt in the mouth. Parents of children aged less than 6 years old should brush the child's teeth (recommended particularly for preschool-aged children) or supervise the toothbrushing. Because many children at this age have not learned to control the swallowing reflex, parents should encourage the child to spit excess toothpaste into the sink to minimize the amount swallowed. See educational materials for parents, Brush Up on Healthy Teeth.

Consult a Dentist or Other Health Care Provider Before Using Fluoride Toothpaste for Children Less than 2 Years of Age
Parents and caregivers should consult a dentist or other health care provider before introducing a child younger than 2 years old to fluoride toothpaste.

Use no More than a Pea-sized Amount of Toothpaste
Parents and caregivers of children younger than 6 years of age who use fluoride toothpaste should follow the directions on the label and place no more than a pea-sized amount (0.25 g) of toothpaste on the toothbrush. Indiscriminate use of toothpaste can result in inadvertent swallowing of more fluoride than is recommended.

Use an Alternative Source of Water for Children 8 Years of Age or Younger Whose Primary Drinking Water Contains Greater than 2 ppm Fluoride
In some regions of the United States, community water supply systems and home wells contain a natural fluoride concentration of more than 2 ppm. At this concentration, children younger than 8 years of age are at increased risk for developing enamel fluorosis, including the moderate and severe forms, and should have an alternative source of drinking water that preferably contains fluoride at the recommended level.

What can health care and public health professionals do to reduce the risk of fluorosis?

Counsel Parents and Caregivers Regarding Use of Fluoride Toothpaste by Young Children, Especially Those Younger than 2 Years of Age
Use of fluoride toothpaste is a cost-effective way to reduce tooth decay. However, there is an increased risk for enamel fluorosis for children younger than 6 years of age, especially those younger than 2 years of age, because their swallowing reflex is not well developed. Parents or caregivers should be counseled on self-care recommendations for toothpaste use for these young children (i.e., limit the child's toothbrushing to not more than 2 times a day, apply a pea-sized amount to the toothbrush, supervise toothbrushing, and encourage the child to spit out excess toothpaste). For children younger than 2 years, the dentist or other health care provider should consider the fluoride level in the community drinking water, other sources of fluoride, and factors likely to affect susceptibility to dental caries when weighing the risk and benefits of using fluoride toothpaste.

Target Mouthrinsing to Children at High Risk for Developing Tooth Decay
Because fluoride mouthrinse has resulted in only limited reductions in tooth decay among schoolchildren, especially as their exposure to other sources of fluoride has increased, its use should be targeted to individuals and groups at high risk for decay. Children younger than 6 years of age should not use fluoride mouthrinse without consulting a dentist or other health care provider because there is a risk for enamel fluorosis if such mouthrinses are repeatedly swallowed.

Judiciously Prescribe Fluoride Supplements
Fluoride supplements can be prescribed for children at high risk for tooth decay and whose primary source of drinking water has a low fluoride concentration. For children who are younger than 6 years of age, the dentist, physician, or other health care provider should weigh the risk for developing decay without fluoride supplements, the benefit of decay prevention offered by supplements, and the potential for enamel fluorosis. Consideration of the child's other sources of fluoride, especially drinking water, is essential in determining this balance. Parents and caregivers should be informed of both the benefits and the risks. The prescription dosage of fluoride supplements should be consistent with the schedule established by American Dental Association (ADA), American Academy of Pediatric Dentistry (AAPD), and American Academy of Pediatrics (AAP). Fluoride supplements can be prescribed for persons as appropriate or used in school-based programs. When practical, supplements should be prescribed as chewable tablets or lozenges to maximize the topical effects of fluoride.

What can consumer product industries and health agencies do to reduce the risk of fluorosis?

Label the Fluoride Concentration of Bottled Water
Producers of bottled water are encouraged to label the fluoride concentration of their products. Such labeling will allow consumers to make informed decisions and dentists, dental hygienists, and other health care professionals to appropriately advise patients regarding fluoride intake and use of their fluoride products.

Promote Use of Small Amounts of Fluoride Toothpaste Among Children Younger Than 6 Years of Age
Labels and advertisements for fluoride toothpaste should promote use of a pea-sized amount (0.25 g) of toothpaste on a child-sized toothbrush for children younger than 6 years of age. Efforts to educate parents and caregivers and to encourage supervised use of fluoride toothpaste among young children can reduce swallowing of excess toothpaste. See Brush Up on Healthy Teeth.

Develop a Low-Fluoride Toothpaste for Children Younger Than 6 Years of Age
Manufacturers are encouraged to develop a dentifrice for children younger than 6 years of age that is effective in preventing dental caries but reduces the risk for enamel fluorosis. A "child-strength" toothpaste with a fluoride concentration lower than products currently available in the United States could reduce the risk for cosmetic concerns associated with swallowing of toothpaste.

Collaborate to Educate Health Care Professionals and the Public
Professional health care organizations, public health agencies, and suppliers of oral care products should collaborate to educate health care professionals and the public regarding the recommendations in this report. Broad collaborative efforts to educate health care professionals and the public and to encourage behavior change can promote improved, coordinated use of all types of fluoride products.