BEST PRACTICES: FLUORIDE THERAPY

Fluoride Therapy
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Fluoride
2018 therapy. The Reference Manual of Pediatric Dentistry. Chicago, Ill.:
American Academy of Pediatric Dentistry; 2022:317-20.

Abstract
This best practice provides information for parents and practitioners regarding use of fluoride as an aid in preventing and controlling dental
caries in pediatric dental patients. These recommendations address systemic fluoride (water fluoridation, dietary fluoride supplements,
possibility of fluorosis), topical fluoride delivery via professional application (acidulated phosphate fluoride gel or foam, sodium fluoride
varnish, silver diamine fluoride), and home use products (toothpastes, mouthrinses). The standard level for community water fluoridation
(0.7 parts per million fluoride) helps balance the risk of caries and the possibility of fluorosis from excessive fluoride ingestion during the early
years of tooth development. Specific recommendations for dietary supplementation of fluoride for children ages six months through 16
years are based on fluoride levels in the drinking water, other dietary sources of fluoride, and caries risk. The specific needs of each patient
determine the appropriate use of systemic and topical fluoride products, whether delivered in a professional or a home setting. Fluoride
has proven to be an effective therapy in reducing the prevalence of dental caries in infants, children, adolescents, and persons with special
needs.
Through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and Scientific Affairs, this best
practice was revised to offer updated information and recommendations to assist healthcare practitioners and parents in using fluoride
therapy for management of caries risk in pediatric patients.

KEYWORDS: ADOLESCENT, CHILD, FLUORIDATION, FLUORIDE, ORAL HEALTH, TOOTHPASTE, SILVER DIAMINE FLUORIDE

Purpose Background
The American Academy of Pediatric Dentistry intends Fluoride has been a major factor in the decline in prevalence
these recommendations to help practitioners and parents and severity of dental caries in the U.S. and other econo-
make decisions concerning appropriate use of fluoride mically developed countries. It has several caries-protective
as part of the comprehensive oral health care for infants, mechanisms of action. Topically, low levels of fluoride in
children, adolescents, and persons with special health care plaque and saliva inhibit the demineralization of sound
needs. enamel and enhance the remineralization of demineralized
enamel. Fluoride also inhibits dental caries by affecting the
Methods metabolic activity of cariogenic bacteria. 10 High levels of
This document was developed by the Liaison with Other fluoride, such as those attained with the use of topical gels
Groups Committee and adopted in 1967. These recommen- or varnishes, produce a temporary layer of calcium fluoride-
dations by the Council of Clinical Affairs are a revision of like material on the enamel surface. The fluoride is released
the previous version, last revised in 2014. To update this when the pH drops in response to acid production and be-
guidance, an electronic search of the scientific literature from comes available to remineralize enamel or affect bacterial
2012 to 2017 regarding the use of systemic and topical metabolism.11 The original belief was that fluoride’s primary
fluoride was completed. Database searches were conducted action was to inhibit dental caries when incorporated into
using the terms: fluoride caries prevention, fluoridation, developing dental enamel (i.e., the systemic route), but the
fluoride gel, fluoride varnish, fluoride toothpaste, fluoride fluoride concentration in sound enamel does not fully explain
therapy, and topical fluoride. Because 720 papers were the marked reduction in dental caries. It is oversimplification
identified through these electronic searches, an alternate to designate fluoride simply as systemic or topical. Fluoride
strategy of limiting the information gathering to systematic that is swallowed, such as fluoridated water and dietary
review using the term fluoride caries prevention yielded 95 supplements, may contribute to a topical effect on erupted
papers since 2012. Nine well-conducted systematic reviews1-9 teeth (before swallowed, as well as a topical effect due to
and their references primarily were used for this update. increasing salivary and gingival crevicular fluoride levels).
Expert opinions and clinical practices also were relied upon
for these recommendations.
ABBREVIATIONS
F: Fluoride. IQ: Intelligence quotient. NaFV: Sodium fluoride varnish.
ppm F: parts per million fluoride. SDF: Silver diamine fluoride.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 317

BEST PRACTICES: FLUORIDE THERAPY

caries increment and, in some cases preventing, devastating

Table. DIETARY FLUORIDE SUPPLEMENTATION SCHEDULE dental disease).
Age <0.3 ppm F 0.3 to 0.6 ppm F >0.6 ppm F Fluoride supplements also are effective in reducing pre-
valence of dental caries and should be considered for children
Birth to 6 months 0 0 0 at high caries risk who drink fluoride-deficient (less than
6 mo to 3 years 0.25 mg 0 0 0.6 ppm F) water 19 (see Table). Determination of dietary
3 to 6 years 0.50 mg 0.25 mg 0 fluoride before prescribing supplements can help reduce
intake of excess fluoride. Sources of dietary fluoride may
6 to at least 16 years 1.00 mg 0.50 mg 0
include drinking water from home, day care, and school;
beverages such as soda20, juice21, and infant formula22; pre-
pared food23; and toothpaste. Concentrated infant formulas
Additionally, elevated plasma fluoride levels can treat the outer requiring reconstitution with water have raised concerns
surface of fully mineralized, but unerupted, teeth topically. regarding an increased risk of fluorosis. 24 Infants may be
Similarly, topical fluoride that is swallowed may have a particularly susceptible because of the large consumption of
systemic effect.12 such liquid in the first year of life, while the body weight
Fluoridation of community drinking water is the most is relatively low. 12 An evidence-based review found that
equitable and cost-effective method of delivering fluoride to consumption of reconstituted infant formula can be associated
all members of most communities.13 Water fluoridation at the with an increased risk of mild fluorosis, but recommended
level of 0.7-1.2 milligrams fluoride ion per liter (i.e., parts the continued use of fluoridated water. 25 One study has
per million fluoride [ppm F]) was introduced in the U.S. in shown that dental fluorosis levels do not vary in fluoridated
the 1940s. Since fluoride from water supplies is now one of areas regardless of premixed versus reconstituted formula.26
several sources of fluoride, the Department of Health and Standardization of the optimal fluoride levels in drinking
Human Services has recommended not having a fluoride water to 0.7 ppm F, however, makes this issue moot.
range, but rather to standardize all water to the 0.7 ppm F Professionally-applied topical fluoride treatments are
level. The rationale is to balance the benefits of preventing efficacious in reducing prevalence of dental caries. The most
dental caries while reducing the chance of fluorosis.1 commonly used agents for professionally-applied fluoride
Community water fluoridation has been associated with treatments are five percent sodium fluoride varnish ([NaFV]
the decline in caries prevalence in U.S. adolescents, from 90 2.26 percent fluoride [F], 22,600 ppm F) and acidulated
percent in at least one permanent tooth in 12-17-year-olds phosphate fluoride ([APF]; 1.23 percent F, 12,300 ppm F).
in the 1960s, to 60 percent in a 1999-2004 survey.14 When Meta-analyses of 23 clinical trials, most with twice yearly
used appropriately, fluoride is both safe and effective in application, favors the use of fluoride varnish in primary and
preventing and controlling dental caries. Although adverse permanent teeth.2 Unit doses of fluoride varnish are the only
health effects (e.g., decreased cognitive ability, endocrine professional topical fluoride agent that are recommended for
disruption and cancer) have been ascribed to the use of children younger than age six. 2 Meta-analyses of placebo-
fluoride over the years, the preponderance of evidence from controlled trials show that fluoride gels, applied at three
large cohort studies and systematic reviews does not support months to one year intervals, also are efficacious in reducing
an association of such health issues and consumption of fluo- caries in permanent teeth.27 Some topical fluoride gel and foam
ridated water.1 Regarding cognitive ability, a recent study of products are marketed with recommended treatment times of
mothers’ urinary fluoride levels and their child’s intelligence less than four minutes, but there are no clinical trials showing
quotient (IQ) levels suggested an association with exposure efficacy of shorter than four-minute application times.28 There
levels greater than those recommended in the U.S. for water also is limited evidence that topical fluoride foams are
fluoridation.15 However, a prospective study in New Zealand efficacious in children. 2 Children at risk for caries should
did not support an association between fluoridated water
and IQ measurements, 16 and a national sample in Sweden
found no relationship between fluoride levels in water supplies
and cognitive ability, non-cognitive ability, and education.17
Consumption of fluoride during the mineralization of teeth,
however, can cause fluorosis (children 1-3 years of age being
most susceptible for fluorosis of the permanent incisors).
The National Health and Nutrition Examination Survey
1999-2004 study found 23 percent of the U.S. population
had very mild or mild fluorosis.18 Decisions concerning the
administration of fluoride are based on the unique needs
of each patient, including the risks and benefits (e.g., risk Figure. Comparison of a smear (left) with a pea-sized (right) amount
of mild or moderate fluorosis versus the benefits of decreasing of toothpaste.

318 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

 BEST PRACTICES: FLUORIDE THERAPY

receive a professional fluoride treatment at least every six 4. There is support from evidence-based reviews that
months.28 fluoridated toothpaste is effective in reducing dental
Silver diamine fluoride ([SDF]; five percent F, 44,800 ppm caries in children with the effect increased in chil-
F) recently has been approved by the U.S. Food and Drug dren with higher baseline level of caries, higher
Administration and currently is used most frequently to arrest concentration of fluoride in the toothpaste, greater
dentinal caries. SDF arrests caries by the antibacterial effect of frequency in use, and supervision. Using no more than
silver and by remineralization of enamel and dentin.9 Some a smear or rice-size amount of fluoridated toothpaste
clinical trials show a caries arrest rate greater than 80 percent,7 for children less than three years of age may decrease
but such studies have a high risk of bias and a wide variation risk of fluorosis. Using no more than a pea-size
of results, leading to conditional recommendations at this amount of fluoridated toothpaste is appropriate for
time.29 Although the product is highly concentrated, less than children aged three to six.
a drop is needed to treat several caries lesions. The only re- 5. There is support from evidenced-based reviews that
ported side effects of SDF are that caries lesions stain black prescription-strength home-use 0.5 percent fluoride
after treatment, and it will temporarily stain skin with contact. gels and pastes and prescription-strength home-use
Home use of fluoride products for children should focus 0.09 percent fluoride mouthrinse also are effective
on regimens that maximize topical contact, in lower-dose in reducing dental caries.
higher-frequency approaches.30 Meta-analyses of more than 6. There is support from evidence-based reviews to
70 randomized or quasi-randomized controlled clinical recommend the use of 38 percent silver diamine
trials show that fluoride toothpaste is efficacious in reducing fluoride for the arrest of cavitated caries lesions in
prevalence of dental caries in permanent teeth, with the effect primary teeth as part of a comprehensive caries man-
increased in children with higher baseline level of caries with agement program.
higher concentration of fluoride in the toothpaste, greater
frequency of use, and supervision of brushing. 31,32 A meta- References
analysis of eight clinical trials on caries increment in preschool 1. U.S. Department of Health and Human Services Panel
children also shows that tooth brushing with fluoridated on Community Water Fluoridation. U.S. Public Health
toothpaste significantly reduces dental caries prevalence in the Services recommendation for fluoride concentration
primary dentition.6 Using no more than a smear or rice-size in drinking water for the prevention of dental caries.
amount of fluoridated toothpaste for children less than three Public Health Reports 2015;130(5):1-14.
years of age may decrease risk of fluorosis. Using no more 2. Weyant RJ, Tracy SL, Anselmo T, et al. Topical fluoride
than a pea-size amount of fluoridated toothpaste is appropriate for caries prevention: Executive summary of the updated
for children aged three to six8 (see Figure). To maximize the clinical recommendations and supporting systematic
beneficial effect of fluoride in the toothpaste, supervised review. J Amer Dent Assoc 2013;144(11):1279-91.
tooth-brushing should be done twice a day and rinsing after 3. Lenzi TL, Montagner A, Soares FLM, et al. Are topical
brushing should be kept to a minimum or eliminated alto- fluorides effective for treating incipient carious lesions:
gether.4 Other topical fluoride products (e.g., prescription- A systematic review and meta-analysis. J Am Dent Assoc
strength home-use 0.5 percent fluoride gels and pastes; 2016;147(2):84-92.e1.
prescription-strength, home-use 0.09 percent fluoride 4. S cottish Intercollegiate Guideline Network, Dental
mouthrinse) have benefit in reducing dental caries in children interventions to prevent caries in children. March 2014.
six years or older.2 Available at: “www.sign.ac.uk/assets/sign138.pdf ”.
Acccessed October 10, 2017.
Recommendations 5. Chou R, Cantor A, Zakher B, Mitchell JP, Pappas M.
1. There is confirmation from evidence-based reviews Prevention of Dental Caries in Children Younger Than
that fluoride use for the prevention and control of 5 Years Old: Systematic Review to Update the U.S. Pre-
caries is both safe and highly effective in reducing ventive Services Task Force Recommendation. Evidence
dental caries prevalence. Synthesis No. 104. AHRQ Publication No. 12-05170-
2. There is support from evidence-based reviews that EF-1. Rockville, Md.: Agency for Healthcare Research
fluoride dietary supplements are effective in reducing and Quality; 2014.
dental caries and should be considered for children 6. Santos APP, Nadanovsky P, Oliveira BH. A systematic
at caries risk who drink fluoride-deficient (less than review and meta-analysis of the effects of fluoride tooth-
0.6 ppm) water. paste on the prevention of dental caries in the primary
3. There is support from evidenced-based reviews that dentition of preschool children. Community Dent Oral
professionally applied topical fluoride treatments as Epidemiol 2013;41(1):1-12.
five percent NaFV or 1.23 percent F gel preparations 7. Gao SS, Zhao IS, Hiraishi N, et al. Clinical trials of silver
are efficacious in reducing caries in children at caries diamine fluoride in arresting caries among children: A
risk. systematic review. Int Amer Assoc Dent Res 2016;1(3):
201-10.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 319

BEST PRACTICES: FLUORIDE THERAPY

8. Wright JT, Hanson N, Ristic H, et al. Fluoride tooth- 21. Kiritsy MC, Levy SM, Warren JJ, Guha-Chowdhury
paste efficacy and safety in children younger than 6 N, Heilman JR, Marshall T. Assessing fluoride concen-
years. J Am Dent Assoc 2014;145(2):182-9. trations of juices and juice-flavored drinks. J Am Dent
9. Zhao IS, Gao SS, Hiraishi N, et al. Mechanisms of silver Assoc 1996;127(7):895-902.
diamine fluoride on arresting caries: A literature review. 22. Levy SM, Kohout FJ, Guha-Chowdhury N, Kiritsy
Int Dent J 2018;68(2):67-76. MC, Heilman JR, Wefel JS. Infants’ fluoride intake from
10. B uzalaf MA, Pessan JP, Honório HM, ten Cate JM. drinking water alone, and from water added to formula,
Mechanism of action of fluoride for caries control. beverages, and food. J Dent Res 1995;74(7):1399-407.
Monogr Oral Sci 2011;22:97-114. 23. Heilman JR, Kiritsy MC, Levy SM, Wefel JS. Fluoride
11. Center for Disease Control and Prevention. Recom- concentrations of infant foods. J Am Dent Assoc 1997;
mendations for using fluoride to prevent and control 128(7):857-63.
dental caries in the United States. MMWR Recomm 24. Hujoel PP, Zina LG. Moimas SAS, Cunha-Cruz J. Infant
Rep 2001;50(RR-14):1-42. formula and enamel fluorosis. A systematic review. J Am
12. Tinanoff N. Use of fluoride. In: Berg J, Slayton RA, eds. Dent Assoc 2009;140(7):841-54.
Early Childhood Oral Health. 2nd ed. Hoboken, 25. Berg J, Gerweck C, Hujoel PP, et al. Evidence-based
N.J.: Wiley-Blackwell; 2016:104-19. clinical recommendations regarding fluoride intake from
13. Division of Oral Health, National Center for Chronic reconstituted infant formula and enamel fluorosis. J Am
Disease Prevention and Health Promotion, Center for Dent Assoc 2011;142(1):79-87.
Disease Control and Prevention. Achievements in public 26. Do LG, Levy SM, Spencer AJ. Association between
health, 1900-1999; Fluoridation of drinking water to infant formula feeding and dental fluorosis and caries in
prevent dental caries. JAMA 2000;283(10):1283-6. Australian children. J Public Health Dent 2012;72(2):
14. U.S. Department of Health and Human Services. Pro- 112-21.
posed HHS recommendation for fluoride concentration 27. Marinho VC, Higgin JP, Logan, S, Sheiham A. System-
in drinking water for prevention of dental caries. Federal atic review of controlled trials on the effectiveness of
register 2011;76(9):2383-8. fluoride gels for the prevention of dental caries in chil-
15. Bashash M, Thomas D, Hu H, et al. Prenatal fluoride dren. J Dent Ed 2003;67(4):448-58.
exposure and cognitive outcomes in children at 4 and 28. Hunter JW, Chan JT, Featherstone DB, et al.
6–12 years of age in Mexico. Environmental Health Professionally-applied topical fluoride: Evidence-based
Perspective, 2017. Available at: “https://208doi.org/10. clinical recommendations. J Am Dent Assoc 2006;137
1289/EHP655”. Accessed October 10, 2017. (8):1151-9.
16. Broadbent JM, Thomson WM, Ramrakha S, et al. Com- 29. Crystal YO, Marghalani AA, Ureles SD, et al. Use of
munity water fluoridation and intelligence: Prospective silver diamine fluoride for dental caries management in
study in New Zealand. Am J Public Health 2015;105 children and adolescents, including those with special
(1):72-6. health care needs. Pediatr Dent 2017;39(5):E135-E145.
17. Aggeborn L, Öhman M. The effects of fluoride in the 30. Adair SM. Evidence-based use of fluoride in contem-
drinking water. 2016. Available at: “https://sites.google. porary pediatric dental practice. Pediatr Dent 2006;28
com/site/linuzaggeborn/aggeborn-ohman-20161103.pdf? (2):133-42.
attredirects=1”. Accessed October. 10, 2017. 31. Marinho VC, Higgins JP, Logan S, Sheiham A. Fluoride
18. Beltrán-Aguilar ED, Barker L, Dye BA. Prevalence and toothpaste for preventing dental caries in children and
severity of dental fluorosis in the United States, 1999- adolescents. Cochrane Database of Sys Rev 2003;(1):
2004, NCHS Data Brief No. 53; 2010:1-8. CD002278.
19. Rozier RG, Adair S, Graham F, et al. Evidence-based 32. Walsh T, Worthington HV, Glenny AM, Appelbe P,
clinical recommendations on the prescription of dietary Marinho VC, Shi X. Fluoride toothpastes of different
fluoride supplements for caries prevention: A report of concentrations for preventing dental caries in children
the American Dental Association Council on Scientific and adolescents. Cochrane Database of Sys Rev 2010;
Affairs. J Am Dent Assoc 2010;141(12):1480-9. (1):CD007868.
20. Heilman JR, Kiritsy MC, Levy SM, Wefel JS. Assessing
fluoride levels of carbonated soft drinks. J Am Dent
Assoc 1999;130(11):1593-9.

320 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY