Fluoride and Water

Keeping kids' teeth healthy requires more than just daily brushing. During a routine well-child exam, you may be surprised to find the doctor examining your child's teeth and asking you about your water supply. That's because fluoride, a substance that's found naturally in water, plays an important role in healthy tooth development and cavity prevention.

About Fluoride

Fluoride exists naturally in water sources and is derived from fluorine, the thirteenth most common element in the Earth's crust. It is well known that fluoride helps prevent and even reverse the early stages of tooth decay.

Tooth decay occurs when plaque — that sticky film of bacteria that accumulates on teeth — breaks down sugars in food. The bacteria produce damaging acids that dissolve the hard enamel surfaces of teeth.

If the damage is not stopped or treated, the bacteria can penetrate through the enamel causing tooth decay (also called cavities or caries). Cavities weaken teeth and can lead to pain, tooth loss, or even widespread infection in the most severe cases.

Fluoride combats tooth decay in two ways:

1. It is incorporated into the structure of developing teeth when it is ingested.
2. It also protects teeth when it comes in contact with the surface of the teeth.

Fluoride prevents the acid produced by the bacteria in plaque from dissolving, or demineralizing, tooth enamel, the hard and shiny substance that protects the teeth. Fluoride also allows teeth damaged by acid to repair, or remineralize, themselves. Fluoride cannot repair cavities, but it can reverse low levels of tooth decay and thus prevent new cavities from forming.

Despite the good news about dental health, tooth decay remains one of the most common diseases of childhood. According to the Centers for Disease Control and Prevention (CDC), more than one quarter of 2- to 5-year-olds and half of kids 12 to 15 years old have one or more cavities, and tooth decay has affected two thirds of 16- to 19-year-olds.

Fluoride and the Water Supply

For over 60 years, water fluoridation has proved to be a safe and cost-effective way to reduce dental caries. Today, water fluoridation is estimated to reduce tooth decay by 20%-40%.

As of 2002, CDC statistics show that almost 60% of the U.S. population receives fluoridated water through the taps in their homes. Some communities have naturally occurring fluoride in their water; others add it at water-processing plants.

Your doctor or dentist may know whether local water supplies contain optimal levels of fluoride, between 0.7 and 1.2 ppm (parts fluoride per million parts of water). If your water comes from a public system, you could also call your local water authority or public health department, or check online at the Environmental Protection Agency's (EPA) database of local water safety reports.

If you use well water or water from a private source, fluoride levels should be checked by a laboratory or public health department.

Some parents purchase bottled water for their kids to drink instead of tap water. Most bottled waters lack fluoride, but fluoridated bottled water is now available. If fluoride is added, the manufacturer is required to list the amount. If fluoride concentration is greater than 0.6 ppm up to 1.0 ppm, you might see the health claim "Drinking fluoridated water may reduce the risk of tooth decay" on the label.

The Controversy Over Fluoride

Opponents of water fluoridation have questioned its safety and effectiveness; however, there has been little evidence to support these concerns.

Scientific research continues to support the benefits of fluoride when it comes to prevention of tooth decay and its safety at current recommended levels of 0.7 to 1.2 ppm. Dramatic reductions in tooth decay in the past 30 years is attributed to fluoridation of the water supply, and parents and health professionals should continue to ensure that kids receive enough fluoride to prevent cavities.

The American Dental Association (ADA), the United States Public Health Service (USPHS), the American Academy of Pediatric (AAP), and the World Health Organization (WHO), among many other national and international organizations, endorse community water fluoridation. The CDC recognized fluoridation of water as one of the 10 greatest public health achievements of the 20th century.

Kids' Fluoride Needs

So how much fluoride do kids need? In general, kids under the age of 6 months do not need fluoride supplements. Your child's 6-month checkup offers a great chance to discuss fluoride supplementation with your doctor. If you live in a nonfluoridated area, your doctor or dentist may prescribe fluoride drops, tablets, or vitamins after your baby is 6 months old.

The AAP recommends that these fluoride supplements be given daily to kids between the ages of 6 months and 16 years. The dosage depends on how much fluoride naturally occurs in the water and the child's age. Only kids living in nonfluoridated areas or those who drink only nonfluoridated bottled water should receive supplements.

What about toothpastes, mouth rinses, and other products that contain fluoride? Here are a few tips:

• Kids under 2 years old should not use fluoride toothpaste unless instructed to by a dentist or health professional.
• Kids younger than 6 may swallow too much toothpaste while brushing, so should be supervised when brushing and taught to spit, not swallow, toothpaste.
• Kids over age 2 should use a fluoride-containing toothpaste that carries the ADA's seal of acceptance.
• Kids should use only a pea-sized amount of toothpaste.
• Kids under age 6 should never use fluoride-containing mouth rinses. However, older kids at high risk for tooth decay may benefit from using them. Your dentist can talk with you about risk factors such as a family history of dental disease, recent periodontal surgery or disease, or a physical impediment to brushing regularly and thoroughly.

Your family dentist or pediatric dentist (one who specializes in the care of children's teeth) is a great resource for information about dental care and fluoride needs. A dentist can help you understand more about how fluoride affects the teeth, and once all of your child's primary teeth have come in, may recommend regular topical fluoride during routine dental visits.

Overexposure to Fluoride

If some fluoride is good, why isn't more fluoride better? As with most medications, including vitamins and mineral supplements, too much can be harmful. Most kids get the right amount of fluoride through a combination of fluoridated toothpaste and fluoridated water or supplements.

Too much fluoride before 8 years of age, a time when teeth are developing, can cause enamel fluorosis, a discoloration or mottling of the permanent teeth. For most, the changes are subtle. In one study, 94% of identified fluorosis cases were very mild to mild. Most cases are due to inappropriate use of fluoride-containing dental products, including toothpaste and mouth rinses. Sometimes kids take daily fluoride supplements but may be getting adequate fluoride from other sources, which also puts them at risk.

Recently, the National Research Council found naturally occurring fluoride levels that exceeded the optimal levels used in community fluoridation programs (0.7 to 1.2 ppm), putting kids under 8 years old at risk for severe enamel fluorosis. The CDC recommends that in communities where natural fluoride levels are greater than 2 ppm, parents should give kids water from other sources.

The ADA also recognizes that infants need less fluoride than older kids and adults. Some infants may be getting too much fluoride in the water used to reconstitute infant formula. If you're concerned that your infant may be getting too much fluoride, talk with your doctor or dentist, who may recommend ready-to-feed formula or formula reconstituted with fluoride-free or low-fluoride water.

Very rarely, fluoride toxicity can occur when large amounts of fluoride are ingested during a short period of time. Kids under age 6 account for more than 80% of reports of suspected overingestion. Although outcomes are generally not serious, fluoride toxicity sends several hundred children to emergency rooms each year.

Symptoms of fluoride toxicity may include nausea, diarrhea, vomiting, abdominal pain, increased salivation, or increased thirst. Symptoms begin 30 minutes after ingestion and can last up to 24 hours. If you suspect your child may have eaten a substantial amount of a fluoridated product or supplement, call the poison control center or 911.

Be sure to keep toothpaste, supplements, mouth rinses, and other fluoride-containing products out of kids' reach or in a locked cabinet. You should also supervise your young child's toothbrushing sessions to prevent swallowing of toothpaste or other fluoridated products.

If you have any questions about your water's fluoride content, the fluoridated products your child uses, or whether your child is receiving too much or too little fluoride, talk to your doctor or dentist.