ADA Guidelines for the Use of Fluoride

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     yli46 
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    Introduction
    1.1. The use of fluorides in dentistry is one of the most important ways of preventing dental caries and has the
    support of peak public health and dental authorities. International bodies such as the US-based Centres for
    Disease Control and Prevention (CDC), the World Health Organisation (WHO) and the US Surgeon General
    actively promote water fluoridation. The CDC placed water fluoridation in the top ten public health
    achievements of the 20th Century. Similarly, scientific bodies in Australia, recognised public health groups and
    professional organisations support water fluoridation.
    1.2. Community water fluoridation continues to be the most cost-effective, equitable and safe means to provide
    protection from tooth decay and has been successfully utilised in Australia for more than 50 years.
    1.3. Community water fluoridation may be impractical in very small communities, particularly those in regional and
    remote areas.
    1.4. A significant number of households are not connected to mains water.
    1.5. The effect of water fluoridation is predominantly topical.
    1.6. Australian infant formula is manufactured to be safe and avoid causing fluorosis when used with fluoridated
    water.
    1.7. Dental fluorosis occurs as a result of interference in the formation of the enamel. It varies from very thin, almost
    invisible, white patches or lines over the tooth surface to significant areas of brown staining and/or pitted
    enamel defects. Dental fluorosis can be a significant and unwanted effect on teeth if a child is exposed to high
    levels of fluoride when the teeth are forming, although instances of severe dental fluorosis are now rare in
    Australia.
    1.8. Dental fluorosis is only one of the numerous causes of hypo-mineralisation blemishes, or mottling, in teeth.
    1.9. Studies have shown that most bottled water sold in Australia does not contain fluoride at sufficient levels to
    protect teeth from caries.
    1.10. Fluoride supplements in the form of drops and tablets are not widely available in Australia.
    Definitions
    1.11. ADDITIONAL SOURCES OF FLUORIDE is an all-encompassing term to include all sources of fluoride other
    than water fluoridation – fluoride drops, rinses, tablets, toothpastes, gels and fluoride in foods and beverages.
    1.12. BOARD is the Dental Board of Australia.
    1.13. DENTAL FLUOROSIS is the staining or mottling of the teeth as a result of greater than optimal fluoride
    exposure while a child’s teeth are developing.
    1.14. DENTAL PRACTITIONER is a person registered by the Board to provide dental care.
    1.15. FLUORIDE SUPPLEMENTS are those products that seek to achieve a similar effect on the individual as
    fluoridation of the water supply. The term is generally limited to fluoride tablets and drops.
    1.16. WATER FLUORIDATION is the treatment of community water supplies for the purpose of adjusting the
    concentration of the free fluoride ion to the optimum level for maximum caries prevention and minimal
    occurrence of dental fluorosis.
    Page 2 | ADA Policies
    2. Principles
    2.1. Water fluoridation is the most effective, equitable and efficient measure for achieving reduction in dental
    caries incidence across a community.
    2.2. All Australians should have equality of access to the benefits of fluoride, either by water fluoridation or
    the use of fluoride supplements.
    2.3. For children, there is a need to use fluorides to strive for optimal caries prevention while ensuring the
    prevalence of dental fluorosis is minimised.
    2.4. Whilst fluoridation of community water supplies is the preferred method of fluoride delivery, fluoride
    supplements can be used to promote a reduction in dental caries in areas that are not optimally
    fluoridated.
    2.5. Fluoridation of community water supplies benefits all age groups.
    3. Policy
    Water Fluoridation
    3.1. Fluoridation of community water supplies is preferred as a safe and effective means of reducing the
    prevalence of dental caries in all age groups and should be implemented and maintained in those
    communities where there is an insufficient natural fluoride content for this purpose.
    3.2. The optimum level of fluoride to be achieved in a water supply should take into account climatic
    conditions and water consumption.
    3.3. Where fluoridation of water supplies is effected, there must be adequate control and supervision of the
    procedure.
    3.4. Governments must adopt water fluoridation as part of Health Policy and actively promote its introduction,
    where it is feasible, as a public health measure.
    3.5. Manufacturers and producers of bottled water should be encouraged to ensure that their products
    contain fluoride at approximately 1 milligram per litre (mg/L) and that the fluoride content is included in
    labelling.
    3.6. Only water filters that do not remove fluorides should be recommended.
    3.7. Manufacturers of water filters or water filtering systems should include information on their products as
    to whether or not fluoride is removed.
    Additional Sources of Fluoride
    3.8. People living with non-fluoridated water supplies should use fluoride supplements by adding them to
    their water to community water fluoridation levels.
    3.9. Because of the variable presence of fluoride in foodstuffs, particularly processed foods and beverages,
    supplementary fluoride must be used under the direction of a dentist and should take into account the
    assessment, conducted by a dentist, of an individual’s caries risk.
    3.10. Fluoride supplements must be readily available at a reasonable cost to those needing them.
    3.11. Toothpastes containing fluoride should be used as an important method of further reducing dental caries
    incidence, regardless of whether or not the area water supply is optimally fluoridated. Fluoride
    toothpastes should be used as recommended by a dentist who should take into account the age of the
    patient, the access to fluoridated water and an assessment of an individual’s caries risk. Special care
    must be taken with very young children to limit the amount of toothpaste used and, thereby, the
    ingestion of fluoride.
    3.12. Professional topical application of fluorides must be selectively used on patients who, as a result of an
    evaluation conducted by a dentist, are assessed as having a high caries risk.
    Page 3 | ADA Policies
    3.13. There is a need to support further studies that examine the impact of fluoride delivery mechanisms in the
    Australian population including: studies of the epidemiology of dental caries and dental fluorosis;
    investigations of the impact of both conditions on people’s well-being and quality of life; risk factors for
    dental caries and dental fluorosis; use of fluoride vehicles in dental practice and the population; and the
    efficacy, effectiveness and cost effectiveness of fluoride vehicles. Research is needed to develop new
    preventive interventions including new vehicles for fluoride delivery as well as other preventive strategies
    that are not based on fluoride. New interventions should be judged for their equivalency or superiority to
    existing preventive approaches that have documented efficacy.
    Dental Fluorosis
    3.14. The control of additional fluoride sources, rather than the reduction or removal of the optimum fluoride
    level in drinking water, is the preferred strategy for maintaining the low incidence of dental fluorosis.
    Policy Statement 2.2.1
    Adopted by ADA Federal Council, November 15/16, 2001.
    Revised version adopted by ADA Federal Council, November 11/12, 2004.
    Amended by ADA Federal Council, April 7/8, 2005.
    Revised version adopted by ADA Federal Council, November 15/16, 2007.
    Amended by ADA Federal Council, November 18/19, 2010.
    Amended by ADA Federal Council, April 12/13, 2012.
    Amended by ADA Federal Council, April 10/14, 2014.
    Amended by ADA Federal Council, November 13/14, 2014.
    Page 4 | ADA Policies
    Appendix to Policy Statement 2.2.1 – ADA guidelines for the
    use of fluoride
    1. Water Fluoridation
    1.1. Water fluoridation is a proven method for reducing the prevalence of dental caries in communities.
    1.2. Surveys of dental caries and dental fluorosis must be undertaken regularly, taking into account all
    fluoride sources and patterns of consumption in a community, in order to confirm the most appropriate
    water fluoridation concentration for that community or region.
    1.3. The optimal fluoride concentration of community water supplies will normally be in the range of 0.6 to
    milligram per litre (mg/Litre) of water (commonly known as parts per million or ppm).
    1.4. The fluoride content of bottled water should be clearly stated on the label.
    2. Fluoride Supplements
    2.1. Fluoride drops or tablets should not be taken (swallowed) directly by an adult or child. They must be
    added to drinking water to achieve a fluoride concentration of 1mg/L.
    2.2. So people in non-fluoridated areas can obtain the benefits of fluoride in water it is recommended that
    people buy bottled water with fluoride at approximately 1mg/L for drinking.
    2.3. Support must be given to ongoing research into the epidemiology of dental caries and the use of fluoride
    to ensure assessments of safety, effectiveness and efficiency of all methods of delivery of fluoride are up
    to date.
    2.4. All dental practitioners must maintain awareness of the latest science as it affects the use of all forms of
    fluoride.
    3. Fluoridated Toothpaste
    3.1. From the time that teeth first erupt (about six months of age) to the age of 17 months, children’s teeth
    should be cleaned by a responsible adult, but not with toothpaste.
    3.2. For children aged 18 months to five years (inclusive), the teeth should be cleaned twice a day with
    toothpaste containing 0.5–0.55mg/g of fluoride (500–550ppm). Toothpaste should always be used under
    supervision of a responsible adult, a small pea-sized amount should be applied to a child-sized soft
    toothbrush and children should spit out, not swallow, and not rinse. Young children should not be
    permitted to lick or eat toothpaste.
    3.3. For people aged six years or more, the teeth must be cleaned twice a day or more frequently with
    standard fluoride toothpaste containing 1- 1.5mg/g fluoride (1000–1500ppm). People aged six years or
    more should spit out, not swallow, and not rinse. Standard toothpaste is not recommended for children
    under six years of age unless on the advice of a dental professional.
    3.4. For children who do not consume fluoridated water or who are at elevated risk of developing caries for
    any other reason, guidelines about toothpaste usage must be varied, as needed, based on dental
    professional advice. Variations could include more frequent use of fluoridated toothpaste,
    commencement of toothpaste use at a younger age, or earlier commencement of use of standard
    toothpaste containing 1mg/g fluoride (1000ppm). This guideline may apply particularly to preschool
    children at high risk of caries.
    3.5. For teenagers, adults and older adults who are at elevated risk of developing caries, dental professional
    advice should be sought to determine if they must use toothpaste containing a higher concentration of
    fluoride (i.e. greater than 1000-1500 ppm up to 5000 ppm of fluoride).
    3.6. Manufacturers must be encouraged to standardise and restrict the toothpaste tube orifice to allow a
    more accurate and consistent amount of toothpaste to be dispensed.
    Page 5 | ADA Policies
    3.7. Manufacturers must be encouraged to avoid flavours that imitate too closely popular food tastes to avoid
    accidental ingestion of large amounts of paste by very young children.
    4. Application of Topical Fluoride
    4.1. Concentrated forms of fluoride should only be applied by suitably-qualified dental practitioners and
    should only be used after taking into account an assessment conducted by a dentist of an individual’s
    caries risk.
    4.2. Fluoride varnish should be used for people who have elevated risk of developing caries, including
    children under the age of 10 years.
    4.3. High concentration fluoride gels and foams (those containing more than 1.5mg/g fluoride ion) may be
    used for people aged 10 years or more who are at an elevated risk of developing caries in situations
    where other fluoride vehicles may be unavailable or impractical.
    5. Fluoride Mouth Rinses
    5.1. Fluoride mouth rinses must not be used by children under the age of six years due to the likelihood that
    they will ingest large amounts and increase their risk of dental fluorosis.
    5.2. Fluoride mouth rinses may be used by people over the age of six years under the direction of a dentist
    where it is considered an appropriate choice for preventing caries in high risk individuals and where
    there is certainty that the individual will understand that the product should be rinsed as directed and
    spat out, not swallowed.
    6. Fluoride, Diet, Cleaning Routines and Smoking
    6.1. The beneficial effects of fluoride must be understood in conjunction with all the major risk factors for
    dental caries.
    6.2. A person’s inappropriate dietary and other habits have the potential to overcome the beneficial effect of
    fluoride, with smoking, poor oral hygiene habits, and high frequency or prolonged exposure to dietary
    sugars, starches and acidic foods and beverages, posing the highest risk.

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