Risk Of Fluorosis Research Articles

Analysis of protection or risk factors for dental fluorosis in 6 to 8 year-old children in Fortaleza, Brazil

To investigate protection or risk factors for dental fluorosis in permanent teeth of 6 to 8 year-old children in a neighborhood of Fortaleza, Brazil. This case-control study included 57 controls and 67 children with fluorosis affecting superior and inferior incisors teeth as determined by the Dean classification criteria. Presence of fluorosis was considered as the dependent variable. Data concerning independent variables were obtained through interviews with the parents. Fisher's exact test was used to determine associations between fluorosis and the independent variables. Odds ratios (OR) were calculated to investigate associations and likelihood of fluorosis in the case group, with 95% significance level. Fluorosis was significantly associated with type of housing (owned, rented or squatted), but not with the source of drinking water or use of fluoridated toothpaste and fluoride supplements. Univariate analysis showed that the risk of fluorosis was higher in children who began drinking powdered milk mixed with water before 2 years of age (OR = 4.53; IC95%: 1.07-26.74) and in those who did not breastfeed (OR = 6.66; IC95%: 1.61-38.62). In the multivariate analysis, only breastfeeding was associated with fluorosis (4.54; IC95%: 1.21-16.66). Breastfeeding was a protection factor against fluorosis. More specific categorization criteria must be established to investigate relationships between fluorosis and socioeconomic class.

Severe dental fluorosis and jowar consumption in Karnataka, India

Dental fluorosis is a major public health problem in 17 states of India. Earlier studies have reported that Jowar (a type of millet) consumption interacts with fluoride (F) in the body and enhances fluorosis. We conducted this study to determine the association between jowar consumption and severity of dental fluorosis. A community based case control study was carried out in villages having different F levels (low, medium, and high) in drinking water in North Karnataka, India. 352 school Children (12-15 years, male 58%) with severe dental fluorosis classified by Thylstrup & Fejerskov Index (1988) were selected as cases. 428 school children (12-15 years, male 48.8%) with no dental fluorosis were selected randomly from the same area as controls. Exposure ascertainment of jowar consumption was done by 24-h diet recall and food frequency questionnaire. Ion selective electrode method was used to estimate the F level in spot urine samples of subjects and in drinking water. Multiple logistic regression analysis was done using SPSS V. 11.01 Children who consumed jowar had 2.67 times more chance of getting severe dental fluorosis compared to those who did not [Odds Ratio (OR) 2.67, CI 1.98-3.62]. Children from high F level villages (OR 1.91, CI 1.27-2.85) had higher odds of severe dental fluorosis compared to children from medium and low F level villages. Daily jowar consumers (OR 2.14, CI 1.64-3.09) and weekly consumers (OR 1.68, CI 1.31-3.45) had higher risk for dental fluorosis compared to non jowar consumers. Children who started consuming jowar before 8 years of age had significantly higher proportion of severe dental fluorosis compared to their counterparts. Urinary F excretion among jowar consumers was significantly lower than non-jowar consumers. Jowar consumption was positively associated with severity of dental fluorosis in this population.

Why Fluoride?

Fluoride has been used in dentistry for over 100 years for the purpose of preventing dental caries. During this time there has been great debate over the mode of action, the optimum method of delivery, and the potential risks associated with its use. This, the first of three papers, will provide a summary of the history of the use of fluoride, the mode of action, benefits and different methods of delivery. It will also discuss the potential risk of dental fluorosis. This article aims to provide a background for general practitioners for the appropriate use of fluorides in dentistry, enable them to understand the wider significance of fluoride in dentistry and to be able to answer non-clinical questions raised by patients.

Associations Between Fluorosis of Permanent Incisors and Fluoride Intake From Infant Formula, Other Dietary Sources and Dentifrice During Early Childhood

The authors describe associations between dental fluorosis and fluoride intakes, with an emphasis on intake from fluoride in infant formula. The authors administered periodic questionnaires to parents to assess children's early fluoride intake sources from beverages, selected foods, dentifrice and supplements. They later assessed relationships between fluorosis of the permanent maxillary incisors and fluoride intake from beverages and other sources, both for individual time points and cumulatively using area-under-the-curve (AUC) estimates. The authors determined effects associated with fluoride in reconstituted powdered infant formulas, along with risks associated with intake of fluoride from dentifrice and other sources. Considering only fluoride intake from ages 3 to 9 months, the authors found that participants with fluorosis (97 percent of which was mild) had significantly greater cumulative fluoride intake (AUC) from reconstituted powdered infant formula and other beverages with added water than did those without fluorosis. Considering only intake from ages 16 to 36 months, participants with fluorosis had significantly higher fluoride intake from water by itself and dentifrice than did those without fluorosis. In a model combining both the 3- to 9-months and 16- to 36-months age groups, the significant variables were fluoride intake from reconstituted powder concentrate formula (by participants at ages 3-9 months), other beverages with added water (also by participants at ages 3-9 months) and dentifrice (by participants at ages 16-36 months). Greater fluoride intakes from reconstituted powdered formulas (when participants were aged 3-9 months) and other water-added beverages (when participants were aged 3-9 months) increased fluorosis risk, as did higher dentifrice intake by participants when aged 16 to 36 months. Results suggest that prevalence of mild dental fluorosis could be reduced by avoiding ingestion of large quantities of fluoride from reconstituted powdered concentrate infant formula and fluoridated dentifrice.

Low-Fluoride Acidic Dentifrice: A Randomized Clinical Trial in a Fluoridated Area

Background: Low-fluoride dentifrices have been suggested as alternatives to reduce dental fluorosis risk, but there is no consensus regarding their clinical effectiveness, which has been suggested to be increased when their pH is acidic. Aims: This single-blind randomized clinical trial evaluated the caries increment during the use of a low-fluoride acidic liquid dentifrice. Methods: Four-year-old schoolchildren (n = 1,402) living in a fluoridated area (0.6–0.8 ppm F) were randomly allocated to 4 groups differing according to the type of dentifrice used over a 20-month period. Group 1 (n = 345): liquid dentifrice, 1,100 ppm F, pH 4.5. Group 2 (n = 343): liquid dentifrice, 1,100 ppm F, pH 7.0. Group 3 (n = 354): liquid dentifrice, 550 ppm F, pH 4.5. Group 4 (n = 360): toothpaste, 1,100 ppm F, pH 7.0. At baseline and after 20 months, clinical examinations were conducted (dmfs index) and caries increment was calculated. Data were analysed by GLM procedure using classrooms (cluster) as unit of analysis (p < 0.05). Results: The mean ± SD (95% CI) net increments found were as follows. Group 1: 2.06 ± 2.38 (1.8–2.3); group 2: 2.08 ± 2.87 (1.7–2.4); group 3: 2.05 ± 2.79 (1.7–2.4), and group 4: 2.08 ± 2.34 (1.8–2.4). No significant differences were detected among the groups. Conclusion: In a population with high caries risk living in a fluoridated area, as the selected sample, and according to the present protocol, the low-fluoride acidic liquid dentifrice seems to lead to similar caries progression rates as conventional 1,100 ppm F toothpaste.

Dietary fluoride intake for fully formula-fed infants in New Zealand: impact of formula and water fluoride

A survey of the fluoride content of infant and toddler formulae available on the New Zealand market was conducted. Results were used to estimate the dietary fluoride intake for a fully formula-fed infant. Infant and toddler formulae were prepared according to manufacturers' instructions with fluoride-free water and analyzed for fluoride by a modification of the microdiffusion method of Taves. A proportion of samples were reanalyzed after reconstitution with water at fluoride concentrations of 0.7 and 1.0 mg/L. A stochastic model was used to estimate dietary fluoride intake. The mean fluoride content of prepared infant formulae was 0.069 mg/L. When formulae were prepared with water of differing fluoride concentrations, the fluoride concentration was found to be a simple linear function of water fluoride concentration. Estimates of dietary fluoride intake for infants consuming formuae prepared with fluoride-free water were well below the upper level of intake (UL) for New Zealand and Australia (0.7 mg/day). At water fluoride concentrations of 0.7 and 1.0 mg/L the UL would be exceeded 30 and 93 percent of the time, respectively. The fluoride content of water used to reconstitute infant formulae has a greater impact on fluoride intake of fully formula-fed infants than the fluoride content of the powdered infant formulae. Infants fully formula-fed on formulae prepared with optimally fluoridated water (0.7-1.0 mg/L) have a high probability of exceeding the UL for fluoride and are at increased risk of dental fluorosis.

Assessment of water contribution on total fluoride intake of various age groups of people in fluoride endemic and non-endemic areas of Dindigul District, Tamil Nadu, South India

The prevalence of fluorosis is mainly due to the intake of large quantities of fluoride through water. It is necessary to determine the contribution of water used for drinking and food processing and other diet sources on daily fluoride intake for finding the ways to reduce the excess fluoride intake than the minimum safe level intake of 0.05 mg/kg/day. The main objectives of this study are to determine the quantitative impact of water through drinking and cooking of food and beverages on total fluoride intake as well as to estimate the contribution of commonly consumed diet sources on total fluoride intake. Contribution of water on daily fluoride intake and estimation of total fluoride intake through the diet sources were accomplished through analysis of fluoride in drinking water, solid and liquid food items, Infant formulae, tea and coffee infusions using fluoride ion selective electrode. Determination of incidence of fluorosis in different fluoride endemic areas in Dindigul District of Tamil Nadu, South India is achieved through clinical survey. The percentage of daily fluoride intake through water is significantly higher for infants than children, adults and old age groups of people. The percentile scores of fluoride intake through water from drinking and cooking increases with increase of water fluoride level. The rate of prevalence of fluorosis is higher in adolescent girls and females than adolescent boys and males residing in high fluoride endemic areas. More than 60% of the total fluoride intake per day derived from water used for drinking and food processing. Hence the people residing in the fluoride endemic areas in Dindigul District of Tamil Nadu, South India are advised to take serious concern about the fluoride level of water used for drinking and cooking to avoid further fluorosis risks.

Fluoride content of beverages intended for infants and young children in Poland

Results of the studies indicate that fluoride content in beverages may be highly variable and children can consume substantial amounts of fluoride with these products. Ingestion of excessive fluoride during infancy and early childhood may cause dental fluorosis of permanent maxillary central incisors – the most aesthetically important teeth.The aim of this study was to determine the fluoride content in Polish beverages designed for infants and young children nutrition.Forty-three brands of juices and juice-flavored drinks and 23 instant teas were evaluated. Analyses were performed with the use of ion-selective fluoride electrode (09-37 type) and a RAE 111 chloride-silver reference electrode (MARAT). Fluoride concentrations in most beverages did not exceed 0.3ppm. However, in three beverages containing tea extract levels of fluoride were higher (0.35–1.14ppm). Consumption of these beverages could significantly increase child’s fluoride exposure. Therefore, the need exists for continuous monitoring of fluoride levels in products intended for children. Listing fluoride content on beverages would be desirable. Knowledge about possible fluoride ingestion from dietary sources permits the clinician to recommend the safest schedule of fluoride treatment so as the optimal caries preventive effect can be obtained and the risk of dental fluorosis reduced.

Children's dental fluorosis and estrogen receptor α gene Xba I polymorphism

Objectives To explore the relationship between polymorphism in estrogen receptor alpha (ERα)gene Xba I and child dental fluorosis.Methods Qiulou township of Kaifeng and Sunying township of Tongxu counties of Henan province were chosen as the investigation spots in 2006.An area of water drinking endemic fluorosis(high fluoride area)and a non-endemic area(control area)were chosen in every spot,where dental fluorosis of children aged 8 to 12 years old were examined and diagnosed by using the Dean method.The children in the high fluoride areas were divided into dental fluorosis group and control group of the endemic areas according to dental fluorosis status,and the children in the control areas as control gruop of non-endemic areas.The Xba I polymorphism in the ERα gene was genotyped using the PCR-RFLP procedure.The fluoride levels in the urine samples from the three groups were detected by fluoride ion selective electrode and over standard rate of the urine was counted.Results The prevalence rate of dental fluorosis in high fluoride areas was 51.7%(74/143)and the community fluorosis index was 1.310.No dental fluorosis case was checked out in the control and the community fluorosis index was 0.021.The over standard rate of urine fluoride in dental fluorosis group[84.6%(121/143)]was significantly higher than that of control in non-endemic area[9.6%(9/94);χ2=125.95,P 0.05). Allele frequency of ERα Xba I genotypes was X 22.7%(30/132), x 77.3%(102/132) in dental fluorosis group and X 35.5%(39/110),x 64.5% (71/110) in the control in endemic area when urine fluorosis of children was exceeding standard and significant difference was found in this two groups(χ2 = 4.768, P < 0.05; OR = 0.535,95% CI:0.305 - 0.941). Conclusion Children who carried X allele frequency of ERα Xba I genotypes have a lower risk of dental fluorosis when children with high-loaded fluoride status. Key words: Estrogen receptor alpha; Polymorphism, genetic; Fluorosis, dental

The Risk of Enamel Fluorosis and Caries Among Norwegian Children: Implications for Norway and the United States

The authors investigated the associations between enamel fluorosis, caries and early fluoride use among Norwegian children who received fluoride supplementation under a protocol similar to the current U.S. protocol. Two examiners whose techniques were calibrated examined randomly selected middle-school-aged children living in Bergen, Norway-where the water supply contains less than 0.10 milligrams of fluoride per liter-for both enamel fluorosis and caries by using the Fluorosis Risk Index and modified National Institute of Dental and Craniofacial Research criteria. The authors ascertained past fluoride exposure via a follow-up questionnaire mailed to parents. The questionnaire had an 88 percent response rate and 87 percent reliability. Adjusted analyses revealed a strong association between regular supplementation (given in the form of lozenges) and mild to moderate enamel fluorosis (odds ratio [OR], 6.85; P < .05), as well as fluorosis of lesser severity (OR, 3.07; P < .05). No children who had exclusively used only a pea-sized amount of toothpaste (0.1 percent fluoride) had mild to moderate fluorosis. The authors found a 40 percent reduction in caries risk associated with early use of pea-sized amounts of fluoridated toothpaste and a 46 percent reduction associated with regular use of fluoride supplement lozenges. These findings suggest that both risk of fluorosis development and caries-preventive benefit are associated with regular use of fluoride supplements, and caries prevention was associated with early use of a pea-sized amount of toothpaste. These findings underscore the need for clinicians to consider thoroughly-and discuss with a child's parent or guardian-both the benefit and the potential risk of fluorosis development associated with preventive fluoride agents before introducing them. Clinicians also should emphasize the proper use of such agents.

Using a fluoridated supplement with a high fluoride concentration in children aged under 6 years may increase the risk of fluorosis

The Cochrane Oral Health Group's Trials Register, Cochrane Central Register of Controlled Trials, Medline, Embase, BIOSIS, Dissertation Abstracts and LILACS/BBO databases were searched. Also, reference lists from relevant articles and five journals (Community Dentistry and Oral Epidemiology, Caries Research, Journal of Dental Research, British Dental Journal, Journal of Public Health Dentistry) were searched by hand, and experts in the field of preventive dentistry and oral epidemiology contacted. Studies [randomised controlled trials (RCT), quasi-RCT, cohort studies, case-control studies and cross-sectional surveys] were selected if they had included children under the age of 6 years when topical fluorides were administered, and in which fluoride toothpastes, mouthrinses, gels, foams, paint-on solutions and varnishes were compared with an alternative fluoride treatment, placebo or no intervention group. Data from all selected studies were extracted by two review authors. Risk ratios (RR) for controlled, prospective studies and odds ratios (OR) for case-control studies or cross-sectional surveys were extracted or calculated. Where both adjusted and unadjusted risk ratios or OR were presented, the adjusted value was included in the meta-analysis. From 3573 identified papers, 25 studies were included: two RCT, one cohort study, six case-control studies and 16 cross-sectional surveys. Only one RCT was judged to be at low risk of bias. The other RCT and all observational studies were judged to be at moderate to high risk of bias. Studies were included in four intervention/ exposure comparisons. A statistically significant reduction in fluorosis was found if brushing of a child's teeth with fluoride toothpaste commenced after the age of 12 months [OR, 0.70; random-effects 95% confidence interval (CI) for topical fluoride, 0.57-0.88; data from observational studies]. Inconsistent but statistically significant associations were found between occurrence of fluorosis and starting use of fluoride toothpaste/ toothbrushing before or after the age of 24 months (data from observational studies). From the RCT, use of higher concentrations of fluoride was associated with an increased risk of fluorosis. No significant association between the frequency of toothbrushing or the amount of fluoride toothpaste used and fluorosis was found. There should be a balanced consideration of the benefits of topical fluorides in caries prevention and the risk of the development of fluorosis. Most of the available evidence focuses on mild fluorosis. There is weak unreliable evidence that starting the use of fluoride toothpaste in children aged <12 months may be associated with an increased risk of fluorosis. The evidence if use begins between the age of 12 and 24 months is equivocal. If the risk of fluorosis is of concern, the fluoride level of toothpaste for young children (under 6 years of age) is recommended to be lower than 1000 parts per million (ppm). More evidence from studies with low risk of bias is needed. Future trials assessing the effectiveness of different types of topical fluorides (including toothpastes, gels, varnishes and mouthrinses) or different concentrations or both should ensure that they include an adequate followup period in order to collect data on potential fluorosis. As it is unethical to propose RCT to assess fluorosis itself, further observational studies will necessarily be undertaken in this area. Attention does, however, need to be given to the choice of study design, bearing in mind that prospective, controlled studies will be less susceptible to bias than retrospective and/ or uncontrolled studies.

Fluoride toothpaste prevents caries in children and adolescents at fluoride concentrations of 1000 ppm and above

The Cochrane Oral Health Group's Trials Register, Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE databases were searched. Previously published systematic reviews of fluoride toothpastes were also screened to identify any reports that met the inclusion criteria. In addition, the trials database at www.controlled-trials.com/ and the meta Register of Controlled Trials (www.controlledtrials.com) were searched to identify any ongoing studies of relevance. Randomised controlled trials (RCT) and cluster-RCT that compared fluoride toothpaste with placebo or fluoride toothpaste of a different concentration in children of up to 16 years of age, with a followup period of at least 1 year, were included. Inclusion of studies, data extraction and quality assessment were undertaken independently and in duplicate by two members of the review team. Disagreements were resolved by discussion and consensus or by a third party. The primary effect measure was the prevented fraction (PF, the caries increment of the control group minus the caries increment of the treatment group, expressed as a proportion of the caries increment in the control group). Where it was appropriate to pool data, network meta-analysis, network meta-regression or meta-analysis models were used. Potential sources of heterogeneity were specified a priori and examined through random-effects metaregression analysis where appropriate. From 535 studies found, 75 were included. From these, 71 studies (79 trials) contributed data to the network meta-analysis, network metaregression or meta-analysis. For the 66 studies (74 trials) that contributed to the network meta-analysis of decayed, missing or filled surfaces [D(M)FS] in the mixed or permanent dentition, the caries preventive effect of fluoride toothpaste increased significantly with higher fluoride concentrations, with a D(M)FS PF compared with placebo of 23% [95% credible interval (CrI), 19-27%] for 1000/ 1055/ 1100/ 1250 ppm concentrations, rising to 36% (95% CrI, 27-44%) for toothpastes with a concentration of 2400/ 2500/ 2800 ppm. Concentrations of 440/ 500/ 550 ppm and below showed no statistically significant effect when compared to placebo.There is some evidence of a dose-response relationship in that the PF increased as the fluoride concentration increased from the baseline although this was not always statistically significant. The effect of fluoride toothpaste also increased with baseline level of D(M)FS and supervised brushing, though this did not reach statistical significance. Six studies assessed the effects of fluoride concentrations on the deciduous dentition with equivocal results dependent upon the fluoride concentrations compared and the outcome measure. Compliance with treatment regimen and unwanted effects was assessed in only a minority of studies. When reported, no differential compliance was observed and unwanted effects such as soft tissue damage and tooth staining were minimal. This review confirms the benefits of using fluoride toothpaste in preventing caries in children and adolescents compared with placebo, but only statistically significantly at fluoride concentrations of 1000 ppm and above. The relative caries preventive effects of fluoride toothpastes of different concentrations increase with higher fluoride concentration. The decision of what fluoride levels to use for children aged under 6 years should be balanced with the risk of fluorosis.

The paradox of overlapping micronutrient risks and benefits obligates risk/benefit analysis

With risk analysis methods in the process of being deployed by European authorities for the purpose of limiting maximum dosages of vitamin and mineral supplements across the European Union (EU), scientific validation of recently emerging approaches using existing risk and benefit data is deemed essential. This review explores the function of existing European nutrient risk analysis methodologies applied to two vitamins, niacin and folate, and two minerals, selenium and fluoride. A major weakness of existing models is their exclusive focus on a single, most sensitive adverse effect on the most susceptible sub-population. Analysis of the four nutrients revealed, paradoxically, that dosages that induce risks in sensitive populations commonly overlap with those which induce benefits in the majority. This situation appears to be the norm, rather than the exception. Such overlaps are exacerbated when risk evaluations fail to consider differences between molecular forms of the same nutrient. A new conceptual risk/benefit model is proposed to replace the over-simplified two-tail risk model that has been widely accepted by regulatory authorities in Europe and the USA in recent years. This new model, which reveals pertinent zones of overlap between risks and benefits, demonstrates that statutory limitation of dosages at levels beneath existing tolerable upper levels would in many cases prevent the majority of the population from experiencing benefits from higher dosages. Accordingly, it is proposed that a critical zone of risk/benefit analysis is established for dosages in excess of the upper level to facilitate policy and risk management decision-making. Conventional risk assessment on fluoride as undertaken by European and US authorities is explored in detail, and it is shown that risk management, if applied by public authorities in a manner which is consistent with that used for other nutrients, would make public drinking water fluoridation programmes unfeasible in light of dental fluorosis risk to children. Possible explanations for the common overlap in dosages which induce both beneficial and adverse effects are given, both at a population and individual level. The review concludes by proposing that statutory restriction of vitamin and mineral food supplement dosages should be delayed in the EU until validated and more scientifically rational methodologies are developed. Where significant health benefits are known to result from habitual or short-term ingestion of dosages in excess of either upper levels or proposed statutory ‘maximum levels’, risk/benefit analysis should be undertaken to allow re-evaluation of risk management strategies.

Topical fluoride as a cause of dental fluorosis in children.

For many years, topical use of fluorides has gained greater popularity than systemic use of fluorides. A possible adverse effect associated with the use of topical fluoride is the development of dental fluorosis due to the ingestion of excessive fluoride by young children with developing teeth. To describe the relationship between the use of topical fluorides in young children and the risk of developing dental fluorosis. Electronic search of the Cochrane Oral Health Group Trials Register, CENTRAL, MEDLINE, EMBASE, BIOSIS, Dissertation Abstracts and LILACS/BBO. Reference lists from relevant articles were searched. Date of the most recent searches: 9th March 09. Randomised controlled trials (RCTs), quasi-RCTs, cohort studies, case-control studies and cross-sectional surveys, in which fluoride toothpastes, mouthrinses, gels, foams, paint-on solutions, and varnishes were compared to an alternative fluoride treatment, placebo or no intervention group. Children under the age of 6 years at the time topical fluorides were used. Data from all included studies were extracted by two review authors. Risk ratios for controlled, prospective studies and odds ratios for case-control studies or cross-sectional surveys were extracted or calculated. Where both adjusted and unadjusted risk ratios or odds ratios were presented, the adjusted value was included in the meta-analysis. 25 studies were included: 2 RCTs, 1 cohort study, 6 case-control studies and 16 cross-sectional surveys. Only one RCT was judged to be at low risk of bias. The other RCT and all observational studies were judged to be at moderate to high risk of bias. Studies were included in four intervention/exposure comparisons. A statistically significant reduction in fluorosis was found if brushing of a child's teeth with fluoride toothpaste commenced after the age of 12 months odds ratio 0.70 (random-effects: 95% confidence interval 0.57 to 0.88) (data from observational studies). Inconsistent statistically significant associations were found between starting using fluoride toothpaste/toothbrushing before or after the age of 24 months and fluorosis (data from observational studies). From the RCTs, use of higher level of fluoride was associated with an increased risk of fluorosis. No significant association between the frequency of toothbrushing or the amount of fluoride toothpaste used and fluorosis was found. There should be a balanced consideration between the benefits of topical fluorides in caries prevention and the risk of the development of fluorosis. Most of the available evidence focuses on mild fluorosis. There is weak unreliable evidence that starting the use of fluoride toothpaste in children under 12 months of age may be associated with an increased risk of fluorosis. The evidence for its use between the age of 12 and 24 months is equivocal. If the risk of fluorosis is of concern, the fluoride level of toothpaste for young children (under 6 years of age) is recommended to be lower than 1000 parts per million (ppm).More evidence with low risk of bias is needed. Future trials assessing the effectiveness of different types of topical fluorides (including toothpastes, gels, varnishes and mouthrinses) or different concentrations or both should ensure that they include an adequate follow-up period in order to collect data on potential fluorosis. As it is unethical to propose RCTs to assess fluorosis itself, it is acknowledged that further observational studies will be undertaken in this area. However, attention needs to be given to the choice of study design, bearing in mind that prospective, controlled studies will be less susceptible to bias than retrospective and/or uncontrolled studies.

Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents

Caries (dental decay) is a disease of the hard tissues of the teeth caused by an imbalance, over time, in the interactions between cariogenic bacteria in dental plaque and fermentable carbohydrates (mainly sugars). The use of fluoride toothpaste is the primary intervention for the prevention of caries. To determine the relative effectiveness of fluoride toothpastes of different concentrations in preventing dental caries in children and adolescents, and to examine the potentially modifying effects of baseline caries level and supervised toothbrushing. A search was undertaken on Cochrane Oral Health Group's Trials Register, CENTRAL, MEDLINE and several other databases. Reference lists of articles were also searched. Date of the most recent searches: 8 June 2009. Randomised controlled trials and cluster-randomised controlled trials comparing fluoride toothpaste with placebo or fluoride toothpaste of a different concentration in children up to 16 years of age with a follow-up period of at least 1 year. The primary outcome was caries increment in the permanent or deciduous dentition as measured by the change in decayed, (missing), filled tooth surfaces (D(M)FS/d(m)fs) from baseline. Inclusion of studies, data extraction and quality assessment were undertaken independently and in duplicate by two members of the review team. Disagreements were resolved by discussion and consensus or by a third party. The primary effect measure was the prevented fraction (PF), the caries increment of the control group minus the caries increment of the treatment group, expressed as a proportion of the caries increment in the control group. Where it was appropriate to pool data, network meta-analysis, network meta-regression or meta-analysis models were used. Potential sources of heterogeneity were specified a priori and examined through random-effects meta-regression analysis where appropriate. 75 studies were included, of which 71 studies comprising 79 trials contributed data to the network meta-analysis, network meta-regression or meta-analysis.For the 66 studies (74 trials) that contributed to the network meta-analysis of D(M)FS in the mixed or permanent dentition, the caries preventive effect of fluoride toothpaste increased significantly with higher fluoride concentrations (D(M)FS PF compared to placebo was 23% (95% credible interval (CrI) 19% to 27%) for 1000/1055/1100/1250 parts per million (ppm) concentrations rising to 36% (95% CrI 27% to 44%) for toothpastes with a concentration of 2400/2500/2800 ppm), but concentrations of 440/500/550 ppm and below showed no statistically significant effect when compared to placebo. There is some evidence of a dose response relationship in that the PF increased as the fluoride concentration increased from the baseline although this was not always statistically significant. The effect of fluoride toothpaste also increased with baseline level of D(M)FS and supervised brushing, though this did not reach statistical significance. Six studies assessed the effects of fluoride concentrations on the deciduous dentition with equivocal results dependent upon the fluoride concentrations compared and the outcome measure. Compliance with treatment regimen and unwanted effects was assessed in only a minority of studies. When reported, no differential compliance was observed and unwanted effects such as soft tissue damage and tooth staining were minimal. This review confirms the benefits of using fluoride toothpaste in preventing caries in children and adolescents when compared to placebo, but only significantly for fluoride concentrations of 1000 ppm and above. The relative caries preventive effects of fluoride toothpastes of different concentrations increase with higher fluoride concentration. The decision of what fluoride levels to use for children under 6 years should be balanced with the risk of fluorosis.

Fluoride content in bottled drinking waters, carbonated soft drinks and fruit juices in Davangere city, India

The regular ingestion of fluoride lowers the prevalence of dental caries. The total daily intake of fluoride for optimal dental health should be 0.05-0.07 mg fluoride/kg body weight and to avoid the risk of dental fluorosis, the daily intake should not exceed a daily level of 0.10 mg fluoride/kg body weight. The main source of fluoride is from drinking water and other beverages. As in other countries, consumption of bottled water, juices and carbonated beverages has increased in our country. To analyze the fluoride content in bottled water, juices and carbonated soft drinks that were commonly available in Davangere city. Three samples of 10 commercially available brands of bottled drinking water, 12 fruit juices and 12 carbonated soft drinks were purchased. Bottled water and carbonated soft drinks were stored at a cold place until fluoride analysis was performed and a clear juice was prepared using different fruits without the addition of water. Then, the fluoride analysis was performed. The mean and standard deviation of fluoride content of bottled water, fruit juices and carbonated soft drinks were measured, which were found to be 0.20 mg (±0.19) F/L, 0.29 mg (±0.06) F/L and 0.22 mg (±0.05) F/L, respectively. In viewing the results of the present study, it can be concluded that regulation of the optimal range of fluoride in bottled drinking water, carbonated soft drinks and fruit juices should be drawn for the Indian scenario.

Determination of fluoride in the bottled drinking waters in iran.

Fluoride is recognized as an effective agent for dental caries prevention. Generally, the main source of fluoride intake is drinking water. In this study, fluoride content in 18 commercial brands of bottled waters was investigated. Six samples from each batch of 18 Iranian commercial brands of bottled waters were supplied. The fluoride content of samples was analyzed by Fluoride Ion Selective Electrode. The mean ± SD fluoride content of the bottled waters was 0.202 ± 0.00152 mg/L with a range from 0.039 to 0.628 mg/L which was lower than the accepted limits for fluoride content of drinking water (1 mg/L). This finding suggested that in the region which water has high fluoride content, drinking bottled water is preferred to drinking tap water, as it could lower the risk of fluorosis. However, the risk of dental caries increases in people who mainly drink bottled waters; thus, they should use fluoride supplements.

Evidence that fluoride in the infant formula causes enamel fluorosis weak

Information was sourced from PubMed, the Cochrane Library, the Web of Science, Controlled Trials, Clinical Trials (a service of the US National Institutes of Health), ProQuest UMI (a dissertation and thesis database), National Institute for Health and Clinical Excellence, Virtual Health Library, Bireme-PAHO-WHO, and the Latin America and Caribbean Centre on Health Sciences Information, along with the reference lists of relevant reports and review articles. Authors were contacted for missing information. Studies conducted in humans were selected if they evaluated fluorosis and infant formula. Studies focussed exclusively on primary teeth were excluded. There were no restrictions on study designs. Two authors independently extracted data and assessed study quality. Disagreements were resolved by discussion. Summary odds ratios and confidence intervals were calculated using a random-effects model. Heterogeneity was quantified using the I(2) statistic and publications bias using a funnel plot and Egger test. Twenty-seven out of 41 studies evaluating the effect of infant formula on enamel fluorosis risk were included. These 27 papers reported the results of 19 observational studies (comprising one prospective cohort study, five retrospective cohort studies, six case-control studies, four cross-sectional studies and three historical-control studies). Seventeen of these 19 studies reported odds ratios (OR) and, among these, infant formula consumption was associated with a higher prevalence of enamel fluorosis in the permanent dentition [summary OR, 1.8; 95% confidence interval (CI), 1.4-2.3]. The studies showed significant heterogeneity (66%) and evidence of publication bias (P 0.002). Metaregression suggests that the OR associating infant formula with enamel fluorosis increased by 5% for each 0.1-ppm increase in the reported levels of fluoride in the water supply (OR, 1.05; 95% CI, 1.02-1.09). Infant formula consumption may be associated with an increased risk of developing at least some detectable level of enamel fluorosis, but this depends on the level of fluoride in the water supply. The evidence that the fluoride in the infant formula caused enamel fluorosis was weak, as other mechanisms could explain the observed association.

The association between osteocalcin gene polymorphism and dental fluorosis among children exposed to fluoride in People's Republic of China

Excessive fluoride intake has been shown to affect dentin and cementum mineralization throughout life. Some studies indicated that a HindIII polymorphism, of osteocalcin (OC) gene, was associated with bone metabolism-related diseases. Therefore, it is possible that the variation in OC genotypes will be associated with dental fluorosis (DF) status and/or serum caciotropic hormone level. A case-control study was conducted among children aged 8–12 years in Henan Province, PR China to investigate the association between dental fluorosis, serum calciotropic hormone level, and polymorphisms in the OC gene. HindIII polymorphism in OC gene was genotyped using the PCR-RFLP procedure. OC and calcitonin (CT) level in serum was detected using radioimmunoassay. No significant difference was observed for OC HindIII genotypes among the cases with dental fluorosis, the controls from endemic fluorosis area (EFA) and the controls from non-endemic fluorosis area (NEFA). A significant negative correlation was observed between serum calcium and OC level. No significant relationship was found between OC HindIII polymorphisms and the level of OC and CT. In conclusion, OC HindIII polymorphisms may not be a useful genetic marker for differential risk of dental fluorosis among children in PR China.

Suplementos fluorados pós-natais: recomendações de pediatras, entidades profissionais e instituições públicas de saúde

OBJETIVOS: identificar a opinião de pediatras e conhecer as recomendações de entidades profissionais e instituições públicas de saúde quanto à prescrição de suplementos fluorados. MÉTODOS: um questionário foi enviado a médicos pediatras. Informações adicionais sobre recomendações de suplementos fluorados foram obtidas junto a sete entidades profissionais e quatro instituições públicas de saúde. RESULTADOS: aproximadamente um em cada dez pediatras declarou prescrever algum suplemento contendo flúor. Risco de fluorose dentária, porque a água é fluoretada, foi a principal razão para afirmar que isso não deve ser feito. Quanto às entidades profissionais, duas deram respostas apropriadas. As respostas das demais não foram satisfatórias quanto ao uso racional de flúor. As respostas das instituições públicas foram apropriadas, embora o Ministério da Saúde não tenha se posicionado a respeito. CONCLUSÕES: um em cada 10 pediatras declarou prescrever suplementos contendo flúor para crianças residentes em São Paulo, cidade com água fluoretada. Em consequência, é necessário que o poder público e as entidades odontológicas assumam suas responsabilidades quanto ao uso dos suplementos fluorados.