Inside:
Continuing Medical Education for U.S. Physicians and Nurses
Recommendations for Using Fluoride
to Prevent and Control Dental Caries
in the United States
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention (CDC)
Atlanta, GA 30333
August 17, 2001 / Vol. 50 / No. RR-14
Recommendations
and
Reports
Inside:
Continuing Medical Education for U.S. Physicians and Nurses
Inside:
Continuing Medical Education for U.S. Physicians and Nurses
Inside:
Continuing Education Examination
Centers for Disease Control and Prevention .................. Jeffrey P. Koplan, M.D., M.P.H.
Director
The material in this report was prepared for publication by
National Center for Chronic Disease Prevention
and Health Promotion ................................................... James S. Marks, M.D., M.P.H.
Director
Division of Oral Health ............................................... William R. Maas, D.D.S., M.P.H.
Director
This report was produced as an
MMWR
serial publication in
Epidemiology Program Office ..................................... Stephen B. Thacker, M.D., M.Sc.
Director
Office of Scientific and Health Communications ........................ John W. Ward, M.D.
Director
Editor,
MMWR
Series
Recommendations and Reports ...................................
Suzanne M. Hewitt, M.P.A.
Managing Editor
....................................................................................................... Amanda Crowell
....................................................................................................... Elizabeth L. Hess
Project Editors
.......................................................................................................... Martha F. Boyd
Visual Information Specialist
................................................................................................. Michele D. Renshaw
Erica R. Shaver
Information Technology Specialists
The
MMWR
series of publications is published by the Epidemiology Program Office,
Centers for Disease Control and Prevention (CDC), U.S. Department of Health and
Human Services, Atlanta, GA 30333.
SUGGESTED CITATION
Centers for Disease Control and Prevention. Recommendations for using fluoride to
prevent and control dental caries in the United States. MMWR 2001;50(No. RR-14):[in-
clusive page numbers].
Vol. 50 / No. RR-14 MMWR i
Contents
Introduction ......................................................................................................... 1
How Fluoride Prevents and Controls Dental Caries .......................................... 3
Risk for Dental Caries ......................................................................................... 5
Risk for Enamel Fluorosis .................................................................................. 6
National Guidelines for Fluoride Use ................................................................ 7
Fluoride Sources and Their Effects .................................................................... 8
Fluoridated Drinking Water and Processed Beverages and Food ............... 9
Fluoride Toothpaste ..................................................................................... 13
Fluoride Mouthrinse .................................................................................... 15
Dietary Fluoride Supplements ..................................................................... 16
Professionally Applied Fluoride Compounds ............................................ 17
Combinations of Fluoride Modalities ......................................................... 19
Quality of Evidence for Dental Caries Prevention and Control ....................... 19
Community Water Fluoridation ................................................................... 20
School Water Fluoridation .......................................................................... 20
Fluoride Toothpaste ..................................................................................... 20
Fluoride Mouthrinse .................................................................................... 20
Dietary Fluoride Supplements ..................................................................... 21
Fluoride Gel .................................................................................................. 21
Fluoride Varnish ........................................................................................... 21
Cost-Effectiveness of Fluoride Modalities ....................................................... 21
Community Water Fluoridation ................................................................... 22
School Water Fluoridation .......................................................................... 23
Fluoride Toothpaste ..................................................................................... 23
Fluoride Mouthrinse .................................................................................... 23
Dietary Fluoride Supplements ..................................................................... 23
Professionally Applied Fluoride Componds .............................................. 23
Combinations of Fluoride Modalities ......................................................... 24
Recommendations ............................................................................................ 24
Public Health and Clinical Practices ........................................................... 26
Self-Care ....................................................................................................... 27
Consumer Product Industries and Health Agencies .................................. 28
Further Research .......................................................................................... 29
Conclusion ........................................................................................................ 30
References ......................................................................................................... 30
Continuing Education Examination ............................................................. CE-1
ii MMWR August 17, 2001
Vol. 50 / No. RR-14 MMWR iii
Fluoride Recommendations Work Group
Steven M. Adair, D.D.S., M.S.
School of Dentistry
Medical College of Georgia
Augusta, Georgia
William H. Bowen, Ph.D.
Caries Research Center
University of Rochester
Rochester, New York
Brian A. Burt, B.D.S., M.P.H., Ph.D.
School of Public Health
University of Michigan
Ann Arbor, Michigan
Jayanth V. Kumar, D.D.S., M.P.H.
New York Department of Health
Albany, New York
Steven M. Levy, D.D.S., M.P.H.
College of Dentistry
University of Iowa
Iowa City, Iowa
David G. Pendrys, D.D.S., Ph.D.
School of Dental Medicine
University of Connecticut
Farmington, Connecticut
R. Gary Rozier, D.D.S., M.P.H.
School of Public Health
University of North Carolina
Chapel Hill, North Carolina
Robert H. Selwitz, D.D.S., M.P.H.
National Institute of Dental and Craniofacial
Research
Bethesda, Maryland
John W. Stamm, D.D.S., D.D.P.H.
School of Dentistry
University of North Carolina
Chapel Hill, North Carolina
George K. Stookey, Ph.D., D.D.S.
School of Dentistry
Indiana University
Indianapolis, Indiana
Gary M. Whitford, Ph.D., D.M.D.
School of Dentistry
Medical College of Georgia
Augusta, Georgia
iv MMWR August 17, 2001
Fluoride Recommendations Reviewers
Myron Allukian, Jr., D.D.S., M.P.H.
Director of Oral Health
Boston Public Health Commission
Boston, Massachusetts
John P. Brown, B.D.S., Ph.D.
Department of Community Dentistry
University of Texas Health Science Center
San Antonio, Texas
Joseph A. Ciardi, Ph.D.
National Institute of Dental and Craniofacial
Research
Bethesda, Maryland
D. Christopher Clark, D.D.S., M.P.H.
Faculty of Dentistry
University of British Columbia
North Vancouver, Canada
Stephen B. Corbin, D.D.S., M.P.H.
Oral Health America
Brookeville, Maryland
Michael W. Easley, D.D.S., M.P.H.
School of Dental Medicine
State University of New York
Buffalo, New York
Caswell A. Evans, D.D.S., M.P.H.
County Dental Director
Los Angeles, California
Lawrence J. Furman, D.D.S., M.P.H.
National Institute of Dental and Craniofacial
Research
Bethesda, Maryland
Stanley B. Heifetz, D.D.S., M.P.H.
Department of Dental Medicine
and Public Health
School of Dentistry
University of Southern California
Los Angeles, California
Keith E. Heller, D.D.S., Dr.P.H.
School of Public Health
University of Michigan
Ann Arbor, Michigan
Amid I. Ismail, D.D.S., Dr.P.H.
School of Dentistry
University of Michigan
Ann Arbor, Michigan
David W. Johnston, B.D.S., M.P.H.
School of Dentistry
University of Western Ontario
London, Canada
John V. Kelsey, D.D.S., M.B.A.
US Food and Drug Administration
Rockville, Maryland
James A. Lalumandier, D.D.S., M.P.H.
School of Dentistry
Case Western Reserve University
Hudson, Ohio
Stephen J. Moss, D.D.S., M.S.
College of Dentistry
New York University
New York, New York
Ernest Newbrun, D.M.D., Ph.D.
School of Dentistry
University of California, San Francisco
San Francisco, California
Kathy R. Phipps, Dr.P.H.
School of Dentistry
Oregon Health Sciences University
Portland, Oregon
Mel L. Ringelberg, D.D.S., Dr.P.H.
State Dental Director
State of Florida Department of Health
Tallahassee, Florida
Jay D. Shulman, D.M.D., M.S.P.H.
Baylor College of Dentistry
Dallas, Texas
Phillip A. Swango, D.D.S., M.P.H.
Private dental consultant
Albuquerque, New Mexico
Gerald R. Vogel, Ph.D.
ADA Health Foundation Paffenbarger
Research Center
Gaithersburg, Maryland
James S. Wefel, Ph.D.
College of Dentistry
University of Iowa
Iowa City, Iowa
B. Alex White, D.D.S., Dr.P.H.
Kaiser-Permanente, Inc.
Portland, Oregon
Vol. 50 / No. RR-14 MMWR v
The following CDC staff members prepared this report:
William G. Kohn, D.D.S.
William R. Maas, D.D.S., M.P.H.
Dolores M. Malvitz, Dr. P.H.
Scott M. Presson, D.D.S., M.P.H.
Kerald K. Shaddix, D.D.S., M.P.H.
Division of Oral Health
National Center for Chronic Disease Prevention and Health Promotion
vi MMWR August 17, 2001
Vol. 50 / No. RR-14 MMWR 1
Recommendations for Using Fluoride to Prevent
and Control Dental Caries in the United States
Summary
Widespread use of fluoride has been a major factor in the decline in the
prevalence and severity of dental caries (i.e., tooth decay) in the United States and
other economically developed countries. When used appropriately, fluoride is
both safe and effective in preventing and controlling dental caries. All U.S.
residents are likely exposed to some degree to fluoride, which is available from
multiple sources. Both health-care professionals and the public have sought
guidance on selecting the best way to provide and receive fluoride. During the late
1990s, CDC convened a work group to develop recommendations for using
fluoride to prevent and control dental caries in the United States. This report
includes these recommendations, as well as a) critical analysis of the scientific
evidence regarding the efficacy and effectiveness of fluoride modalities in
preventing and controlling dental caries, b) ordinal grading of the quality of the
evidence, and c) assessment of the strength of each recommendation.
Because frequent exposure to small amounts of fluoride each day will best
reduce the risk for dental caries in all age groups, the work group recommends
that all persons drink water with an optimal fluoride concentration and brush their
teeth twice daily with fluoride toothpaste. For persons at high risk for dental
caries, additional fluoride measures might be needed. Measured use of fluoride
modalities is particularly appropriate during the time of anterior tooth enamel
development (i.e., age <6 years).
The recommendations in this report guide dental and other health-care
providers, public health officials, policy makers, and the public in the use of
fluoride to achieve maximum protection against dental caries while using
resources efficiently and reducing the likelihood of enamel fluorosis. The
recommendations address public health and professional practice, self-care,
consumer product industries and health agencies, and further research. Adoption
of these recommendations could further reduce dental caries in the United States
and save public and private resources.
INTRODUCTION
Dental caries (i.e., tooth decay) is an infectious, multifactorial disease afflicting most
persons in industrialized countries and some developing countries (
1
). Fluoride reduces
the incidence of dental caries and slows or reverses the progression of existing lesions
(i.e., prevents cavities). Although pit and fissure sealants, meticulous oral hygiene, and
appropriate dietary practices contribute to caries prevention and control, the most effec-
tive and widely used approaches have included fluoride use. Today, all U.S. residents are
exposed to fluoride to some degree, and widespread use of fluoride has been a major
factor in the decline in the prevalence and severity of dental caries in the United States
and other economically developed countries (
1
). Although this decline is a major public
2 MMWR August 17, 2001
health achievement, the burden of disease is still considerable in all age groups. Because
many fluoride modalities are effective, inexpensive, readily available, and can be used in
both private and public health settings, their use is likely to continue.
Fluoride is the ionic form of the element fluorine, the 13th most abundant element in
the earth’s crust. Fluoride is negatively charged and combines with positive ions (e.g.,
calcium or sodium) to form stable compounds (e.g., calcium fluoride or sodium fluoride).
Such fluorides are released into the environment naturally in both water and air. Fluoride
compounds also are produced by some industrial processes that use the mineral apatite,
a mixture of calcium phosphate compounds. In humans, fluoride is mainly associated
with calcified tissues (i.e., bones and teeth) because of its high affinity for calcium.
Fluoride’s ability to inhibit or even reverse the initiation and progression of dental
caries is well documented. The first use of adjusted fluoride in water for caries control
began in 1945 and 1946 in the United States and Canada, when the fluoride concentra-
tion was adjusted in the drinking water supplying four communities (
2–5
). The U.S. Public
Health Service (PHS) developed recommendations in the 1940s and 1950s regarding
fluoride concentrations in public water supplies. At that time, public health officials as-
sumed that drinking water would be the major source of fluoride for most U.S. residents.
The success of water fluoridation in preventing and controlling dental caries led to the
development of fluoride-containing products, including toothpaste (i.e., dentifrice),
mouthrinse, dietary supplements, and professionally applied or prescribed gel, foam, or
varnish. In addition, processed beverages, which constitute an increasing proportion of
the diets of many U.S. residents (
6,7
), and food can contain small amounts of fluoride,
especially if they are processed with fluoridated water. Thus, U.S. residents have more
sources of fluoride available now than 50 years ago.
Much of the research on the efficacy and effectiveness of individual fluoride modali-
ties in preventing and controlling dental caries was conducted before 1980, when dental
caries was more common and more severe. Modalities were usually tested separately
and with the assumption that the method would provide the main source of fluoride.
Thus, various modes of fluoride use have evolved, each with its own recommended
concentration, frequency of use, and dosage schedule. Health-care professionals and
the public have sought guidance regarding selection of preventive modalities from among
the available options. The United States does not have comprehensive recommenda-
tions for caries prevention and control through various combinations of fluoride modali-
ties. Adoption of such recommendations could further reduce dental caries while saving
public and private resources and reducing the prevalence of enamel fluorosis, a gener-
ally cosmetic developmental condition of tooth enamel.
This report presents comprehensive recommendations on the use of fluoride to pre-
vent and control dental caries in the United States. These recommendations were devel-
oped by a work group of 11 specialists in fluoride research or policy convened by CDC
during the late 1990s and reviewed by an additional 23 specialists. Although the recom-
mendations were developed specifically for the United States, aspects of this report
could be relevant to other countries. The recommendations guide health-care providers
and the public on efficient and appropriate use of fluoride modalities, direct attention to
fluoride intake among children aged <6 years to decrease the risk for enamel fluorosis,
and suggest areas for further research. This report focuses on critical analysis of the
scientific evidence regarding the efficacy and effectiveness of each fluoride modality in
preventing and controlling dental caries and on the use of multiple sources of fluoride.
Vol. 50 / No. RR-14 MMWR 3
The safety of fluoride, which has been documented comprehensively by other scientific
and public health organizations (e.g., PHS [
8
], National Research Council [
9
], World
Health Organization [
10
], and Institute of Medicine [
11
]) is not addressed.
HOW FLUORIDE PREVENTS AND CONTROLS DENTAL CARIES
Dental caries is an infectious, transmissible disease in which bacterial by-products
(i.e., acids) dissolve the hard surfaces of teeth. Unchecked, the bacteria can penetrate the
dissolved surface, attack the underlying dentin, and reach the soft pulp tissue. Dental
caries can result in loss of tooth structure, pain, and tooth loss and can progress to acute
systemic infection.
Cariogenic bacteria (i.e., bacteria that cause dental caries) reside in dental plaque, a
sticky organic matrix of bacteria, food debris, dead mucosal cells, and salivary compo-
nents that adheres to tooth enamel. Plaque also contains minerals, primarily calcium and
phosphorus, as well as proteins, polysaccharides, carbohydrates, and lipids. Cariogenic
bacteria colonize on tooth surfaces and produce polysaccharides that enhance adher-
ence of the plaque to enamel. Left undisturbed, plaque will grow and harbor increasing
numbers of cariogenic bacteria. An initial step in the formation of a carious lesion takes
place when cariogenic bacteria in dental plaque metabolize a substrate from the diet
(e.g., sugars and other fermentable carbohydrates) and the acid produced as a metabolic
by-product demineralizes (i.e., begins to dissolve) the adjacent enamel crystal surface
(Figure 1). Demineralization involves the loss of calcium, phosphate, and carbonate.
These minerals can be captured by surrounding plaque and be available for reuptake by
the enamel surface. Fluoride, when present in the mouth, is also retained and concen-
trated in plaque.
Fluoride works to control early dental caries in several ways. Fluoride concentrated
in plaque and saliva inhibits the demineralization of sound enamel and enhances the
remineralization (i.e., recovery) of demineralized enamel (
12,13
). As cariogenic bacteria
metabolize carbohydrates and produce acid, fluoride is released from dental plaque in
response to lowered pH at the tooth-plaque interface (
14
). The released fluoride and the
fluoride present in saliva are then taken up, along with calcium and phosphate, by de-
mineralized enamel to establish an improved enamel crystal structure. This improved
structure is more acid resistant and contains more fluoride and less carbonate (
12,15–
19
) (Figure 1). Fluoride is more readily taken up by demineralized enamel than by sound
enamel (
20
). Cycles of demineralization and remineralization continue throughout the
lifetime of the tooth.
Fluoride also inhibits dental caries by affecting the activity of cariogenic bacteria. As
fluoride concentrates in dental plaque, it inhibits the process by which cariogenic bacte-
ria metabolize carbohydrates to produce acid and affects bacterial production of adhe-
sive polysaccharides (
21
). In laboratory studies, when a low concentration of fluoride is
constantly present, one type of cariogenic bacteria,
Streptococcus mutans
, produces
less acid (
22–25
). Whether this reduced acid production reduces the cariogenicity of
these bacteria in humans is unclear (
26
).
Saliva is a major carrier of topical fluoride. The concentration of fluoride in ductal
saliva, as it is secreted from salivary glands, is low — approximately 0.016 parts per
million (ppm) in areas where drinking water is fluoridated and 0.006 ppm in nonfluoridated
areas (
27
). This concentration of fluoride is not likely to affect cariogenic activity. How-
ever, drinking fluoridated water, brushing with fluoride toothpaste, or using other fluoride
4 MMWR August 17, 2001
FIGURE 1. The demineralization and remineralization processes lead to remineralized
enamel crystals with surfaces rich in fluoride and lower in solubility
Source: Adapted from Featherstone JDB. Prevention and reversal of dental caries: role of low
level fluoride. Community Dent Oral Epidemiol 1999;27:31–40. Reprinted with permission
from Munksgaard International Publishers Ltd., Copenhagen, Denmark.
dental products can raise the concentration of fluoride in saliva present in the mouth 100-
to 1,000-fold. The concentration returns to previous levels within 1–2 hours but, during
this time, saliva serves as an important source of fluoride for concentration in plaque and
for tooth remineralization (
28
).
Applying fluoride gel or other products containing a high concentration of fluoride to
the teeth leaves a temporary layer of calcium fluoride-like material on the enamel sur-
face. The fluoride in this material is released when the pH drops in the mouth in response
to acid production and is available to remineralize enamel (
29
).
In the earliest days of fluoride research, investigators hypothesized that fluoride af-
fects enamel and inhibits dental caries only when incorporated into developing dental
enamel (i.e., preeruptively, before the tooth erupts into the mouth) (
30,31
). Evidence
supports this hypothesis (
32–34
), but distinguishing a true preeruptive effect after teeth
erupt into a mouth where topical fluoride exposure occurs regularly is difficult. However,
a high fluoride concentration in sound enamel cannot alone explain the marked reduction
in dental caries that fluoride produces (
35,36
). The prevalence of dental caries in a
population is not inversely related to the concentration of fluoride in enamel (
37
), and a
higher concentration of enamel fluoride is not necessarily more efficacious in preventing
dental caries (
38
).
The laboratory and epidemiologic research that has led to the better understanding
of how fluoride prevents dental caries indicates that fluoride’s predominant effect is
posteruptive and topical and that the effect depends on fluoride being in the right amount
in the right place at the right time. Fluoride works primarily after teeth have erupted,
especially when small amounts are maintained constantly in the mouth, specifically in
dental plaque and saliva (
37
). Thus, adults also benefit from fluoride, rather than only
children, as was previously assumed.
Vol. 50 / No. RR-14 MMWR 5
RISK FOR DENTAL CARIES
The prevalence and severity of dental caries in the United States have decreased
substantially during the preceding 3 decades (
39
). National surveys have reported that
the prevalence of any dental caries among children aged 12–17 years declined from
90.4% in 1971–1974 to 67% in 1988–1991; severity (measured as the mean number of
decayed, missing, or filled teeth) declined from 6.2 to 2.8 during this period (
40–43
).
These decreases in caries prevalence and severity have been uneven across the
general population; the burden of disease now is concentrated among certain groups
and persons. For example, 80% of the dental caries in permanent teeth of U.S. children
aged 5–17 years occurs among 25% of those children (
43
). To develop and apply appro-
priate and effective caries prevention and control strategies, identification and assess-
ment of groups and persons at high risk for developing new carious lesions is essential
(
44
). Caries risk assessment is difficult because it attempts to account for the complex
interaction of multiple factors. Although various methods for assessing risk exist, no
single model predominates in this emerging science. Models that take multiple factors
into account predict the risk more accurately, especially for groups rather than persons.
However, for persons in a clinical setting, models do not improve on a dentist’s percep-
tion of risk after examining a patient and considering the personal circumstances (
45
).
Populations believed to be at increased risk for dental caries are those with low
socioeconomic status (SES) or low levels of parental education, those who do not seek
regular dental care, and those without dental insurance or access to dental services (
45–
47
). Persons can be at high risk for dental caries even if they do not have these recog-
nized factors. Individual factors that possibly increase risk include active dental caries; a
history of high caries in older siblings or caregivers; root surfaces exposed by gingival
recession; high levels of infection with cariogenic bacteria; impaired ability to maintain
oral hygiene; malformed enamel or dentin; reduced salivary flow because of medica-
tions, radiation treatment, or disease; low salivary buffering capacity (i.e., decreased
ability of saliva to neutralize acids); and the wearing of space maintainers, orthodontic
appliances, or dental prostheses. Risk can increase if any of these factors are combined
with dietary practices conducive to dental caries (i.e., frequent consumption of refined
carbohydrates). Risk decreases with adequate exposure to fluoride (
44,45
).
Risk for dental caries and caries experience* exists on a continuum, with each person
at risk to some extent; 85% of U.S. adults have experienced tooth decay (
48
). Caries risk
can vary over time — perhaps numerous times during a person’s lifetime — as risk
factors change. Because caries prediction is an inexact, developing science, risk is di-
chotomized as low and high in this report. If these two categories of risk were applied to
the U.S. population, most persons would be classified as low risk at any given time.
Children and adults who are at low risk for dental caries can maintain that status
through frequent exposure to small amounts of fluoride (e.g., drinking fluoridated water
and using fluoride toothpaste). Children and adults at high risk for dental caries might
benefit from additional exposure to fluoride (e.g., mouthrinse, dietary supplements, and
professionally applied products). All available information on risk factors should be con-
sidered before a group or person is identified as being at low or high risk for dental caries.
However, when classification is uncertain, treating a person as high risk is prudent until
further information or experience allows a more accurate assessment. This assumption
*For this report, the term “caries experience” is used to mean the sum of filled and unfilled
cavities, along with any missing teeth resulting from tooth decay.
6 MMWR August 17, 2001
increases the immediate cost of caries prevention or treatment and might increase the
risk for enamel fluorosis for children aged <6 years, but reduces the risk for dental caries
for groups or persons misclassified as low risk.
RISK FOR ENAMEL FLUOROSIS
The proper amount of fluoride helps prevent and control dental caries. Fluoride in-
gested during tooth development can also result in a range of visually detectable changes
in enamel opacity (i.e., light refraction at or below the surface) because of
hypomineralization. These changes have been broadly termed enamel fluorosis, certain
extremes of which are cosmetically objectionable (
49
). (Many other developmental
changes that affect the appearance of enamel are not related to fluoride [
50
].) Severe
forms of this condition can occur only when young children ingest excess fluoride, from
any source, during critical periods of tooth development. The occurrence of enamel
fluorosis is reported to be most strongly associated with cumulative fluoride intake dur-
ing enamel development, but the severity of the condition depends on the dose, duration,
and timing of fluoride intake. The transition and early maturation stages of enamel devel-
opment appear to be most susceptible to the effects of fluoride (
51
); these stages occur
at varying times for different tooth types. For central incisors of the upper jaw, for ex-
ample, the most sensitive period is estimated at age 15–24 months for boys and age 21–
30 months for girls (
51,52
).
Concerns regarding the risk for enamel fluorosis are limited to children aged
<8
years; enamel is no longer susceptible once its preeruptive maturation is complete (
11
).
Fluoride sources for children aged
<8 years are drinking water, processed beverages
and food, toothpaste, dietary supplements that include fluoride (tablets or drops), and
other dental products. This report discusses the risk for enamel fluorosis among children
aged <6 years. Children aged
>6 years are considered past the age that fluoride inges-
tion can cause cosmetically objectionable fluorosis because only certain posterior teeth
are still at a susceptible stage of enamel development, and these will not be readily
visible. In addition, the swallowing reflex has developed sufficiently by age 6 years for
most children to be able to control inadvertent swallowing of fluoride toothpaste and
mouthrinse.
The very mild and mild forms of enamel fluorosis appear as chalklike, lacy markings
across a tooth’s enamel surface that are not readily apparent to the affected person or
casual observer (
53
). In the moderate form, >50% of the enamel surface is opaque
white. The rare, severe form manifests as pitted and brittle enamel. After eruption, teeth
with moderate or severe fluorosis might develop areas of brown stain (
54
). In the severe
form, the compromised enamel might break away, resulting in excessive wear of the
teeth. Even in its severe form, enamel fluorosis is considered a cosmetic effect, not an
adverse functional effect (
8,11,55,56
). Some persons choose to modify this condition
with elective cosmetic treatment.
The benefits of reduced dental caries and the risk for enamel fluorosis are linked.
Early studies that examined the cause of “mottled enamel” (now called moderate to
severe enamel fluorosis) led to the unexpected discovery that fluoride in community
drinking water inhibits dental caries (
57
). Historically, a low prevalence of the milder
forms of enamel fluorosis has been accepted as a reasonable and minor consequence
balanced against the substantial protection from dental caries from drinking water con-
Vol. 50 / No. RR-14 MMWR 7
taining an optimal concentration of fluoride, either naturally occurring or through adjust-
ment (
11,53
). When enamel fluorosis was first systematically investigated during the
1930s and 1940s, its prevalence was 12%–15% for very mild and mild forms and zero for
moderate and severe forms among children who lived in communities with drinking
water that naturally contained 0.9–1.2 ppm fluoride (
53
). Although the prevalence of this
condition in the United States has since increased (
8,58,59
), most fluorosis today is of the
mildest form, which affects neither cosmetic appearance nor dental function. The in-
creased prevalence in areas both with and without fluoridated community drinking wa-
ter (
8
) indicates that, during the first 8 years of life (i.e., the window of time when this
condition can develop), the total intake of fluoride from all sources has increased for
some children.
The 1986–1987 National Survey of Dental Caries in U.S. School Children (the most
recent national estimates of enamel fluorosis prevalence) indicated that the prevalence
of any enamel fluorosis among children was 22%–23% (range: 26% of children aged 9
years to 19% of those aged 17 years) (
60,61
). Almost all cases reported in the survey
were of the very mild or mild form, but some cases of the moderate (1.1%) and severe
(0.3%) forms were observed. Cases of moderate and severe forms occurred even among
children living in areas with low fluoride concentrations in the drinking water (
61
). Al-
though this level of enamel fluorosis is not considered a public health problem (
53
),
prudent public health practice should seek to minimize this condition, especially moder-
ate to severe forms. In addition, changes in public perceptions of what is cosmetically
acceptable could influence support for effective caries-prevention measures. Research
into the causes of enamel fluorosis has focused on identifying risk factors (
62–65
). Ad-
herence to the recommendations in this report regarding appropriate use of fluoride for
children aged
<6 years will reduce the prevalence and severity of enamel fluorosis.
NATIONAL GUIDELINES FOR FLUORIDE USE
PHS recommendations for fluoride use include an optimally adjusted concentration
of fluoride in community drinking water to maximize caries prevention and limit enamel
fluorosis. This concentration ranges from 0.7 ppm to 1.2 ppm depending on the average
maximum daily air temperature of the area (
66–68
). In 1991, PHS also issued policy and
research recommendations for fluoride use (
8
). The U.S. Environmental Protection
Agency (EPA), which is responsible for the safety and quality of drinking water in the
United States, sets a maximum allowable limit for fluoride in community drinking water
at 4 ppm and a secondary limit (i.e., nonenforceable guideline) at 2 ppm (
69,70
). The U.S.
Food and Drug Administration (FDA) is responsible for approving prescription and over-
the-counter fluoride products marketed in the United States and for setting standards for
labeling bottled water (
71
) and over-the-counter fluoride products (e.g., toothpaste and
mouthrinse) (
72
).
Nonfederal agencies also have published guidelines on fluoride use. The American
Dental Association (ADA) reviews fluoride products for caries prevention through its
voluntary Seal of Acceptance program; accepted products are listed in the
ADA Guide to
Dental Therapeutics
(
73
). A dosage schedule for fluoride supplements for infants and
children aged
<16 years, which is scaled to the fluoride concentration in the community
drinking water, has been jointly recommended by ADA, the American Academy of Pedi-
atric Dentistry (AAPD), and the American Academy of Pediatrics (AAP) (Table 1)
(
44,74,75
). In 1997, the Institute of Medicine published age-specific recommendations
8 MMWR August 17, 2001
for total dietary intake of fluoride (Table 2). These recommendations list adequate intake
to prevent dental caries and tolerable upper intake, defined as a level unlikely to pose risk
for adverse effects in almost all persons.
TABLE 1. Recommended dietary fluoride supplement* schedule
Fluoride concentration in community drinking water
†
Age <0.3 ppm 0.3–0.6 ppm >0.6 ppm
0–6 months None None None
6 months–3 years 0.25 mg/day None None
3–6 years 0.50 mg/day 0.25 mg/day None
6–16 years 1.0 mg/day 0.50 mg/day None
* Sodium fluoride (2.2 mg sodium fluoride contains 1 mg fluoride ion).
†
1.0 parts per million (ppm) = 1 mg/L.
Sources:
Meskin LH, ed. Caries diagnosis and risk assessment: a review of preventive strategies and
management. J Am Dent Assoc 1995;126(suppl):1S–24S.
American Academy of Pediatric Dentistry. Special issue: reference manual 1994–95. Pediatr
Dent 1995;16(special issue):1–96.
American Academy of Pediatrics Committee on Nutrition. Fluoride supplementation for
children: interim policy recommendations. Pediatrics 1995;95:777.
TABLE 2. Recommended total dietary fluoride intake
Age Reference weight* Adequate intake
†
Tolerable upper intake
§
kg lb mg/day mg/day
0–6 months 7 16 0.01 0.7
6–12 months 9 20 0.5 0.9
1–3 years 13 29 0.7 1.3
4–8 years 22 48 1.1 2.2
>9 years 40–76 88–166 2.0–3.8 10.0
* Values based on data collected during 1988–1994 as part of the third National Health and
Nutrition Examination Survey.
†
Intake that maximally reduces occurrence of dental caries without causing unwanted side
effects, including moderate enamel fluorosis.
§
Highest level of nutrient intake that is likely to pose no risks for adverse health effects in
almost all persons.
Source: Adapted from Institute of Medicine. Fluoride. In: Dietary reference intakes for calcium,
phosphorus, magnesium, vitamin D, and fluoride. Washington, DC: National Academy Press,
1997:288–313.
FLUORIDE SOURCES AND THEIR EFFECTS
Fluoridated community drinking water and fluoride toothpaste are the most common
sources of fluoride in the United States and are largely responsible for the low risk for
dental caries for most persons in this country. Persons at high risk for dental caries might
require more frequent or more concentrated exposure to fluoride and might benefit from
use of other fluoride modalities (e.g., mouthrinse, dietary supplements, and topical gel,
foam, or varnish). The effects of each of these fluoride sources on dental caries and
enamel fluorosis are described.
Vol. 50 / No. RR-14 MMWR 9
Fluoridated Drinking Water and Processed Beverages
and Food
Fluoridated drinking water contains a fluoride concentration effective for preventing
dental caries; this concentration can occur naturally or be reached through water fluori-
dation, which is the controlled addition of fluoride to a public water supply. When fluori-
dated water is the main source of drinking water, a low concentration of fluoride is
routinely introduced into the mouth. Some of this fluoride is taken up by dental plaque;
some is transiently present in saliva, which serves as a reservoir for plaque fluoride; and
some is loosely held on the enamel surfaces (
76
). Frequent consumption of fluoridated
drinking water and beverages and food processed in fluoridated areas maintains the
concentration of fluoride in the mouth.
Estimates of fluoride intake among U.S. and Canadian adults have ranged from
<1.0
mg fluoride per day in nonfluoridated areas to 1–3 mg fluoride per day in fluoridated
areas (
77–80
). The average daily dietary fluoride intake for both children and adults in
fluoridated areas has remained relatively constant for several years (
11
). For children
who live in optimally fluoridated areas, this average is approximately 0.05 mg/kg/day
(range: 0.02–0.10); for children who live in nonfluoridated areas, the average is approxi-
mately half (
11
). In a survey of four U.S. cities with different fluoride concentrations in the
drinking water (range: 0.37–1.04 ppm), children aged 2 years ingested 0.41–0.61 mg
fluoride per day and infants aged 6 months ingested 0.21–0.54 mg fluoride per day
(
81,82
).
In the United States, water and processed beverages (e.g., soft drinks and fruit juices)
can provide approximately 75% of a person’s fluoride intake (
83
). Many processed
beverages are prepared in locations where the drinking water is fluoridated. Foods and
ingredients used in food processing vary in their fluoride content (
11
). As consumption of
processed beverages by children increases, fluoride intake in communities without fluo-
ridated water will increase whenever the water source for the processed beverage is
fluoridated (
84
). In fluoridated areas, dietary fluoride intake has been stable because
processed beverages have been substituted for tap water and for beverages prepared
in the home using tap water (
11
).
A study of Iowa infants estimated that the mean fluoride intake from water during
different periods during the first 9 months of life, either consumed directly or added to
infant formula or juice, was 0.29–0.38 mg per day, although estimated intake for some
infants was as high as 1.73 mg per day (
85
). As foods are added to an infant’s diet,
replacing some of the formula prepared with fluoridated water, the amount of fluoride
the infant receives typically decreases (
86
). The Iowa study also reported that infant
formula and processed baby food contained variable amounts of fluoride. Since 1979,
U.S. manufacturers of infant formula have voluntarily lowered the fluoride concentration
of their products, both ready-to-feed and concentrates, to <0.3 ppm fluoride (
87
).
Drinking Water
Community Water. During the 1940s, researchers determined that 1 ppm fluoride
was the optimal concentration in community drinking water for climates similar to the
Chicago area (
88,89
). This concentration would substantially reduce the prevalence of
dental caries, while allowing an acceptably low prevalence (i.e., 10%–12%) of very mild
and mild enamel fluorosis and no moderate or severe enamel fluorosis. Water fluorida-
tion for caries control began in 1945 and 1946, when the fluoride concentration was
10 MMWR August 17, 2001
FIGURE 2. Percentage of state populations with access to fluoridated water through
public water systems
Source: CDC, unpublished data, 2000.
adjusted in the drinking water supplying four communities in the United States and
Canada (
2–5
). This public health approach followed a long period of epidemiologic re-
search into the effects of naturally occurring fluoride in drinking water (
53,57,88,89
).
Current federal fluoridation guidelines, maintained by the PHS since 1962, state that
community drinking water should contain 0.7–1.2 ppm fluoride, depending on the aver-
age maximum daily air temperature of the area. These temperature-related guidelines
are based on epidemiologic studies conducted during the 1950s that led to the develop-
ment of an algebraic formula for determining optimal fluoride concentrations (
67,90–
92
). This formula determined that a lower fluoride concentration was appropriate for
communities in warmer climates because persons living in warmer climates drank more
tap water. However, social and environmental changes since 1962 (e.g., increased use of
air conditioning and more sedentary lifestyles) have reduced the likelihood that persons
in warmer regions drink more tap water than persons in cooler regions (
7
).
By 1992, fluoridated water was reaching 144 million persons in the United States
(56% of the total population and 62% of those receiving municipal water supplies) (
93
).
Approximately 10 million of these persons were receiving water containing naturally
occurring fluoride at a concentration of
>0.7 ppm. In 11 states and the District of Colum-
bia, >90% of the population had such access, whereas <5% received this benefit in two
states. In 2000, a total of 38 states and the District of Columbia provided access to
fluoridated public water supplies to
>50% of their population (CDC, unpublished data,
2000) (Figure 2).
Vol. 50 / No. RR-14 MMWR 11
Initial studies of community water fluoridation demonstrated that reductions in child-
hood dental caries attributable to fluoridation were approximately 50%–60% (
94–97
).
More recent estimates are lower — 18%–40% (
98,99
). This decrease in attributable
benefit is likely caused by the increasing use of fluoride from other sources, with the
widespread use of fluoride toothpaste probably the most important. The diffusion or
“halo” effect of beverages and food processed in fluoridated areas but consumed in
nonfluoridated areas also indirectly spreads some benefit of fluoridated water to
nonfluoridated communities. This effect lessens the differences in caries experience
among communities (
100
).
Quantifying the benefits of water fluoridation among adults is more complicated be-
cause adults are rarely surveyed, their fluoride histories are potentially more varied, and
their tooth loss or restorations might be caused by dental problems other than caries
(e.g., trauma or periodontal diseases). Nevertheless, adults are reported to receive
caries-preventive benefits from community water fluoridation (
99,101–103
). These ben-
efits might be particularly advantageous for adults aged >50 years, many of whom are at
increased risk for dental caries. Besides coronal caries, older adults typically experience
gingival recession, which results in teeth with exposed root surfaces. Unlike the crowns
of teeth, these root surfaces are not covered by enamel and are more susceptible to
caries. Because tooth retention among older age groups has increased in recent decades
in the United States (
39
), these groups’ risk for caries will increase as the country’s
population ages. Older adults also frequently require multiple medications for chronic
conditions, and many of these medications can reduce salivary output (
104
). Drinking
water containing an optimal concentration of fluoride can mitigate the risk factors for
caries among older adults. Studies have reported that the prevalence of root caries
among adults is inversely related to fluoride concentration in the community drinking
water (
105–107
).
Water fluoridation also reduces the disparities in caries experience among poor and
nonpoor children (
108–111
). Caries experience is considerably higher among persons in
low SES strata than among those in high SES strata (
39,46,112
). The reasons for this
discrepancy are not well understood; perhaps persons in low SES strata have less knowl-
edge of oral diseases, have less access to dental care, are less likely to follow recom-
mended self-care practices, or are harder to reach through traditional approaches,
including public health programs and private dental care (
48
). Thus, these persons might
receive more benefit from fluoridated community water than persons from high SES
strata. Regardless of SES, water fluoridation is the most effective and efficient strategy
to reduce dental caries (
112
).
Enamel fluorosis occurs among some persons in all communities, even in communi-
ties with a low natural concentration of fluoride. During 1930–1960, U.S. studies docu-
mented that, in areas with a natural or adjusted concentration of fluoride of approximately
1.0 ppm in the community drinking water, the permanent teeth of 7%–16% of children
with lifetime residence in those areas exhibited very mild or mild forms of enamel fluoro-
sis (
53,113,114
). Before 1945, when naturally fluoridated drinking water was virtually
the only source of fluoride, the moderate and severe forms of this condition were not
observed unless the natural fluoride concentration was
>2 ppm (
53
). The likelihood of a
child developing the mild forms of enamel fluorosis might be higher in a fluoridated area
than in a nonfluoridated area, but prevalence might not change in every community
(
115,116
). The most recent national study of this condition indicated that its prevalence
had increased in both fluoridated and nonfluoridated areas since the 1940s, with the
12 MMWR August 17, 2001
relative increase higher in nonfluoridated areas. In communities with drinking water
containing 0.7–1.2 ppm fluoride, the prevalence was 1.3% for the moderate form of
enamel fluorosis and zero for the severe form; thus, few cases of enamel fluorosis were
likely to be of cosmetic consequence (
8,61
). Because combined fluoride intake from
drinking water and processed beverages and food by children in fluoridated areas has
reportedly remained stable since the 1940s, the increase in fluoride intake resulting in
increased enamel fluorosis almost certainly stems from use of fluoride-containing dental
products by children aged <6 years (
11
).
Two studies reported that extended consumption of infant formula beyond age 10–12
months was a risk factor for enamel fluorosis, especially when formula concentrate was
mixed with fluoridated water (
62,63
). These studies examined children who used pre-
1979 formula (with higher fluoride concentrations). Whether fluoride intake from for-
mula that exceeds the recommended amount during only the first 10–12 months of life
contributes to the prevalence or severity of enamel fluorosis is unknown.
Fluoride concentrations in drinking water should be maintained at optimal levels,
both to achieve effective caries prevention and because changes in fluoride concentra-
tion as low as 0.2 ppm can result in a measurable change in the prevalence and severity
of enamel fluorosis (
52,117
). Since the late 1970s, CDC has provided guidelines and
recommendations for managers of fluoridated water supply systems at state and local
levels to help them establish and maintain appropriate fluoride concentrations. CDC
periodically updates these guidelines; the most recent revision was published in 1995
(
68
).
School Water Systems. In some areas of the United States where fluoridating a
community’s drinking water was not feasible (e.g., rural areas), the alternative of fluori-
dating a school’s public water supply system was promoted for many years. This method
was used when a school had its own source of water and was not connected to a commu-
nity water supply system (i.e., stand-alone systems). Because children are at school only
part of each weekday, a fluoride concentration of 4.5 times the optimal concentration for
a community in the same geographic area was recommended (
118
) to compensate for
the more limited consumption of fluoridated water. At the peak of this practice in the
early 1980s, a total of 13 states had initiated school water fluoridation in 470 schools
serving 170,000 children (
39
). Since then, school water fluoridation has been phased out
in several states; the current extent of this practice is not known.
Studies of the effects of school water fluoridation in the United States reported that
this practice reduced caries among schoolchildren by approximately 40% (
118–122
). A
more recent study indicated that this effect might no longer be as pronounced (
123
).
Several concerns regarding school water fluoridation exist. Operating and maintain-
ing small fluoridation systems (i.e., those serving <500 persons) create practical and
logistical difficulties (
68
). These difficulties have occasionally caused higher than recom-
mended fluoride concentrations in the school drinking water, but no lasting effects among
children have been observed (
124–126
). In schools that enroll preschoolers in day care
programs, children aged <6 years might receive more than adequate fluoride.
Bottled Water. Many persons drink bottled water, replacing tap water partially or
completely as a source of drinking water. Water is classified as “bottled water” if it meets
all applicable federal and state standards, is sealed in a sanitary container, and is sold for
human consumption. Although some bottled waters marketed in the United States con-
tain an optimal concentration of fluoride (approximately 1.0 ppm), most contain <0.3 ppm
fluoride (
127–129
). Thus, a person substituting bottled water with a low fluoride concen-
Vol. 50 / No. RR-14 MMWR 13
tration for fluoridated community water might not receive the full benefits of community
water fluoridation (
130
). For water bottled in the United States, current FDA regulations
require that fluoride be listed on the label only if the bottler adds fluoride during process-
ing; the concentration of fluoride is regulated but does not have to be stated on the label
(Table 3). Few bottled water brands have labels listing the fluoride concentration.
TABLE 3. U.S. Food and Drug Administration (FDA) fluoride requirements for bottled water
packaged in the United States
Maximum fluoride concentration (mg/L)
allowed in bottled water
Annual average of maximum daily air No fluoride added Fluoride added to
temperature (F) where the bottled water to bottled water bottled water
is sold at retail
<53.7 2.4 1.7
53.8–58.3 2.2 1.5
58.4–63.8 2 1.3
63.9–70.6 1.8 1.2
70.7–79.2 1.6 1
79.3–90.5 1.4 0.8
Note: FDA regulations require that fluoride be listed on the label only if the bottler adds
fluoride during processing; the bottler is not required to list the fluoride concentration,
which might or might not be optimal. FDA does not allow imported bottled water with no
added fluoride to contain >1.4 mg fluoride/L or imported bottled water with added fluoride to
contain >0.8 mg fluoride/L.
Source: US Department of Health and Human Services, Food and Drug Administration. 21
CFR Part 165.110. Bottled water. Federal Register 1995;60:57124–30.
Determining Fluoride Concentration. Uneven geographic coverage of community
water fluoridation throughout the United States, wide variations in natural fluoride con-
centrations found in drinking water, and almost nonexistent labeling of fluoride concen-
tration in bottled water make knowing the concentration of fluoride in drinking water
difficult for many persons. Persons in nonfluoridated areas can mistakenly believe their
water contains an optimal concentration of fluoride. To obtain the fluoride concentration
of community drinking water, a resident can contact the water supplier or a local public
health authority, dentist, dental hygienist, physician, or other knowledgeable source. EPA
requires that all community water supply systems provide each customer an annual
report on the quality of water, including the fluoride concentration (
131
). Testing for
private wells is available through local and state public health departments as well as
some private laboratories. If the fluoride concentration is not listed on the label of bottled
water, the bottler can be contacted directly to obtain this information.
Fluoride Toothpaste
Fluoride is the only nonprescription toothpaste additive proven to prevent dental
caries. When introduced into the mouth, fluoride in toothpaste is taken up directly by
dental plaque (
132–134
) and demineralized enamel (
135,136
). Brushing with fluoride
toothpaste also increases the fluoride concentration in saliva 100- to 1,000-fold; this
concentration returns to baseline levels within 1–2 hours (
137
). Some of this salivary
fluoride is taken up by dental plaque. The ambient fluoride concentration in saliva and
plaque can increase during regular use of fluoride toothpaste
(132,133
).
14 MMWR August 17, 2001
By the 1990s, fluoride toothpaste accounted for >90% of the toothpaste market in the
United States, Canada, and other developed countries (
138
). Because water fluoridation
is not available in many countries, toothpaste might be the most important source of
fluoride globally (
1
).
Studies of 2–3 years duration have reported that fluoride toothpaste reduces caries
experience among children by a median of 15%–30% (
139–148
). This reduction is mod-
est compared with the effect of water fluoridation, but water fluoridation studies usually
measured lifetime — rather than a few years’ — exposure. Regular lifetime use of fluo-
ride toothpaste likely provides ongoing benefits that might approach those of fluoridated
water. Combined use of fluoride toothpaste and fluoridated water offers protection above
either used alone (
99,149,150
).
Few studies evaluating the effectiveness of fluoride toothpaste, gel, rinse, and var-
nish among adult populations are available. Child populations have typically been used
for studies on caries prevention because of perceived increased caries susceptibility and
logistical reasons. However, teeth generally remain susceptible to caries throughout life,
and topically applied fluorides could be effective in preventing caries in susceptible pa-
tients of any age
(151,152
).
Most persons report brushing their teeth at least once per day (
153,154
), but more
frequent use can offer additional protection (
139,141,155–158
). Brushing twice a day is
a reasonable social norm that is both effective and convenient for most persons’ daily
routines, and this practice has become a basic recommendation for caries prevention.
Whether increasing the number of daily brushings from two to three times a day results
in lower dental caries experience is unclear. Because the amount and vigor of rinsing
after toothbrushing affects fluoride concentration in the mouth and reportedly affects
caries experience (
157–160
), persons aged >6 years can retain more fluoride in the
mouth by either rinsing briefly with a small amount of water or not at all.
In the United States, the standard concentration of fluoride in fluoride toothpaste is
1,000–1,100 ppm. Toothpaste containing 1,500 ppm fluoride has been reported to be
slightly more efficacious in reducing dental caries in U.S. and European studies (
161–
164
). Products with this fluoride concentration have been marketed in the United States,
but are not available in all areas. These products might benefit persons aged
>6 years at
high risk for dental caries.
Children who begin using fluoride toothpaste at age <2 years are at higher risk for
enamel fluorosis than children who begin later or who do not use fluoride toothpaste at
all (
62,63,165–170
). Because studies have not used the same criteria for age of initiation,
amount of toothpaste used, or frequency of toothpaste use, the specific contribution of
each factor to enamel fluorosis among this age group has not been established.
Fluoride toothpaste contributes to the risk for enamel fluorosis because the swallow-
ing reflex of children aged <6 years is not always well controlled, particularly among
children aged <3 years (
171,172
). Children are also known to swallow toothpaste delib-
erately when they like its taste. A child-sized toothbrush covered with a full strip of
toothpaste holds approximately 0.75–1.0 g of toothpaste, and each gram of fluoride
toothpaste, as formulated in the United States, contains approximately 1.0 mg of fluo-
ride. Children aged <6 years swallow a mean of 0.3 g of toothpaste per brushing (
11
) and
can inadvertently swallow as much as 0.8 g (
138,173–176
). As a result, multiple brushings
with fluoride toothpaste each day can result in ingestion of excess fluoride (
177
). For this
reason, high-fluoride toothpaste (i.e., containing 1,500 ppm fluoride) is generally con-
traindicated for children aged <6 years.
Vol. 50 / No. RR-14 MMWR 15
Use of a pea-sized amount (approximately 0.25 g) of fluoride toothpaste <2 times per
day by children aged <6 years is reported to sharply reduce the importance of fluoride
toothpaste as a risk factor for enamel fluorosis (
65
). Since 1991, manufacturers of fluo-
ride toothpaste marketed in the United States have, as a requirement for obtaining the
ADA Seal of Acceptance, placed instructions on the package label stating that children
aged <6 years should use only this amount of toothpaste. Toothpaste labeling require-
ments mandated by FDA in 1996 (
72
) also direct parents of children aged <2 years to
seek advice from a dentist or physician before introducing their child to fluoride tooth-
paste.
The propensity of young children to swallow toothpaste has led to development of
“child-strength” toothpaste with lower fluoride concentrations (
176
). Such a product
would be a desirable alternative to currently available products for many young children.
Clinical trials outside the United States have reported that toothpaste containing 250
ppm fluoride is less effective than toothpaste containing 1,000 ppm fluoride in preventing
dental caries (
178,179
). However, toothpaste containing 500–550 ppm fluoride might be
almost as efficacious as that containing 1,000 ppm fluoride (
180
). A British study re-
ported that the prevalence of diffuse enamel opacities (an indicator of mild enamel
fluorosis) in the upper anterior incisors was substantially lower among children who
used toothpaste containing 550 ppm fluoride than among those who used toothpaste
containing 1,050 ppm fluoride (
181
). Toothpaste containing 400 ppm fluoride has been
available in Australia and New Zealand for approximately 20 years, but has not been
tested in clinical trials, and no data are available to assess whether toothpaste at this
concentration has reduced the prevalence of enamel fluorosis in those countries. A U.S.
clinical trial of the efficacy of toothpaste with lower fluoride concentrations, required by
FDA before approval for marketing and distribution, has not been conducted (
182
).
Fluoride Mouthrinse
Fluoride mouthrinse is a concentrated solution intended for daily or weekly use. The
fluoride from mouthrinse, like that from toothpaste, is retained in dental plaque and
saliva to help prevent dental caries (
183
). The most common fluoride compound used in
mouthrinse is sodium fluoride. Over-the-counter solutions of 0.05% sodium fluoride (230
ppm fluoride) for daily rinsing are available for use by persons aged >6 years. Solutions
of 0.20% sodium fluoride (920 ppm fluoride) are used in supervised, school-based weekly
rinsing programs. Throughout the 1980s, approximately 3 million children in the United
States participated in school-based fluoride mouthrinsing programs (
39
). The current
extent of such programs is not known.
Studies indicating that fluoride mouthrinse reduces caries experience among school-
children date mostly from the 1970s and early 1980s (
184–191
). In one review, the
average caries reduction in nonfluoridated communities attributable to fluoride
mouthrinse was 31% (
191
). Two studies reported benefits of fluoride mouthrinse ap-
proximately 2.5 and 7 years after completion of school-based mouthrinsing programs
(
192,193
), but a more recent study did not find such benefits 4 years after completion of
a mouthrinsing program (
194
). The National Preventive Dentistry Demonstration Pro-
gram (NPDDP), a large project conducted in 10 U.S. cities during 1976–1981 to compare
the cost and effectiveness of combinations of caries-prevention procedures, reported
that fluoride mouthrinse had little effect among schoolchildren, either among first-grade
students with high and low caries experience (
195
) or among all second- and fifth-grade
16 MMWR August 17, 2001
students (
196
). NPDDP documented only a limited reduction in dental caries attributable
to fluoride mouthrinse, especially when children were also exposed to fluoridated water.
Although no studies of enamel fluorosis associated with use of fluoride mouthrinse
have been conducted, studies of the amount of fluoride swallowed by children aged 3–5
years using such rinses indicated that some young children might swallow substantial
amounts (
191
). Use of fluoride mouthrinse by children aged >6 years does not place
them at risk for cosmetically objectionable enamel fluorosis because they are generally
past the age that fluoride ingestion might affect their teeth.
Dietary Fluoride Supplements
Dietary fluoride supplements in the form of tablets, lozenges, or liquids (including
fluoride-vitamin preparations) have been used throughout the world since the 1940s.
Most supplements contain sodium fluoride as the active ingredient. Tablets and lozenges
are manufactured with 1.0, 0.5, or 0.25 mg fluoride. To maximize the topical effect of
fluoride, tablets and lozenges are intended to be chewed or sucked for 1–2 minutes
before being swallowed. For infants, supplements are available as a liquid and used with
a dropper.
In 1986, an estimated 16% of U.S. children aged <2 years used fluoride supplements
(
197
). All fluoride supplements must be prescribed by a dentist or physician. The pre-
scription should be consistent with the 1994 dosage schedule developed by ADA, AAPD,
and AAP (Table 1). Because fluoride supplements are intended to compensate for
fluoride-deficient drinking water, the dosage schedule requires knowledge of the fluoride
content of the child’s primary drinking water; consideration should also be given to other
sources of water (e.g., home, child care settings, school, or bottled water) and to other
sources of fluoride (e.g., toothpaste or mouthrinse), which can complicate the prescribing
decision.
The evidence for using fluoride supplements to mitigate dental caries is mixed. Use of
fluoride supplements by pregnant women does not benefit their offspring (
198
). Several
studies have reported that fluoride supplements taken by infants and children before
their teeth erupt reduce the prevalence and severity of caries in teeth (
98,199–207
), but
several other studies have not (
19,208–212
). Among children aged 6–16 years, fluoride
supplements taken after teeth erupt reduce caries experience (
213–215
). Fluoride supple-
ments might be beneficial among adults who have limitations with toothbrushing, but this
use requires further study.
A few studies have reported no association between supplement use by children
aged <6 years and enamel fluorosis (
208,216
), but most have reported a clear associa-
tion (
19,62,64,165,170,199–201,209,210,212,217–222
). In one study, the risk for this con-
dition was high when supplements were used in fluoridated areas (odds ratio = 23.74;
95% confidence interval = 3.43–164.30) (
62
), a use inconsistent with the supplement
schedule. Reports of the frequency of supplement use in fluoridated areas have ranged
from 7% to 35% (
223–228
). In response to the accumulated data on fluoride intake and
the prevalence of enamel fluorosis, the supplement dosage schedule for children aged
<6 years was markedly reduced in 1994 when ADA, AAPD, and AAP jointly established
the current schedule (Table 1) (
73
). The risk for enamel fluorosis among children this age
attributable to fluoride supplements could be lower, but not enough information is avail-
able yet to evaluate the effects of this change.
Vol. 50 / No. RR-14 MMWR 17
When prescribing any pharmaceutical agent, dentists and physicians should attempt
to maximize benefit and minimize harm (
229
). For infants and children aged <6 years,
both a benefit of dental caries prevention and a risk for enamel fluorosis are possible.
Although the primary (i.e., “baby”) teeth of children aged 1–6 years would benefit from
fluoride’s posteruptive action, and some preeruptive benefit for developing permanent
teeth could exist, fluoride supplements also could increase the risk for enamel fluorosis
at this age (
138,223
).
Professionally Applied Fluoride Compounds
In the United States, dentists and dental hygienists have been applying high-
concentration fluoride compounds directly to patients’ teeth for approximately 50 years.
Application procedures were developed on the assumption that the fluoride would be
incorporated into the crystalline structure of the dental enamel and develop a more acid-
resistant enamel. To maximize this reaction, a professional tooth cleaning was consid-
ered mandatory before the application. However, subsequent research has
demonstrated that high-concentration fluoride compounds (e.g., those in gel or varnish)
do not directly enter the enamel’s crystalline structure (
230
). The compound forms a
calcium fluoride-like material on the enamel’s surface that releases fluoride for
remineralization when the pH in the mouth drops. Thus, professional tooth cleaning
solely to prepare the teeth for application of a fluoride compound is unnecessary;
toothbrushing and flossing appear equally effective in improving the efficacy of high-
concentration fluoride compounds (
231
).
Fluoride Gel and Foam
Because an early study reported that fluoride uptake by dental enamel increased in
an acidic environment (
232
), fluoride gel is often formulated to be highly acidic (pH of
approximately 3.0). Products available in the United States include gel of acidulated
phosphate fluoride (1.23% [12,300 ppm] fluoride), gel or foam of sodium fluoride (0.9%
[9,040 ppm] fluoride), and self-applied (i.e., home use) gel of sodium fluoride (0.5% [5,000
ppm] fluoride) or stannous fluoride (0.15% [1,000 ppm] fluoride) (
73
).
Clinical trials conducted during 1940–1970 demonstrated that professionally applied
fluorides effectively reduce caries experience in children (
233
). In more recent studies,
semiannual treatments reportedly caused an average decrease of 26% in caries experi-
ence in the permanent teeth of children residing in nonfluoridated areas (
191,234–236
).
The application time for the treatments was 4 minutes. In clinical practice, applying
fluoride gel for 1 minute rather than 4 minutes is common, but the efficacy of this shorter
application time has not been tested in human clinical trials. In addition, the optimal
schedule for repeated application of fluoride gel has not been adequately studied to
support definitive guidelines, and studies that have examined the efficacy of various gel
application schedules in preventing and controlling dental caries have reported mixed
results. On the basis of the available evidence, the usual recommended frequency is
semiannual (
151,237,238
).
Because these applications are relatively infrequent, generally at 3- to 12-month
intervals, fluoride gel poses little risk for enamel fluorosis, even among patients aged <6
years. Proper application technique reduces the possibility that a patient will swallow the
gel during application.
18 MMWR August 17, 2001
Fluoride Varnish
High-concentration fluoride varnish is painted directly onto the teeth. Fluoride var-
nish is not intended to adhere permanently; this method holds a high concentration of
fluoride in a small amount of material in close contact with the teeth for many hours.
Fluoride varnish has practical advantages (e.g., ease of application, a nonoffensive taste,
and use of smaller amounts of fluoride than required for gel applications). Such var-
nishes are available as sodium fluoride (2.26% [2,600 ppm] fluoride) or difluorsilane
(0.1% [1,000 ppm] fluoride) preparations.
Fluoride varnish has been widely used in Canada and Europe since the 1970s to
prevent dental caries (
152,239
). FDA’s Center for Devices and Radiological Health has
cleared fluoride varnish as a medical device to be used as a cavity liner (i.e., to provide
fluoride at the junction of filling material and tooth) and root desensitizer (i.e., to reduce
sensitivity to temperature and touch that sometimes occurs on root surfaces exposed by
receding gingiva) (
240
); FDA has not yet approved this product as an anticaries agent.
Caries prevention is regarded as a drug claim, and companies would be required to
submit appropriate clinical trial evidence for review before this product could be mar-
keted as an anticaries agent. However, a prescribing practitioner can use fluoride var-
nish for caries prevention as an “off-label” use, based on professional judgement (
241
).
Studies conducted in Canada (
242
) and Europe (
243–246
) have reported that fluo-
ride varnish is efficacious in preventing dental caries in children. Applied semiannually,
this modality is as effective as professionally applied fluoride gel (
247
). Some research-
ers advocate application of fluoride varnish as many as four times per year to achieve
maximum effect, but the evidence of benefits from more than two applications per year
remains inconclusive (
240,246,248
). Other studies have reported that three applications
in 1 week, once per year, might be more effective than the more conventional semian-
nual regimen (
249,250
).
European studies have reported that fluoride varnish prevents decalcification (i.e., an
early stage of dental caries) beneath orthodontic bands (
251
) and slows the progression
of existing enamel lesions (
252
). Studies examining the effectiveness of varnish in con-
trolling early childhood caries are being conducted in the United States. Research on
fluoride varnish (e.g., optimal fluoride concentration, the most effective application pro-
tocols, and its efficacy relative to other fluoride modalities) is likely to continue in both
Europe and North America.
No published evidence indicates that professionally applied fluoride varnish is a risk
factor for enamel fluorosis, even among children aged <6 years. Proper application
technique reduces the possibility that a patient will swallow varnish during its application
and limits the total amount of fluoride swallowed as the varnish wears off the teeth over
several hours.
Fluoride Paste
Fluoride-containing paste is routinely used during dental prophylaxis (i.e., cleaning).
The abrasive paste, which contains 4,000–20,000 ppm fluoride, might restore the con-
centration of fluoride in the surface layer of enamel removed by polishing, but it is not an
adequate substitute for fluoride gel or varnish in treating persons at high risk for dental
caries (
151
). Fluoride paste is not accepted by FDA or ADA as an efficacious way to
prevent dental caries.
Vol. 50 / No. RR-14 MMWR 19
Combinations of Fluoride Modalities
Studies comparing various combinations of fluoride modalities have generally re-
ported that their effectiveness in preventing dental caries is partially additive. That is, the
percent reduction in the prevalence or severity of dental caries from a combination of
modalities is higher than the percent reduction from each modality, but less than the sum
of the percent reduction of the modalities combined. Attempts to use a formula to apply
sequentially the percent reduction of an additional modality to the estimated remaining
caries increment have overestimated the effect (
151,253
). For example, if the first mo-
dality reduces caries by 40% and the second modality reduces caries by 30%, then the
calculation that caries will be reduced by a total of 58% (i.e., 40% plus 18% [30% of the
60% decay remaining after the first modality]) will likely be an overestimate.
QUALITY OF EVIDENCE FOR DENTAL CARIES PREVENTION
AND CONTROL
Members of the work group convened by CDC identified the published research in
their areas of expertise and evaluated the quality of scientific evidence for each fluoride
modality in preventing and controlling dental caries. Evidence was drawn from the most
relevant English-language, peer-reviewed scientific publications regarding the current
effectiveness of fluoride modalities. Additional references were suggested by review-
ers. Members used their own methods for critically analyzing articles. A formal protocol
for duplicate review was not followed, but members collectively agreed on the grade
reflecting the quality of evidence regarding each fluoride modality. Criteria used to grade
the quality of scientific evidence (i.e., ordinal grading) was adapted from the U.S. Preven-
tive Services Task Force (Box 1) (
254
). Grades range from I to III.
BOX 1. Grading system used for determining the quality of evidence for a fluoride modality
Grade Criteria
I Evidence obtained from one or more properly conducted randomized
clinical trials (i.e., one using concurrent controls, double-blind design,
placebos, valid and reliable measurements, and well-controlled study
protocols).
II-1 Evidence obtained from one or more controlled clinical trials without
randomization (i.e., one using systematic subject selection, some type
of concurrent controls, valid and reliable measurements, and well-
controlled study protocols).
II-2 Evidence obtained from one or more well-designed cohort or case-control
analytic studies, preferably from more than one center or research group.
II-3 Evidence obtained from cross-sectional comparisons between times and
places; studies with historical controls; or dramatic results in uncontrolled
experiments (e.g., the results of the introduction of penicillin treatment in
the 1940s).
III Opinions of respected authorities on the basis of clinical experience,
descriptive studies or case reports, or reports of expert committees.
Source: US Preventive Services Task Force. Guide to clinical preventive services. 2nd ed.
Alexandria, VA: International Medical Publishing, 1996.
20 MMWR August 17, 2001
Community Water Fluoridation
Studies on the effectiveness of adjusting fluoride in community water to the optimal
concentration cannot be designed as randomized clinical trials. Random allocation of
study subjects is not possible when a community begins to fluoridate the water because
all residents in a community have access to and are exposed to this source of fluoride. In
addition, clinical studies cannot be conducted double-blind because both study subjects
and researchers usually know whether a community’s water has been fluoridated. Ef-
forts to blind the examiners by moving study subjects to a neutral third site for clinical
examinations, using radiographs of teeth without revealing where the subjects live, or
including transient residents as study subjects have not fully resolved these inherent
limitations. Early studies that led to the unexpected discovery that dental caries was less
prevalent and severe among persons with mottled enamel (subsequently identified as a
form of enamel fluorosis) were conducted before the caries-preventive effects of fluo-
ride were known (
255
). In those studies, researchers did not have an a priori reason to
suspect they would find either reduced or higher levels of dental caries experience in
communities with low levels of mottled enamel. Researchers also had no reason to
believe that patients selected where they lived according to their risk for dental caries. In
that regard, these studies were randomized, and examiners were blinded.
Despite the strengths of early studies of the efficacy of naturally occurring fluoride in
community drinking water, the limitations of these studies make summarizing the quality
of evidence on community water fluoridation as Grade I inappropriate (Table 1). The
quality of evidence from studies on the effectiveness of adjusting fluoride concentration
in community water to optimal levels is Grade II-1. Research limitations are counterbal-
anced by broadly similar results from numerous well-conducted field studies by other
investigators that included thousands of persons throughout the world (
256,257
).
School Water Fluoridation
Field trials on the effect of school water fluoridation were not blindly conducted and
had no concurrent controls (
118
). Thus, the quality of evidence for this modality is Grade
II-3.
Fluoride Toothpaste
Studies that have demonstrated the efficacy of fluoride toothpaste in preventing and
controlling dental caries include all of the essential features of well-conducted clinical
trials. These include randomized groups, double-blind designs, placebo controls, and
meticulous procedural protocols. Taken together, the trials on fluoride toothpaste pro-
vide solid evidence that fluoride is efficacious in controlling caries (
144
). The quality of
evidence for toothpaste is Grade I.
Fluoride Mouthrinse
Early studies of the efficacy of fluoride mouthrinse in reducing dental caries experi-
ence were randomized clinical trials (
184,185
) or studies that used historical control
groups rather than concurrent control groups (
186–189
). The quality of evidence for
fluoride mouthrinse is Grade I.
Vol. 50 / No. RR-14 MMWR 21
Dietary Fluoride Supplements
The only randomized controlled trial to assess fluoride supplements taken by preg-
nant women provides Grade I evidence of no benefit for their children. Many studies of
the effectiveness of fluoride supplements in preventing dental caries among children
aged <6 years have been flawed in design and conduct. Problems included self-selection
into test and control groups, absence of concurrent controls, high attrition rates, and
nonblinded examiners. Because of these flaws, the quality of evidence to support use of
fluoride supplements by children aged <6 years is Grade II-3. The well-conducted ran-
domized clinical trials on the effects of fluoride supplements on dental caries among
children aged 6–16 years in programs conducted in schools provide Grade I evidence.
Fluoride Gel
The quality of evidence for using fluoride gel to prevent and control dental caries in
children is Grade I. However, data were gathered when dental caries was more preva-
lent and severe than today. Subjects in earlier studies were probably more representa-
tive of persons who now would be characterized as being at high risk for caries.
Fluoride Varnish
The quality of evidence for the efficacy of high-concentration fluoride varnish in pre-
venting and controlling dental caries in children is Grade I. Although the randomized
controlled clinical studies that established Grade I evidence were conducted in Europe,
U.S. results should be the same.
COST-EFFECTIVENESS OF FLUORIDE MODALITIES
Documented effectiveness is the most basic requirement for providing a health-care
service and an important prerequisite for preventive services (e.g., caries-preventive
modalities). However, effectiveness alone is not a sufficient reason to initiate a service.
Other factors, including cost, must be considered (
254
). A modality is more cost-
effective when deemed a less expensive way, from among competing alternatives, of
meeting a stated objective (
258
). In public health planning, determination of the most
cost-effective alternative for prevention is essential to using scarce resources efficiently.
Dental-insurance carriers are also interested in cost-effectiveness so they can help pur-
chasers use funds efficiently. Because half of dental expenditures are out of pocket
(
259
), this topic interests patients and their dentists as well. Potential improvement to
quality of life is also a consideration. The contribution of a healthy dentition to quality of
life at any age has not been quantified, but is probably valued by most persons.
Although solid data on the cost-effectiveness of fluoride modalities alone and in com-
bination are needed, this information is scarce. In 1989, the Cost Effectiveness of Caries
Prevention in Dental Public Health workshop, which was attended by health economists,
epidemiologists, and dental public health professionals, attempted to assess the cost-
effectiveness of caries-preventive approaches available in the United States (
260
).
All other things being equal, fluoride modalities are most cost-effective for persons at
high risk for dental caries. Because persons at low risk develop little dental caries, limited
benefit is gained by adding caries-preventive modalities to water fluoridation and fluo-
ride toothpaste, even those demonstrated to be effective among populations at high risk.
22 MMWR August 17, 2001
Members of the CDC work group reached consensus regarding the populations for which
each modality would be expected to have the necessary level of cost-effectiveness to
warrant its use.
Community Water Fluoridation
Health economists at the 1989 workshop on cost-effectiveness of caries prevention
calculated that the average annual cost of water fluoridation in the United States was
$0.51 per person (range: $0.12–$5.41) (
260
). In 1999 dollars,* this cost would be $0.72
per person (range: $0.17–$7.62). Factors reported to influence the per capita cost in-
cluded
• size of the community (the larger the population reached, the lower the per capita
cost);
• number of fluoride injection points in the water supply system;
• amount and type of system feeder and monitoring equipment used;
• amount and type of fluoride chemical used, its price, and its costs of transportation
and storage; and
• expertise of personnel at the water plant.
When the effects of caries are repaired, the price of the restoration is based on the
number of tooth surfaces affected. A tooth can have caries at >1 location (i.e., surface), so
the number of surfaces saved is a more appropriate measure in calculating cost-
effectiveness than the number of teeth with caries. The 1989 workshop participants
concluded that water fluoridation is one of the few public health measures that results in
true cost savings (i.e., the measure saves more money than it costs to operate); in the
United States, water fluoridation cost an estimated average of $3.35 per carious surface
saved ($4.71 in 1999 dollars*) (
260
). Even under the least favorable assumptions in
1989 (i.e., cities with populations <10,000, higher operating costs, and effectiveness
projected at the low end of the range), the cost of a carious surface saved because of
community water fluoridation ranged from $8 to $12 ($11–$17 in 1999 dollars*) (
260
),
which is still lower than the fee for a one-surface restoration ($54 in 1995 or $65 in 1999
dollars
†
) (
261
).
A Scottish study conducted in 1980 reported that community water fluoridation re-
sulted in a 49% saving in dental treatment costs for children aged 4–5 years and a 54%
saving for children aged 11–12 years (
262
). These savings were maintained even after
the secular decline in the prevalence of dental caries was recognized (
263
). The effect of
community water fluoridation on the costs of dental care for adults is less clear. This topic
cannot be fully explored until the generations who grew up drinking optimally fluoridated
water are older.
*US$ 1988 converted to US$ 1999 using the Consumer Price Index for All Urban Customers
(CPI-Urban) (all items). More information is available at the U.S. Department of Labor, Bureau
of Labor Statistics website at <http://stats.bls.gov/cpihome.htm>. Accessed June 25, 2001.
†
US$ 1995 converted to US$ 1999 using CPI-Urban (dental services). More information is
available at the U.S. Department of Labor, Bureau of Labor Statistics website at <http://
stats.bls.gov/cpihome.htm>. Accessed June 25, 2001.
Vol. 50 / No. RR-14 MMWR 23
School Water Fluoridation
Costs for school water fluoridation are similar to those of any public water supply
system serving a small population (i.e., <1,000 persons). In 1988, the average annual cost
of school water fluoridation was $4.52 per student per year (range: $0.81–$9.72) (
264
).
In 1999 dollars,* this cost would be $6.37 per person (range: $1.14–$13.69). Use of this
modality must be carefully weighed in the current environment of low caries prevalence,
widespread use of fluoride toothpaste, and availability of other fluoride modalities that
can be delivered in the school setting.
Fluoride Toothpaste
Fluoride toothpaste is widely available, no more expensive than nonfluoride tooth-
paste, and periodically improved. Use of a pea-sized amount (0.25 g) twice per day
requires approximately two tubes of toothpaste per year, for an estimated annual cost of
$6–$12, depending on brand, tube size, and retail source (
265
). Persons who brush and
use toothpaste regularly to maintain periodontal health and prevent stained teeth and
halitosis (i.e., bad breath) incur no additional cost for the caries-preventive benefit of
fluoride in toothpaste. Because of its multiple benefits, most persons consider fluoride
toothpaste a highly cost-effective caries-preventive modality.
Fluoride Mouthrinse
Public health programs of fluoride mouthrinsing have long been presumed to be cost-
effective, especially when teachers can supervise weekly rinsing in classrooms at no
direct cost to the program. In other programs, volunteers or hourly workers provide
supervision. Under these circumstances, administrators of fluoride mouthrinsing pro-
grams have claimed annual program costs of approximately $1 per child ($1.41 in 1999
dollars*) (
264
). This figure likely is an underestimate because indirect costs are not
included (
196,266
). Fluoride mouthrinsing is a reasonable procedure for groups and
persons at high risk for dental caries, but its cost-effectiveness as a universal, population-
wide strategy in the modern era of widespread fluoride exposure is questionable (
267
).
Dietary Fluoride Supplements
Dietary fluoride supplements prescribed to persons cost an estimated $37 per year.
Fluoride supplements in school programs have direct costs of approximately $2.50 per
child ($3.52 in 1999 dollars*) for the tablet or lozenge (
264
); program administrative
costs and considerations are similar to those in school mouthrinsing programs.
Professionally Applied Fluoride Compounds
High-concentration fluoride gel and varnish are effective in preventing dental caries,
but because application requires professional expertise, they are inherently more ex-
pensive than self-applied methods (e.g., drinking fluoridated water or brushing with
fluoride toothpaste). For groups and persons at low risk for dental caries, professionally
applied methods are unlikely to be cost-effective (
268,269
). In the NPDDP study, prophy-
*US$ 1988 converted to US$ 1999 using CPI-Urban (all items). More information is available
at the U.S. Department of Labor, Bureau of Labor Statistics website at <http://stats.bls.gov/
cpihome.htm>. Accessed June 25, 2001.
24 MMWR August 17, 2001
lactic cleaning and gel application costs were $23 per year ($66 in 1999 dollars*) for
semiannual applications, which prevented 0.03–0.26 decayed surfaces per year (
196
). A
Swedish study claimed that fluoride varnish was cost-effective, but few supporting data
were presented (
270
). Varnish might be cost-effective in Scandinavian school dental
services, in which dental professionals regularly examine and treat each student, but the
cost-effectiveness of fluoride varnish in public health programs in the United States
remains undocumented. Whether fluoride varnish or gel would be most efficiently used
in clinical programs targeting groups at high risk for dental caries or should be reserved
for individual patients at high risk is unclear.
Combinations of Fluoride Modalities
Because the caries-preventive effects of a combination of fluoride modalities are
only partially additive, estimates of the cost-effectiveness when adding a modality (e.g.,
fluoride mouthrinse for a group already drinking fluoridated water and using fluoride
toothpaste) should take into account these smaller, incremental reductions in caries. This
consideration is particularly relevant for groups and persons at low risk for caries (
253
).
The scarcity of research on the cost-effectiveness of combinations limits the ability to
draw more detailed conclusions.
RECOMMENDATIONS
In developing the recommendations for specific fluoride modalities that address pub-
lic health and clinical practice and self-care, the CDC work group considered the quality of
evidence of each modality’s effect on dental caries, its association with enamel fluorosis,
and its cost-effectiveness. The strength of the recommendation for each fluoride modal-
ity was determined by the work group, which adapted a coding system used by the U.S.
Preventive Services Task Force (Box 2). The work group considered these factors when
determining the population for which each recommendation applies (Table 4). The work
*US$ 1981 converted to US$ 1999 using CPI-Urban (dental services). More information is
available at the U.S. Department of Labor, Bureau of Labor Statistics website at <http://
stats.bls.gov/cpihome.htm>. Accessed June 25, 2001.
BOX 2. Coding system used to classify recommendations for use of specific fluoride
modalities to control dental caries
Code Criteria
A Good evidence to support the use of the modality.
B Fair evidence to support the use of the modality.
C Lack of evidence to develop a specific recommendation (i.e., the modality
has not been adequately tested) or mixed evidence (i.e., some studies
support the use of the modality and some oppose it).
D Fair evidence to reject the use of the modality.
E Good evidence to reject the use of the modality.
Source: US Preventive Services Task Force. Guide to clinical preventive services. 2nd ed.
Alexandria, VA: International Medical Publishing, 1996.
Vol. 50 / No. RR-14 MMWR 25
group recognized that some recommendations can only be addressed by health-care
industries or agencies and that additional research is required to resolve some questions
regarding fluoride modalities.
Before promoting a fluoride modality or combination of modalities, the dental-care or
other health-care provider must consider a person’s or group’s risk for dental caries,
current use of other fluoride sources, and potential for enamel fluorosis. Although these
recommendations are based on assessments of caries risk as low or high, the health-
care provider might also differentiate among patients at high risk and provide more
intensive interventions as needed. Also, a risk category can change over time; the type
and frequency of preventive interventions should be adjusted accordingly.
TABLE 4. Quality of evidence, strength of recommendation, and target population of
recommendation for each fluoride modality to prevent and control dental caries
Quality Strength
of evidence of recommendation Target
Modality* (grade) (code) population
†
Community water fluoridation II-1 A All areas
School water fluoridation II-3 C Rural,
nonfluoridated
areas
Fluoride toothpaste I A All persons
Fluoride mouthrinse I A High risk
§
Fluoride supplements
Pregnant women I E None
Children aged <6 years II-3 C High risk
Children aged 6–16 years I A High risk
Persons aged >16 years
¶
C High risk
Fluoride gel I A High risk
Fluoride varnish I A High risk
* Modalities are assumed to be used as directed in terms of dosage and age of user.
†
Quality of evidence for targeting some modalities to persons at high risk is grade III (i.e.,
representing the opinion of respected authorities) and is based on considerations of cost-
effectiveness that were not included in the studies establishing efficacy or effectiveness.
§
Populations believed to be at increased risk for dental caries are those with low socioeco-
nomic status or low levels of parental education, those who do not seek regular dental care,
and those without dental insurance or access to dental services. Individual factors that
possibly increase risk include active dental caries; a history of high caries experience in older
siblings or caregivers; root surfaces exposed by gingival recession; high levels of infection
with cariogenic bacteria; impaired ability to maintain oral hygiene; malformed enamel or
dentin; reduced salivary flow because of medications, radiation treatment, or disease; low
salivary buffering capacity (i.e., decreased ability of saliva to neutralize acids); and the
wearing of space maintainers, orthodontic appliances, or dental prostheses. Risk can in-
crease if any of these factors are combined with dietary practices conducive to dental caries
(i.e., frequent consumption of refined carbohydrates). Risk decreases with adequate expo-
sure to fluoride.
¶
No published studies confirm the effectiveness of fluoride supplements in controlling den-
tal caries among persons aged >16 years.
26 MMWR August 17, 2001
Public Health and Clinical Practice
Continue and Extend Fluoridation of Community Drinking Water
Community water fluoridation is a safe, effective, and inexpensive way to prevent
dental caries. This modality benefits persons in all age groups and of all SES, including
those difficult to reach through other public health programs and private dental care.
Community water fluoridation also is the most cost-effective way to prevent tooth decay
among populations living in areas with adequate community water supply systems.
Continuation of community water fluoridation for these populations and its adoption in
additional U.S. communities are the foundation for sound caries-prevention programs.
In contrast, the appropriateness of fluoridating stand-alone water systems that sup-
ply individual schools is limited. Widespread use of fluoride toothpaste, availability of
other fluoride modalities that can be delivered in the school setting, and the current
environment of low caries prevalence limit the appropriateness of fluoridating school
drinking water at 4.5 times the optimal concentration for community drinking water.
Decisions to initiate or continue school fluoridation programs should be based on an
assessment of present caries risk in the target school(s), alternative preventive modali-
ties that might be available, and periodic evaluation of program effectiveness.
Counsel Parents and Caregivers Regarding Use of Fluoride Toothpaste
by Young Children, Especially Those Aged <2 Years
Fluoride toothpaste is a cost-effective way to reduce the prevalence of dental caries.
However, for children aged <6 years, especially those aged <2 years, an increased risk
for enamel fluorosis exists because of inadequately developed control of the swallowing
reflex. Parents or caregivers should be counseled regarding self-care recommendations
for toothpaste use for young children (i.e., limit the child’s toothbrushing to
<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 aged <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 Persons at High Risk
Because fluoride mouthrinse has resulted in only limited reductions in caries experi-
ence among schoolchildren, especially as their exposure to other sources of fluoride has
increased, its use should be targeted to groups and persons at high risk for caries (see
Risk for Dental Caries). Children aged <6 years should not use fluoride mouthrinse with-
out consultation with a dentist or other health-care provider because enamel fluorosis
could occur if such mouthrinses are repeatedly swallowed.
Judiciously Prescribe Fluoride Supplements
Fluoride supplements can be prescribed for children at high risk for dental caries and
whose primary drinking water has a low fluoride concentration. For children aged <6
years, the dentist, physician, or other health-care provider should weigh the risk for
caries without fluoride supplements, the caries prevention offered by supplements, and
the potential for enamel fluorosis. Consideration of the child’s other sources of fluoride,
Vol. 50 / No. RR-14 MMWR 27
especially drinking water, is essential in determining this balance. Parents and caregivers
should be informed of both the benefit of protection against dental caries and the possi-
bility of enamel fluorosis. The prescription dosage of fluoride supplements should be
consistent with the schedule established by ADA, AAPD, and AAP. Supplements can be
prescribed for persons as appropriate or used in school-based programs. When practi-
cal, supplements should be prescribed as chewable tablets or lozenges to maximize the
topical effects of fluoride.
Apply High-Concentration Fluoride Products to Persons at High Risk
for Dental Caries
High-concentration fluoride products can play an important role in preventing and
controlling dental caries among groups and persons at high risk. Dentists and other
health-care providers must consider the risk status and age of the patient to determine
the appropriate intensity of treatment. Routine use of professionally applied fluoride gel
or foam likely provides little benefit to persons not at high risk for dental caries, especially
those who drink fluoridated water and brush daily with fluoride toothpaste.
If FDA approves use of fluoride varnish to prevent and control dental caries, its indi-
cations for use will be similar to those of fluoride gel. Such varnishes have practical
advantages for children aged <6 years at high risk.
Self-Care
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, optimal, or above optimal. This knowledge is the basis
for all individual and professional decisions regarding use of other fluoride modalities
(e.g., mouthrinse or supplements). Parents and caregivers of children, especially chil-
dren aged <6 years, must know the fluoride concentration in their child’s drinking water
when considering whether to alter the child’s fluoride intake. 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 concen-
tration is >2 ppm, children should use alternative sources of drinking water. Knowledge
of the water’s fluoride concentration is also key in public policy discussions regarding
community water fluoridation.
Frequently Use Small Amounts of Fluoride
All persons should receive frequent exposure to small amounts of fluoride, which
minimizes dental caries by inhibiting demineralization of tooth enamel and facilitating
tooth remineralization. This exposure can be readily accomplished by drinking water
with an optimal fluoride concentration and brushing with a fluoride toothpaste twice
daily.
Supervise Use of Fluoride Toothpaste Among Children Aged <6 Years
Children’s teeth should be cleaned daily from the time the teeth erupt in the mouth.
Parents and caregivers should consult a dentist or other health-care provider before
introducing a child aged <2 years to fluoride toothpaste. Parents and caregivers of chil-
dren aged <6 years who use fluoride toothpaste should follow the directions on the label,
28 MMWR August 17, 2001
place no more than a pea-sized amount (0.25 g) of toothpaste on the toothbrush, brush
the child’s teeth (recommended particularly for preschool-aged children) or supervise
the toothbrushing, and encourage the child to spit excess toothpaste into the sink to
minimize the amount swallowed. Indiscriminate use can result in inadvertent swallowing
of more fluoride than is recommended.
Consider Additional Measures for Persons at High Risk for Dental Caries
Persons at high risk for dental caries might require additional fluoride or other pre-
ventive measures to reduce development of caries. This additional fluoride can come
from daily use of another fluoride product at home or from professionally applied, topical
fluoride products. Other preventive measures might include dental sealants and tar-
geted antimicrobial therapies. Parents and caregivers should not provide additional fluo-
ride to children aged <6 years without consulting a dentist or other health-care provider
regarding the associated benefits and potential for enamel fluorosis. Persons should
seek professional advice regarding their risk status or that of their children.
Use an Alternative Source of Water for Children Aged <8 Years
Whose Primary Drinking Water Contains >2 ppm Fluoride
In some regions in the United States, community water supply systems and home
wells contain a natural concentration of fluoride >2 ppm. At this concentration, children
aged
<8 years are at increased risk for developing enamel fluorosis, including the mod-
erate and severe forms, and should have an alternative source of drinking water, prefer-
ably one containing fluoride at an optimal concentration.
In areas where community water supply systems contain >2 ppm but <4 ppm fluo-
ride, EPA requires that each household be notified annually of the desirability of using an
alternative source of water for children aged
<8 years. For families receiving water from
home wells, testing is necessary to determine the natural fluoride concentration.
Consumer Product Industries and Health Agencies
Label the Fluoride Concentration of Bottled Water
Producers of bottled water should 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 regard-
ing fluoride intake and use of fluoride products.
Promote Use of Small Amounts of Fluoride Toothpaste Among Children
Aged <6 Years
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 aged <6 years.
Efforts to educate parents and caregivers and to encourage supervised use of fluoride
toothpaste among young children can reduce inadvertent swallowing of excess tooth-
paste.
Vol. 50 / No. RR-14 MMWR 29
Develop a Low-Fluoride Toothpaste for Children Aged <6 Years
Manufacturers are encouraged to develop a dentifrice for children aged <6 years that
is effective in preventing dental caries but alleviates the risk for enamel fluorosis. A
“child-strength” toothpaste with a fluoride concentration lower than current products
could reduce the risk for cosmetic concerns associated with inadvertent 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 trainees 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 fluoride modalities.
Further Research
Continue Metabolic Studies of Fluoride
Metabolic studies with animals and humans to determine the influence of environ-
mental, physiological, and pathological conditions on the pharmacokinetics and effects of
fluoride should continue. Research in these areas will enhance the knowledge base
concerning fluoride use, thereby resulting in more effective and efficient use of fluoride.
Identify Biomarkers of Fluoride
As an alternative to direct fluoride intake measurement, biomarkers (i.e., distinct
biological indicators) should be identified to estimate a person’s fluoride intake and the
amount of fluoride in the body. Identification of such biomarkers could allow more effi-
cient research.
Reevaluate the Method of Determining Optimal Fluoride Concentration
of Community Drinking Water
The current method of determining the optimal concentration of fluoride in commu-
nity drinking water, which depends on the average maximum annual ambient air tem-
perature, should be reevaluated because of the social and environmental changes that
have occurred since it was adopted in 1962. Research into current consumption patterns
of water, processed beverages, and processed foods is also needed. Such research will
either validate the current method for determining optimal fluoride concentration in
community drinking water or indicate improved methods.
Evaluate the Effect of Fluoride Mouthrinse, Fluoride Supplements,
and Other Fluoride Modalities on Dental Caries
Additional clinical trials are needed to evaluate the current effect of fluoride
mouthrinse, supplements, and other modalities on dental caries both individually and in
combination. Cohorts of particular interest are groups and persons at high risk for dental
caries, including older adults (i.e., those aged >50 years). Such research, as well as
studies to determine the effects of new fluoride modalities and various combinations
among groups and persons at high risk, could lead to more effective and efficient use of
these interventions.
30 MMWR August 17, 2001
Study the Current Cost-Effectiveness of Fluoride Modalities
The increasing availability of multiple fluoride modalities and the lower caries preva-
lence in the United States indicate a need for current cost-effectiveness studies of fluo-
ride modalities, especially logical combinations of regimens in populations with different
caries risks. Such research will allow both more efficient use of resources and a better
understanding of the additive effects of combined modalities.
Conduct Descriptive and Analytic Epidemiologic Studies
Descriptive and analytic epidemiologic studies should be conducted to determine the
association between dental caries and fluoride exposure from several sources, as well
as the current role of community water fluoridation in preventing coronal and root caries
among adults. Studies should assess the effect of interruption or discontinuation of water
fluoridation; the prevalence of fluorosis associated with different patterns of fluoride use
and intake among various populations; and the relationship between objectively mea-
sured fluorosis and the aesthetic perceptions of persons, parents, and dentists and other
health-care professionals. Studies are needed to refine methods of caries risk assess-
ment. As appropriate, studies should use national, state, and local data. Research ad-
dressing these questions will improve understanding of the relationships between
fluoride modalities and the benefits and unintended effects of their use.
Identify Effective Strategies to Promote Adoption of Recommendations
for Using Fluoride
Effective strategies should be identified to promote adherence by parents, caregivers,
children, adults, and health-care providers to recommendations regarding fluoride use.
Such research could result in more effective behavior change, more efficient use of
resources, improved caries prevention, and less enamel fluorosis.
CONCLUSION
When used appropriately, fluoride is a safe and effective agent that can be used to
prevent and control dental caries. Fluoride has contributed profoundly to the improved
dental health of persons in the United States and other countries. Fluoride is needed
regularly throughout life to protect teeth against tooth decay. To ensure additional gains
in oral health, water fluoridation should be extended to additional communities, and
fluoride toothpaste should be used widely. Adoption of these and other recommenda-
tions in this report could lead to considerable savings in public and private resources
without compromising fluoride’s substantial benefit of improved dental health.
References
1. Bratthall D, Hänsel Petersson G, Sundberg H. Reasons for the caries decline: what do the
experts believe? Eur J Oral Sci 1996;104:416–22.
2. Blaney JR, Tucker WH. The Evanston Dental Caries Study. II. Purpose and mechanism of the
study. J Dent Res 1948;27:279–86.
3. Ast DB, Finn SB, McCaffrey I. The Newburgh-Kingston Caries Fluorine Study. I. Dental
findings after three years of water fluoridation. Am J Public Health 1950;40:716–24.
4. Dean HT, Arnold FA, Jay P, Knutson JW. Studies on mass control of dental caries through
fluoridation of the public water supply. Public Health Rep 1950;65:1403–8.
5. Hutton WL, Linscott BW, Williams DB. The Brantford fluorine experiment: interim report
after five years of water fluoridation. Can J Public Health 1951;42:81–7.
Vol. 50 / No. RR-14 MMWR 31
6. Pao EM. Changes in American food consumption patterns and their nutritional
significance. Food Technol 1981;35:43–53.
7. Heller KE, Sohn W, Burt BA, Eklund SA. Water consumption the United States in 1994–
1996 and implications for water fluoridation policy. J Public Health Dent 1999;59:3–11.
8. Public Health Service Committee to Coordinate Environmental Health and Related
Programs. Review of fluoride: benefits and risk. Washington, DC: US Department of
Health and Human Services, Public Health Service, 1991.
9. National Research Council Committee on Toxicology. Health effects of ingested fluoride.
Washington, DC: National Academy Press, 1993.
10. World Health Organization. Environmental health criteria 36: fluorine and fluorides. Geneva:
World Health Organization, 1984.
11. Institute of Medicine. Fluoride. In: Dietary reference intakes for calcium, phosphorus,
magnesium, vitamin D, and fluoride. Washington, DC: National Academy Press, 1997:288–
313.
12. Featherstone JDB. Prevention and reversal of dental caries: role of low level fluoride.
Community Dent Oral Epidemiol 1999;27:31–40.
13. Koulourides T. Summary of session II: fluoride and the caries process. J Dent Res
1990;69(special issue):558.
14. Tatevossian A. Fluoride in dental plaque and its effects. J Dent Res 1990;69(special
issue):645–52.
15. Chow LC. Tooth-bound fluoride and dental caries. J Dent Res 1990;69(special issue):595–
600.
16. Ericsson SY. Cariostasis mechanisms of fluorides: clinical observations. Caries Res
1977;11(suppl 1):2–23.
17. Kidd EAM, Thylstrup A, Fejerskov O, Bruun C. Influence of fluoride in surface enamel and
degree of dental fluorosis on caries development in vitro. Caries Res 1980;14:196–202.
18. Thylstrup A. Clinical evidence of the role of pre-eruptive fluoride in caries prevention. J
Dent Res 1990;69(special issue):742–50.
19. Thylstrup A, Fejerskov O, Bruun C, Kann J. Enamel changes and dental caries in 7-year-
old children given fluoride tablets from shortly after birth. Caries Res 1979;13:265–76.
20. White DJ, Nancollas GH. Physical and chemical considerations of the role of firmly and
loosely bound fluoride in caries prevention. J Dent Res 1990;69(special issue):587–94.
21. Hamilton IR. Biochemical effects of fluoride on oral bacteria. J Dent Res 1990;69(special
issue):660–7.
22. Bowden GHW. Effects of fluoride on the microbial ecology of dental plaque. J Dent Res
1990;69(special issue):653–9.
23. Bowden GHW, Odlum O, Nolette N, Hamilton IR. Microbial populations growing in the
presence of fluoride at low pH isolated from dental plaque of children living in an area
with fluoridated water. Infect Immun 1982;36:247–54.
24. Marquis RE. Diminished acid tolerance of plaque bacteria caused by fluoride. J Dent Res
1990;69(special issue):672–5.
25. Rosen S, Frea JI, Hsu SM. Effect of fluoride-resistant microorganisms on dental caries. J
Dent Res 1978;57:180.
26. Van Loveren C. The antimicrobial action of fluoride and its role in caries inhibition. J Dent
Res 1990;69(special issue):676–81.
27. Oliveby A, Twetman S, Ekstrand J. Diurnal fluoride concentration in whole saliva in
children living in a high- and a low-fluoride area. Caries Res 1990;24:44–7.
28. Rölla G, Ekstrand J. Fluoride in oral fluids and dental plaque. In: Fejerskov O, Ekstrand J,
Burt BA, eds. Fluoride in dentistry. 2nd ed. Copenhagen: Munksgaard, 1996:215–29.
29. LeGeros RZ. Chemical and crystallographic events in the caries process. J Dent Res
1990;69(special issue):567–74.
30. Dean HT, Dixon RM, Cohen C. Mottled enamel in Texas. Public Health Rep 1935;50:424–42.
32 MMWR August 17, 2001
31. McClure FJ, Likins RC. Fluorine in human teeth studied in relation to fluorine in the
drinking water. J Dent Res 1951;30:172–6.
32. Marthaler TM. Fluoride supplements for systemic effects in caries prevention. In: Johansen
E, Taves DR, Olsen TO, eds. Continuing evaluation of the use of fluorides. Boulder, CO:
Westview, 1979:33–59. (American Assocation for the Advancement of Science selected
symposium no. 11).
33. Murray JJ. Efficacy of preventive agents for dental caries. Systemic fluorides: water
fluoridation. Caries Res 1993;27(suppl 1):2–8.
34. Groeneveld A, Van Eck AAMJ, Backer Dirks O. Fluoride in caries prevention: is the effect
pre- or post-eruptive? J Dent Res 1990;69(special issue):751–5.
35. Levine RS. The action of fluoride in caries prevention: a review of current concepts. Br
Dent J 1976;140:9–14.
36. Margolis HC, Moreno EC. Physicochemical perspectives on the cariostatic mechanisms
of systemic and topical fluorides. J Dent Res 1990;69(special issue):606–13.
37. Clarkson BH, Fejerskov O, Ekstrand J, Burt BA. Rational use of fluorides in caries control.
In: Fejerskov O, Ekstrand J, Burt BA, eds. Fluorides in dentistry. 2nd ed. Copenhagen:
Munksgaard, 1996:347–57.
38. Arends J, Christoffersen J. Nature and role of loosely bound fluoride in dental caries. J
Dent Res 1990;69(special issue):601–5.
39. Burt BA, Eklund SA. Dentistry, dental practice, and the community. 5th ed. Philadelphia,
PA: W.B. Saunders, 1999.
40. National Institute of Dental Research. The prevalence of dental caries in United States
children, 1979–1980. Bethesda, MD: U.S. Public Health Service, Department of Health and
Human Services, National Institutes of Health, 1981; NIH publication no. 82-2245.
41. Kelly JE, Harvey CR. Basic dental examination findings of persons 1–74 years. In: Basic
data on dental examination findings of persons 1–74 years, United States, 1971–1974.
Hyattsville, MD: US Department of Health, Education, and Welfare, Public Health Service,
Office of Health Research, Statistics, and Technology, National Center for Health Statistics,
1979; DHEW publication no. (PHS) 79-1662. (Vital and health statistics data from the
National Health Interview Survey; series 11, no. 214).
42. National Institute of Dental Research. Oral health of United States children. The National
Survey of Dental Caries in U.S. School Children: 1986–1987. National and regional findings.
Bethesda, MD: US Department of Health and Human Services, Public Health Service,
National National Institutes of Health, National Institute of Dental Research, 1989; NIH
publication no. 89-2247.
43. Kaste LM, Selwitz RH, Oldakowski RJ, Brunelle JA, Winn DM, Brown LJ. Coronal caries in
the primary and permanent dentition of children and adolescents 1–17 years of age:
United States, 1988–1991. J Dent Res 1996;75(special issue):631–41.
44. Meskin LH, ed. Caries diagnosis and risk assessment: a review of preventive strategies
and management. J Am Dent Assoc 1995;126(suppl):15–245.
45. Pitts NB. Risk assessment and caries prediction. J Dent Educ 1998;62:762–70.
46. Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution of pediatric dental
caries: NHANES III, 1988–1994. J Am Dent Assoc 1998;129:1229–38.
47. Edelstein BL. The medical management of dental caries. J Am Dent Assoc
1994;125(suppl):31–9.
48. US Department of Health and Human Services. Oral health in America: a report of the
Surgeon General. Rockville, MD: US Department of Health and Human Services, National
Institute of Dental and Craniofacial Research, National Institutes of Health, 2000:63, 74–
94, 245–74.
Vol. 50 / No. RR-14 MMWR 33
49. Fejerskov O, Manji F, Baelum V. The nature and mechanisms of dental fluorosis in man. J
Dent Res 1990;69(special issue):692–700.
50. Avery JK. Agents affecting tooth and bone development. In: Avery JK, ed. Oral development
and histology. 2nd ed. New York, NY: Theime Medical Publishers, 1994:130–41.
51. DenBesten PK, Thariani H. Biological mechanisms of fluorosis and level and timing of
systemic exposure to fluoride with respect to fluorosis. J Dent Res 1992;71:1238–43.
52. Evans RW, Stamm JW. Dental fluorosis following downward adjustment of fluoride in
drinking water. J Public Health Dent 1991;51:91–8.
53. Dean HT. The investigation of physiological effects by the epidemiological method. In:
Moulton FR, ed. Fluorine and dental health. Washington, DC: American Association for
the Advancement of Science, 1942;19:23–31.
54. Fejerskov O, Manji F, Baelum V, Møller IJ. Dental fluorosis—a handbook for health workers.
Copenhagen: Munksgaard, 1988.
55. Kaminsky LS, Mahoney MC, Leach J, Melius J, Miller MJ. Fluoride: benefits and risks of
exposure. Crit Rev Oral Biol Med 1990;1:261–81.
56. Clark DC, Hann HJ, Williamson MF, Berkowitz J. Aesthetic concerns of children and
parents in relation to different classifications of the Tooth Surface Index of Fluorosis.
Community Dent Oral Epidemiol 1993;21:360–4.
57. Dean HT. Endemic fluorosis and its relation to dental caries. Public Health Rep 1938;53:1443–
52.
58. Clark DC. Trends in prevalence of dental fluorosis in North America. Community Dent Oral
Epidemiol 1994;22:148–52.
59. Szpunar SM, Burt BA. Trends in the prevalence of dental fluorosis in the United States: a
review. J Public Health Dent 1987;47:71–9.
60. Brunelle JA. The prevalence of dental fluorosis in U.S. children, 1987. J Dent Res
1989;68(special issue):995.
61. Heller KE, Eklund SA, Burt BA. Dental caries and dental fluorosis at varying water fluoride
concentrations. J Public Health Dent 1997;57:136–43.
62. Pendrys DG, Katz RV, Morse DR. Risk factors for enamel fluorosis in a fluoridated
population. Am J Epidemiol 1994;140:461–71.
63. Osuji OO, Leake JL, Chipman ML, Nikiforuk G, Locker D, Levine N. Risk factors for dental
fluorosis in a fluoridated community. J Dent Res 1988;67:1488–92.
64. Pendrys DG, Katz RV. Risk for enamel fluorosis associated with fluoride supplementation,
infant formula, and fluoride dentifrice use. Am J Epidemiol 1989;130:1199–208.
65. Pendrys DG. Risk for fluorosis in a fluoridated population: implications for the dentist
and hygienist. J Am Dent Assoc 1995;126:1617–24.
66. US Department of Health, Education, and Welfare. Public Health Service drinking water
standards, revised 1962. Washington, DC: US Public Health Service, Department of Health,
Education, and Welfare, 1962; PHS publication no. 956.
67. Galagan DJ, Vermillion JR. Determining optimum fluoride concentrations. Public Health
Rep 1957;72:491–3.
68. CDC. Engineering and administrative recommendations for water fluoridation, 1995. MMWR
1995;44(No. RR-13):1–40.
69. US Environmental Protection Agency. 40 CFR Part 141.62. Maximum contaminant levels
for inorganic contaminants. Code of Federal Regulations 1998:402.
70. US Environmental Protection Agency. 40 CFR Part 143. National secondary drinking water
regulations. Code of Federal Regulations 1998;514–7.
71. US Department of Health and Human Services, Food and Drug Administration. 21 CFR
Part 165.110. Bottled water. Federal Register 1995;60:57124–30.
72. US Food and Drug Administration. 21 CFR Part 355. Anticaries drug products for over-
the-counter human use. Code of Federal Regulations 1999:280–5.
34 MMWR August 17, 2001
73. American Dental Association. ADA guide to dental therapeutics. 1st ed. Chicago, IL:
American Dental Association, 1998.
74. American Academy of Pediatric Dentistry. Special issue: reference manual 1995. Pediatr
Dent 1994–95;16(special issue):1–96.
75. American Academy of Pediatrics Committee on Nutrition. Fluoride supplementation for
children: interim policy recommendations. Pediatrics 1995;95:777.
76. Singer L, Jarvey BA, Venkateswarlu P, Armstrong WD. Fluoride in plaque. J Dent Res
1970;49:455.
77. Dabeka RW, McKenzie AD, Lacroix GMA. Dietary intakes of lead, cadmium, arsenic and
fluoride by Canadian adults: a 24-hour duplicate diet study. Food Addit Contam 1987;4:89–
102.
78. Kramer L, Osis D, Wiatrowski E, Spencer H. Dietary fluoride in different areas of the United
States. Am J Clin Nutr 1974;27:590–4.
79. Osis D, Kramer L, Wiatrowski E, Spencer H. Dietary fluoride intake in man. J Nutr
1974;104:1313–8.
80. Singer L, Ophaug RH, Harland BF. Fluoride intake of young adult males in the United
States. Am J Clin Nutr 1980;33:328–32.
81. Ophaug RH, Singer L, Harland BF. Estimated fluoride intake of average two-year-old
children in four dietary regions of the United States. J Dent Res 1980;59:777–81.
82. Ophaug RH, Singer L, Harland BF. Estimated fluoride intake of 6-month-old infants in four
dietary regions of the United States. Am J Clin Nutr 1980;33:324–7.
83. Singer L, Ophaug RH, Harland BF. Dietary fluoride intake of 15-19-year-old male adults
residing in the United States. J Dent Res 1985;64:1302–5.
84. Pang DTY, Phillips CL, Bawden JW. Fluoride intake from beverage consumption in a
sample of North Carolina children. J Dent Res 1992;71:1382–8.
85. Levy SM, Kohout FJ, Guha-Chowdhury N, Kiritsy MC, Heilman JR, Wefel JS. Infants’
fluoride intake from drinking water alone, and from water added to formula, beverages,
and food. J Dent Res 1995;74:1399–407.
86. Levy SM, Kiritsy MC, Warren JJ. Sources of fluoride intake in children. J Public Health
Dent 1995;55:39–52.
87. Johnson J Jr, Bawden JW. The fluoride content of infant formulas available in 1985.
Pediatr Dent 1987;9:33–7.
88. Dean HT, Jay P, Arnold FA Jr, Elvove E. Domestic water and dental caries. II. A study of
2,832 white children, aged 12–14 years, of 8 suburban Chicago communities, including
Lactobacillus acidophilus
studies of 1,761 children. Public Health Rep 1941;56:761–92.
89. Dean HT, Arnold FA Jr, Elvove E. Domestic water and dental caries. V. Additional studies
of the relation of fluoride domestic water to dental caries experience in 4,425 white
children, aged 12 to 14 years, of 13 cities in 4 states. Public Health Rep 1942;57:1155–79.
90. Galagan DJ. Climate and controlled fluoridation. J Am Dent Assoc 1953;47:159–70.
91. Galagan DJ, Lamson GG Jr. Climate and endemic dental fluorosis. Public Health Rep
1953;68:497–508.
92. Galagan DJ, Vermillion JR, Nevitt GA, Stadt ZM, Dart RE. Climate and fluid intake. Public
Health Rep 1957;72:484–90.
93. CDC. Fluoridation census 1992 summary. Atlanta, GA: US Department of Health and
Human Services, Public Health Service, CDC, 1993.
94. Arnold FA Jr, Likins RC, Russell AL, Scott DB. Fifteenth year of the Grand Rapids Fluoridation
Study. J Am Dent Assoc 1962;65:780–5.
95. Ast DB, Fitzgerald B. Effectiveness of water fluoridation. J Am Dent Assoc 1962;65:581–7.
96. Blayney JR, Hill IN. Fluorine and dental caries. J Am Dent Assoc 1967;74(special issue):225–
302.
97. Hutton WL, Linscott BW, Williams DB. Final report of local studies on water fluoridation
in Brantford. Can J Public Health 1956;47:89–92.
Vol. 50 / No. RR-14 MMWR 35
98. Brunelle JA, Carlos JP. Recent trends in dental caries in U.S. children and the effect of
water fluoridation. J Dent Res 1990;69(special issue):723–7.
99. Newbrun E. Effectiveness of water fluoridation. J Public Health Dent 1989;49(special
issue):279–89.
100. Ripa LW. A half-century of community water fluoridation in the United States: review and
commentary. J Public Health Dent 1993;53:17–44.
101. Grembowski D, Fiset L, Spadafora A. How fluoridation affects adult dental caries: systemic
and topical effects are explored. J Am Dent Assoc 1992;123:49–54.
102. Wiktorsson A-M, Martinsson T, Zimmerman M. Salivary levels of lactobacilli, buffer
capacity and salivary flow rate related to caries activity among adults in communities
with optimal and low water fluoride concentrations. Swed Dent J 1992;16:231–7.
103. Eklund SA, Burt BA, Ismail AI, Calderone JJ. High-fluoride drinking water, fluorosis, and
dental caries in adults. J Am Dent Assoc 1987;114:324–8.
104. Sreebny LM, Schwartz SS. A reference guide to drugs and dry mouth—2nd ed.
Gerodontology 1997;14:33–47.
105. Burt BA, Ismail AI, Eklund SA. Root caries in an optimally fluoridated and a high-fluoride
community. J Dent Res 1986;65:1154–8.
106. Stamm JS, Banting DW, Imrey PB. Adult root caries survey of two similar communities
with contrasting natural water fluoride levels. J Am Dent Assoc 1990;120:143–9.
107. Brustman B. Impact of exposure to fluoride-adequate water on root surface caries in
elderly. Gerodontics 1986;2:203–7.
108. Jones CM, Taylor GO, Whittle JG, Evans D, Trotter DP. Water fluoridation, tooth decay in
5 year olds, and social deprivation measured by the Jarman score: analysis of data from
British dental surveys. BMJ 1997;315:514–7.
109. Provart SJ, Carmichael CL. The relationship between caries, fluoridation, and material
deprivation in five-year-old children in County Durham. Community Dent Health
1995;12:200–3.
110. Slade GD, Spencer AJ, Davies MJ, Stewart JF. Influence of exposure to fluoridated water
on socioeconomic inequalities in children’s caries experience. Community Dent Oral
Epidemiol 1996;24:89–100.
111. Kumar JV, Swango PA, Lininger LL, Leske GS, Green EL, Haley VB. Changes in dental
fluorosis and dental caries in Newburgh and Kingston, New York. Am J Public Health
1998;88:1866–70.
112. Graves RC, Bohannan HM, Disney JA, Stamm JW, Bader JD, Abernathy JR. Recent dental
caries and treatment patterns in US children. J Public Health Dent 1986;46:23–9.
113. Ast DB, Smith DJ, Wachs B, Cantwell KT. Newburgh-Kingston caries-fluorine study. XIV.
Combined clinical and roentgenographic dental findings after ten years of fluoride
experience. J Am Dent Assoc 1956;52:314–25.
114. Russell AL. Dental fluorosis in Grand Rapids during the seventeenth year of fluoridation.
J Am Dent Assoc 1962;65:608–12.
115. Lewis DW, Banting DW. Water fluoridation: current effectiveness and dental fluorosis.
Community Dent Oral Epidemiol 1994;22:153–8.
116. Kumar JV, Swango PA. Fluoride exposure and dental fluorosis in Newburgh and Kingston,
New York: policy implications. Community Dent Oral Epidemiol 1999;27:171–80.
117. Szpunar SM, Burt BA. Dental caries, fluorosis, and fluoride exposure in Michigan
schoolchildren. J Dent Res 1988;67:802–6.
118. Horowitz HS. School fluoridation for the prevention of dental caries. Int Dent J 1973;23:346–
53.
119. Horowitz HS, Law FE, Pritzker T. Effect of school water fluoridation on dental caries, St.
Thomas, V.I. Public Health Rep 1965;80:381–8.
120. Horowitz HS, Heifetz SB, Law FE, Driscoll WS. School fluoridation studies in Elk Lake,
Pennsylvania, and Pike County, Kentucky—results after eight years. Am J Public Health
1968;58:2240–50.
36 MMWR August 17, 2001
121. Horowitz HS, Heifetz SB, Law FE. Effect of school water fluoridation on dental caries: final
results in Elk Lake, PA, after 12 years. J Am Dent Assoc 1972;84:832–8.
122. Heifetz SB, Horowitz HS, Brunelle JA. Effect of school water fluoridation on dental caries:
results in Seagrove, NC, after 12 years. J Am Dent Assoc 1983;106:334–7.
123. King RS, Iafolla TJ, Rozier RG, Satterfield WC, Spratt CJ. Effectiveness of school water
fluoridation and fluoride mouthrinses. J Dent Res 1995;74(special issue):192.
124. CDC. Acute fluoride poisoning—North Carolina. MMWR 1974;23:199.
125. Hoffman R, Mann J, Calderone J, Trumbull J, Burkhart M. Acute fluoride poisoning in a
New Mexico elementary school. Pediatrics 1980;65:897–900.
126. Vogt RL, Witherell L, LaRue D, Klaucke DN. Acute fluoride poisoning associated with an
on-site fluoridator in a Vermont elementary school. Am J Public Health 1982;72:1168–9.
127. Stannard J, Rovero J, Tsamtsouris A, Gavris V. Fluoride content of some bottled waters
and recommendations for fluoride supplementation. J Pedod 1990;14:103–7.
128. Weinberger SJ. Bottled drinking waters: are the fluoride concentrations shown on the
label accurate? Int J Paediatr Dent 1991;1:143–6.
129. Van Winkle S, Levy SM, Kiritsy MC, Heilman JR, Wefel JS, Marshall T. Water and formula
fluoride concentrations: significance for infants fed formula. Pediatr Dent 1995;17:305–
10.
130. Mark AM. Americans taking to the bottle: loss of important fluoride source may be result.
ADA News 1998;29:12.
131. US Environmental Protection Agency. 40 CFR Part 141 Subpart O. Consumer confidence
reports. Federal Register 1998;63:44526–36.
132. Duckworth RM, Morgan SN, Burchell CK. Fluoride in plaque following use of dentifrices
containing sodium monofluorophosphate. J Dent Res 1989;68:130–3.
133. Duckworth RM, Morgan SN. Oral fluoride retention after use of fluoride dentifrices.
Caries Res 1991;25:123–9.
134. Sidi AD. Effect of brushing with fluoride toothpastes on the fluoride, calcium, and
inorganic phosphorus concentrations in approximal plaque of young adults. Caries Res
1989;23:268–71.
135. Reintsema H, Schuthof J, Arends J. An in vivo investigation of the fluoride uptake in
partially demineralized human enamel from several different dentifrices. J Dent Res
1985;64:19–23.
136. Stookey GK, Schemehorn BR, Cheetham BL, Wood GD, Walton GV. In situ fluoride uptake
from fluoride dentifrices by carious enamel. J Dent Res 1985;64:900–3.
137. Bruun C, Givskov H, Thylstrup A. Whole saliva fluoride after toothbrushing with NaF and
MFP dentifrices with different F concentrations. Caries Res 1984;18:282–8.
138. Levy SM. Review of fluoride exposures and ingestion. Community Dent Oral Epidemiol
1994;22:173–80.
139. Horowitz HS, Law FE, Thompson MB, Chamberlin SR. Evaluation of a stannous fluoride
dentifrice for use in dental public health programs. I. Basic findings. J Am Dent Assoc
1966;72:408–22.
140. James PMC, Anderson RJ. Clinical testing of a stannous fluoride-calcium pyrophosphate
dentifrice in Buckinghamshire school children. Br Dent J 1967;123:33–9.
141. Jordan WA, Peterson JK. Caries-inhibiting value of a dentifrice containing stannous
fluoride: final report of a two year study. J Am Dent Assoc 1959;58:42–4.
142. Muhler JC. Effect of a stannous fluoride dentifrice on caries reduction in children during
a three-year study period. J Am Dent Asoc 1962;64:216–24.
143. Stookey GK. Are all fluoride dentifrices the same? In: Wei SHY, ed. Clinical uses of
fluorides: a state of the art conference on the uses of fluorides in clinical dentistry: May
11 and 12, 1984, Holiday Inn, Union Square, San Francisco, California. Philadelphia, PA:
Lea & Febiger, 1985:105–31.
Vol. 50 / No. RR-14 MMWR 37
144. Clarkson JE, Ellwood RP, Chandler RE. A comprehensive summary of fluoride dentifrice
caries clinical trials. Am J Dent 1993;6(special issue):59–106.
145. Stamm JW. The value of dentifrices and mouthrinses in caries prevention. Int Dent J
1993;43:517–27.
146. Mellberg JR, Ripa LW. Fluoride dentifrices. In: Mellberg JR, Ripa LW. Fluoride in preventive
dentistry: theory and clinical applications. Chicago, IL: Quintessence Publishing Co.,
1983:215–41.
147. Mellberg JR. Fluoride dentifrices: current status and prospects. Int Dent J 1991;41:9–16.
148. Richards A, Banting DW. Fluoride toothpastes. In: Fejerskov O, Ekstrand J, Burt BA, eds.
Fluoride in dentistry. 2nd ed. Copenhagen: Munksgaard, 1996:328–46.
149. Lind OP, von der Fehr FR, Joost Larsen M, Möller IJ. Anti-caries effect of a 2% Na
2
PO
3
F-
dentifrice in a Danish fluoride area. Community Dent Oral Epidemiol 1976;4:7–14.
150. O’Mullane DM, Clarkson J, Holland T, O’Hickey S, Whelton H. Effectiveness of water
fluoridation in the prevention of dental caries in Irish children. Community Dent Health
1988;5:331–44.
151. Stookey GK, Beiswanger BB. Topical fluoride therapy. In: Harris NO, Christen AG, eds.
Primary preventive dentistry. 4th ed. Stamford, CT: Appleton & Lang, 1995:193–233.
152. Horowitz HS, Ismail AI. Topical fluorides in caries prevention. In: Fejerskov O, Ekstrand J,
Burt BA, eds. Fluorides in dentistry. 2nd ed. Copenhagen: Munksgaard, 1996:311–27.
153. Ronis DL, Land WP, Passow E. Tooth brushing, flossing, and preventive dental visits by
Detroit-area residents in relation to demographic and socioeconomic factors. J Public
Health Dent 1993;53:138–45.
154. Wagener DK, Nourjah P, Horowitz AM. Trends in childhood use of dental care products
containing fluoride: United States, 1983–89. Hyattsville, MD: U.S. Department of Health
and Human Services, Public Health Service, CDC, 1992. (Advanced data from vital health
statistics; no. 219).
155. Peffley GE, Muhler JC. The effect of a commercially available stannous fluoride dentifrice
under controlled brushing habits on dental caries incidence in children: preliminary
report. J Dent Res 1960;39:871–5.
156. Bixler D, Muhler JC. Experimental clinical human caries test design and interpretation. J
Am Dent Assoc 1962;65:482–90.
157. Chesters RK, Huntington E, Burchell CK, Stephen KW. Effect of oral care habits on caries
in adolescents. Caries Res 1992;26:299–304.
158. Chesnutt IG, Schafer F, Jacobson APM, Stephen KW. The influence of toothbrushing
frequency and post-brushing rinsing on caries experience in a caries clinical trial.
Community Dent Oral Epidemiol 1998;26:406–11.
159. Duckworth RM, Knoop DTM, Stephen KW. Effect of mouthrinsing after toothbrushing
with a fluoride dentifrice on human salivary fluoride levels. Caries Res 1991;25:287–91.
160. Sjögren K, Birkhed D, Ruben J, Arends J. Effect of post-brushing water rinsing on caries-
like lesions at approximal and buccal sites. Caries Res 1995;9:337–42.
161. Conti AJ, Lotzkar S, Daley R, Cancro L, Marks RG, McNeal DR. A 3-year clinical trial to
compare efficacy of dentifrices containing 1.14% and 0.76% sodium
monofluorophosphate. Community Dent Oral Epidemiol 1988;16:135–8.
162. Fogels HR, Meade JJ, Griffith J, Miragliuolo R, Cancro LP. A clinical investigation of a
high-level fluoride dentifrice. J Dent Child 1988;55:210–5.
163. Hanachowicz L. Caries prevention using a 1.2% sodium monofluorophosphate dentifrice
in an aluminum oxide trihydrate base. Community Dent Oral Epidemiol 1984;12:10–6.
164. O’Mullane DM, Kavanagh D, Ellwood RP, et al. A three-year clinical trial of a combination
of trimetaphosphate and sodium fluoride in silica toothpastes. J Dent Res 1997;76:1776–
81.
165. Lalumandier JA, Rozier RG. The prevalence and risk factors of fluorosis among patients
in a pediatric dental practice. Pediatr Dent 1995;17:19–25.
38 MMWR August 17, 2001
166. Mascarenhas AK, Burt BA. Fluorosis risk from early exposure to fluoride toothpaste.
Community Dent Oral Epidemiol 1998;26:241–8.
167. Milsom K, Mitropoulos CM. Enamel defects in 8-year-old children in fluoridated and non-
fluoridated parts of Cheshire. Caries Res 1990;24:286–9.
168. Riordan PJ. Dental fluorosis, dental caries and fluoride exposure among 7-year-olds.
Caries Res 1993;27:71–7.
169. Skotowski MC, Hunt RJ, Levy SM. Risk factors for dental fluorosis in pediatric dental
patients. J Public Health Dent 1995;55:154–9.
170. Pendrys DG, Katz RV, Morse DE. Risk factors for enamel fluorosis in a nonfluoridated
population. Am J Epidemiol 1996;143:808–15.
171. Nacacche H, Simard PL, Trahan L, et al. Factors affecting the ingestion of fluoride dentrifice
by children. J Public Health Dent 1992;52:222–6.
172. Simard PL, Naccache H, Lachapelle D, Brodeur JM. Ingestion of fluoride from dentifrices
by children aged 12 to 24 months. Clin Pediatr 1991;30:614–7.
173. Barnhart WE, Hiller LK, Leonard GJ, Michaels SE. Dentifrice usage and ingestion among
four age groups. J Dent Res 1974;53:1317–22.
174. Baxter PM. Toothpaste ingestion during toothbrushing by school children. Br Dent J
1980;148:125–8.
175. Hargreaves JA, Ingram GS, Wagg BJ. A gravimetric study of the ingestion of toothpaste
by children. Caries Res 1972;6:236–43.
176. Beltrán ED, Szpunar SM. Fluoride in toothpastes for children: suggestion for change.
Pediatr Dent 1988;10:185–8.
177. Levy SM. A review of fluoride intake from fluoride dentifrice. J Dent Child 1993;61:115–24.
178. Koch G, Petersson L-G, Kling E, Kling L. Effect of 250 and 1000 ppm fluoride dentifrice on
caries: a three-year clinical study. Swed Dent J 1982;6:233–8.
179. Mitropoulos CM, Holloway PJ, Davies TGH, Worthington HV. Relative efficacy of dentifrices
containing 250 or 1000 ppm F
-
in preventing dental caries—report of a 32-month clinical
trial. Community Dent Health 1984;1:193–200.
180. Winter GB, Holt RD, Williams BF. Clinical trial of a low-fluoride toothpaste for young
children. Int Dent J 1989;39:227–35.
181. Holt RD, Morris CE, Winter GB, Downer MC. Enamel opacities and dental caries in children
who used a low fluoride toothpaste between 2 and 5 years of age. Int Dent J 1994;44:331–
41.
182. Horowitz HS. The need for toothpastes with lower than conventional fluoride
concentrations for preschool-aged children. J Public Health Dent 1992;52:216–21.
183. Zero DT, Raubertas RF, Fu J, Pedersen AM, Hayes AL, Featherstone JDB. Fluoride
concentrations in plaque, whole saliva, and ductal saliva after application of home-use
topical fluorides. J Dent Res 1992;71:1768–75.
184. Horowitz HS, Creighton WE, McClendon BJ. The effect on human dental caries of weekly
oral rinsing with a sodium fluoride mouthwash: a final report. Arch Oral Biol 1971;16:609–
16.
185. Rugg-Gunn AJ, Holloway PJ, Davies TGH. Caries prevention by daily fluoride
mouthrinsing: report of a three-year clinical trial. Br Dent J 1973;135:353–60.
186. DePaola PF, Soparkar P, Foley S, Bookstein F, Bakhos Y. Effect of high-concentration
ammonium and sodium fluoride rinses in dental caries in schoolchildren. Community
Dent Oral Epidemiol 1977;5:7–14.
187. Leverett DH, Sveen OB, Jensen ØE. Weekly rinsing with a fluoride mouthrinse in an
unfluoridated community: results after seven years. J Public Health Dent 1985;45:95–100.
188. Ripa LW, Leske GS, Sposato A, Rebich T. Supervised weekly rinsing with a 0.2 percent
neutral NaF solution: final results of a demonstration program after six school years. J
Public Health Dent 1983;43:53–62.
189. Ripa LW, Leske GS, Sposato AL, Rebich T Jr. Supervised weekly rinsing with a 0.2%
neutral NaF solution: results after 5 years. Community Dent Oral Epidemiol 1983;11:1–6.
Vol. 50 / No. RR-14 MMWR 39
190. Ripa LW, Leske G. Effect on the primary dentition of mouthrinsing with a 0.2 percent
neutral NaF solution: results from a demonstration program after four school years.
Pediatr Dent 1981;3:311–5.
191. Ripa LW. A critique of topical fluoride methods (dentifrices, mouthrinses, operator-, and
self-applied gels) in an era of decreased caries and increased fluorosis prevalence. J
Public Health Dent 1991;51:23–41.
192. Haugejorden O, Lervik T, Riordan PJ. Comparison of caries prevalence 7 years after
discontinuation of school-based fluoride rinsing or toothbrushing in Norway. Community
Dent Oral Epidemiol 1985;13:2–6.
193. Leske GS, Ripa LW, Green E. Posttreatment benefits in a school-based fluoride
mouthrinsing program: final results after 7 years of rinsing by all participants. Clin Prev
Dent 1986;8:19–23.
194. Holland TJ, Whelton H, O’Mullane DM, Creedon P. Evaluation of a fortnightly school-
based sodium fluoride mouthrinse 4 years following its cessation. Caries Res 1995;29:431–
4.
195. Disney JA, Graves RC, Stamm JW, Bohannan HM, Abernathy JR. Comparative effects of
a 4-year fluoride mouthrinse program on high and low caries forming grade 1 children.
Community Dent Oral Epidemiol 1989;17:139–43.
196. Klein SP, Bohannan HM, Bell RM, Disney JA, Foch CB, Graves RC. The cost and effectiveness
of school-based preventive dental care. Am J Public Health 1985;75:382–91.
197. Nourjah P, Horowitz AM, Wagener DK. Factors associated with the use of fluoride
supplements and fluoride dentifrice by infants and toddlers. J Public Health Dent
1994;54:47–54.
198. Leverett DH, Adair SM, Vaughan BW, Proskin HM, Moss ME. Randomized clinical trial of
the effect of prenatal fluoride supplements in preventing dental caries. Caries Res
1997;31:174–9.
199. Aasenden R, Peebles TC. Effects of fluoride supplementation from birth on human
deciduous and permanent teeth. Arch Oral Biol 1974;19:321–6.
200. de Liefde B, Herbison GP. The prevalence of developmental defects of enamel and dental
caries in New Zealand children receiving differing fluoride supplementation in 1982 and
1985. N Z Dent J 1989;85:2–8.
201. D’Hoore W, Van Nieuwenhuysen J-P. Benefits and risks of fluoride supplementation:
caries prevention versus dental fluorosis. Eur J Pediatr 1992;151:613–6.
202. Allmark C, Green HP, Linney AD, Wills DJ, Picton DCA. A community study of fluoride
tablets for school children in Portsmouth: results after six years. Br Dent J 1982;153:426–
30.
203. Fanning EA, Cellier KM, Somerville CM. South Australian kindergarten children: effects of
fluoride tablets and fluoridated water on dental caries in primary teeth. Aust Dent J
1980;25:259–63.
204. Marthaler TM. Caries-inhibiting effect of fluoride tablets. Helv Odont Acta 1969;13:1–13.
205. Widenheim J, Birkhed D. Caries-preventive effect on primary and permanent teeth and
cost-effectiveness of an NaF tablet preschool program. Community Dent Oral Epidemiol
1991;19:88–92.
206. Widenheim J, Birkhed D, Granath L, Lindgren G. Preeruptive effect of NaF tablets on
caries in children from 12 to 17 years of age. Community Dent Oral Epidemiol 1986;14:1–
4.
207. Margolis FJ, Reames HR, Freshman E, Macauley JC, Mehaffey H. Fluoride: ten-year
prospective study of deciduous and permanent dentition. Am J Dis Child 1975;129:794–
800.
208. Bagramian RA, Narendran S, Ward M. Relationship of dental caries and fluorosis to
fluoride supplement history in a non-fluoridated sample of schoolchildren. Adv Dent
Res 1989;3:161–7.
40 MMWR August 17, 2001
209. Holm A-K, Andersson R. Enamel mineralization disturbances in 12-year-old children with
known early exposure to fluorides. Community Dent Oral Epidemiol 1982;10:335–9.
210. Awad MA, Hargreaves JA, Thompson GW. Dental caries and fluorosis in 7–9 and 11–14
year old children who received fluoride supplements from birth. J Can Dent Assoc
1994;60:318–22.
211. Friis-Hasché E, Bergmann J, Wenzel A, Thylstrup A, Pedersen KM, Petersen PE. Dental
health status and attitudes to dental care in families participating in a Danish fluoride
tablet program. Community Dent Oral Epidemiol 1984;12:303–7.
212. Kalsbeek H, Verrips GH, Backer Dirks O. Use of fluoride tablets and effect on prevalence
of dental caries and dental fluorosis. Community Dent Oral Epidemiol 1992;20:241–5.
213. DePaola PF, Lax M. The caries-inhibiting effect of acidulated phosphate-fluoride chewable
tablets: a two-year double-blind study. J Am Dent Assoc 1968;76:554–7.
214. Driscoll WS, Heifetz SB, Korts DC. Effect of chewable fluoride tablets on dental caries in
schoolchildren: results after six years of use. J Am Dent Assoc 1978;97:820–4.
215. Stephen KW, Campbell D. Caries reduction and cost benefit after 3 years of sucking
fluoride tablets daily at school: a double-blind trial. Br Dent J 1978;144:202–6.
216. Stephen KW, McCall DR, Gilmour WH. Incisor enamel mottling in child cohorts which
had or had not taken fluoride supplements from 0–12 years of age. Proc Finn Dent Soc
1991;87:595–605.
217. Larsen MJ, Kirkegaard E, Poulsen S, Fejerskov O. Dental fluorosis among participants in
a non-supervised fluoride tablet program. Community Dent Oral Epidemiol 1989;17:204–
6.
218. Riordan PJ, Banks JA. Dental fluorosis and fluoride exposure in Western Australia. J
Dent Res 1991;70:1022–8.
219. Suckling GW, Pearce EIF. Developmental defects of enamel in a group of New Zealand
children: their prevalence and some associated etiological factors. Community Dent Oral
Epidemiol 1984;12:177–84.
220. Wöltgens JHM, Etty EJ, Nieuwland WMD. Prevalence of mottled enamel in permanent
dentition of children participating in a fluoride programme at the Amsterdam dental
school. J Biol Buccale 1989;17:15–20.
221. Woolfolk MW, Faja BW, Bagramian RA. Relation of sources of systemic fluoride to
prevalence of dental fluorosis. J Public Health Dent 1989;49:78–82.
222. Ismail AI, Brodeur J-M, Kavanagh M, Boisclair G, Tessier C, Picotte L. Prevalence of dental
caries and dental fluorosis in students, 11–17 years of age, in fluoridated and non-
fluoridated cities in Quebec. Caries Res 1990;24:290–7.
223. Margolis FJ, Burt BA, Schork A, Bashshur RL, Whittaker BA, Burns TL. Fluoride supplements
for children: a survey of physicians’ prescription practices. Am J Dis Child 1980;134:865–
8.
224. Szpunar SM, Burt BA. Fluoride exposure in Michigan schoolchildren. J Public Health
Dent 1990;50:18–23.
225. Levy SM, Muchow G. Provider compliance with recommended dietary fluoride supplement
protocol. Am J Public Health 1992:82:281–3.
226. Pendrys DG, Morse DE. Use of fluoride supplementation by children living in fluoridated
communities. J Dent Child 1990;57:343–7.
227. Pendrys DG, Morse DE. Fluoride supplement use by children in fluoridated communities.
J Public Health Dent 1995;55:160–4.
228. Jackson RD, Kelly SA, Katz BP, Hull JR, Stookey GK. Dental fluorosis and caries prevalence
in children residing in communities with different levels of fluoride in the water. J Public
Health Dent 1995;55:79–84.
229. Lasagna L. Balancing risks versus benefits in drug therapy decisions. Clin Ther
1998;20(suppl C):72–9.
Vol. 50 / No. RR-14 MMWR 41
230. Dijkman TG, Arends J. The role of ‘CaF
2
-like’ material in topical fluoridation of enamel in
situ. Acta Odontol Scand 1988;46:391–7.
231. Houpt M, Koenigsberg S, Shey Z. The effect of prior toothcleaning on the efficacy of
topical fluoride treatment: two-year results. Clin Prev Dent 1983;5:8–10.
232. Brudevold F, Savory A, Gardner DE, Spinelli M, Speirs R. A study of acidulated fluoride
solutions. I. In vitro effects on enamel. Arch Oral Biol 1963;8:167–77.
233. Ripa LW. Professionally (operator) applied topical fluoride therapy: a critique. Int Dent J
1981;31:105–20.
234. Wei SHY, Yiu CKY. Evaluation of the use of topical fluoride gel. Caries Res 1993;27(suppl
I):29–34.
235. Hagen PP, Rozier RG, Bawden JW. The caries-preventive effect of full- and half-strength
topical acidulated phosphate fluoride. Pediatr Dent 1985;7:185–91.
236. Ripa LW. An evaluation of the use of professional (operator-applied) topical fluorides. J
Dent Res 1990;69(special issue):786–96.
237. Horowitz HS, Doyle J. The effect on dental caries of topically applied acidulated phosphate-
fluoride: results after three years. J Am Dent Assoc 1971;82:359–65.
238. Johnston DW, Lewis DW. Three-year randomized trial of professionally applied topical
fluoride gel comparing annual and biannual application with/without prior prophylaxis.
Caries Res 1995;29:331–6.
239. Petersson LG. Fluoride mouthrinses and fluoride varnishes. Caries Res 1993;27(suppl
1):35–42.
240. Mandel ID. Fluoride varnishes—a welcome addition [Editorial]. J Public Health Dent
1994;54:67.
241. Wakeen LM. Legal implications of using drugs and devices in the dental office. J Public
Health Dent 1992;52:403–8.
242. Clark DC, Stamm JW, Tessier C, Robert G. The final results of the Sherbrooke-Lac Mégantic
fluoride varnish study. J Can Dent Assoc 1987;53:919–22.
243. de Bruyn H, Arends J. Fluoride varnishes—a review. J Biol Buccale 1987;15:71–82.
244. Helfenstein U, Steiner M. Fluoride varnishes (Duraphat): a meta-analysis. Community
Dent Oral Epidemiol 1994;22:1–5.
245. Twetman S, Petersson LG, Pakhomov GN. Caries incidence in relation to salivary mutans
streptococci and fluoride varnish applications in preschool children from low- and
optimal-fluoride areas. Caries Res 1996;30:347–53.
246. Seppä L. Studies of fluoride varnishes in Finland. Proc Finn Dent Soc 1991;87:541–7.
247. Seppä L, Leppänen T, Hausen H. Fluoride varnish versus acidulated phosphate fluoride
gel: a 3-year clinical trial. Caries Res 1995;29:327–30.
248. Seppä L, Tolonen T. Caries preventive effect of fluoride varnish applications performed
two or four times a year. Scand J Dent Res 1990;98:102–5.
249. Petersson LG, Arthursson L, Östberg C, Jönsson P, Gleerup A. Caries-inhibiting effects
of different modes of Duraphat varnish reapplication: a 3-year radiographic study. Caries
Res 1991;25:70–3.
250. Sköld L, Sundquist B, Eriksson B, Edeland C. Four-year study of caries inhibition of
intensive Duraphat application in 11–15-year-old children. Community Dent Oral Epidemiol
1994;22:8–12.
251. Adriaens ML, Dermaut LR, Verbeeck RMH. The use of ‘Fluor Protector,’ a fluoride varnish,
as a caries prevention method under orthodontic molar bands. Eur J Orthod 1990;12:316–
9.
252. Peyron M, Matsson L, Birkhed D. Progression of approximal caries in primary molars and
the effect of Duraphat treatment. Scand J Dent Res 1992;100:314–8.
253. Marthaler TM. Cariostatic efficacy of the combined use of fluorides. J Dent Res
1990;69(special issue):797–800.
42 MMWR August 17, 2001
254. US Preventive Services Task Force. Guide to clinical preventive services. 2nd ed.
Alexandria, VA: International Medical Publishing, 1996.
255. McKay FS. Relation of mottled enamel to caries. J Am Dent Assoc 1928;15:1429–37.
256. Clark DC, Hann HJ, Williamson MF, Berkowitz J. Effects of lifelong consumption of
fluoridated water or use of fluoride supplements on dental caries prevalence. Community
Dent Oral Epidemiol 1995;23:20–4.
257. Murray JJ, Rugg-Gunn AJ. Fluorides in caries prevention. 2nd ed. Boston, MA: Wright-
PSG, 1982. (Dental practitioner handbook no. 20).
258. Warner KE, Luce BR. Cost-benefit and cost-effectiveness analysis in health care: principles,
practice, and potential. Ann Arbor, MI: Health Administration Press, 1982.
259. Manski RJ, Moeller JF, Maas WR. Dental services: use, expenditures and sources of
payment, 1987. J Am Dent Assoc 1999;130:500–8.
260. Burt BA, ed. Proceedings for the workshop: Cost-effectiveness of caries prevention in
dental public health, Ann Arbor, Michigan, May 17–19, 1989. J Public Health Dent
1989;49(special issue):331–7.
261. Brown LJ, Lazar V. Dental procedure fees 1975 through 1995: how much have they
changed? J Am Dent Assoc 1998;129:1291–5.
262. Downer MC, Blinkhorn AS, Attwood D. Effect of fluoridation on the cost of dental treatment
among urban Scottish schoolchildren. Community Dent Oral Epidemiol 1981;9:112–6.
263. Attwood D, Blinkhorn AS. Reassessment of the effect of fluoridation on cost of dental
treatment among Scottish schoolchildren. Community Dent Oral Epidemiol 1989;17:79–
82.
264. Garcia AI. Caries incidence and costs of prevention programs. J Public Health Dent
1989:49(special issue):259–71.
265. Anonymous. Which toothpaste is right for you? Consumer Reports 1998;August:11–4.
266. Doherty NJG, Brunelle JA, Miller AJ, Li S-H. Costs of school-based mouthrinsing in 14
demonstration programs in USA. Community Dent Oral Epidemiol 1984;12:35–8.
267. Leverett DH. Effectiveness of mouthrinsing with fluoride solutions in preventing coronal
and root caries. J Public Health Dent 1989;49(special issue):310–6.
268. van Rijkom HM, Truin GJ, van ’t Hof MA. A meta-analysis of clinical studies on the caries-
inhibiting effect of fluoride gel treatment. Caries Res 1998;32:83–92.
269. Eklund SA, Pittman JL, Heller KE. Professionally applied topical fluoride and restorative
care in insured children. J Public Health Dent 2000;60:33–8.
270. Petersson LG, Westerberg I. Intensive fluoride varnish program in Swedish adolescents:
economic assessment of a 7-year follow-up study on proximal caries incidence. Caries
Res1994;28:59–63.
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August 17, 2001 / Vol. 50 / No. RR-14
Recommendations
and
Reports
Continuing Education Activity
Sponsored by CDC
Recommendations for Using Fluoride to Prevent and Control Dental Caries
in the United States
EXPIRATION — August 17, 2002
You must complete and return the response form electronically or by mail by August 17, 2002, to receive
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CE-2 MMWR August 17, 2001
GOAL AND OBJECTIVES
This
MMWR
provides recommendations regarding the use of fluoride to prevent and control dental caries in the
United States. These recommendations were prepared by CDC staff members and a work group of specialists in
fluoride research or policy. This goal of this report is to increase appropriate use of fluoride modalities in
preventing and controlling dental caries through improved professional understanding and practice. Upon
completion of this continuing educational activity, the reader should be able to a) list the factors used in the
decision to prescribe fluoride supplements; b) describe the recommendations for counseling patients on the use
of fluoride products in oral self-care practices, especially for children aged <6 years; c) list the sources for
determining the current level of fluoride delivered by a community water system; d) identify the factors used to
assess caries risk; e) explain how fluoride prevents dental caries; f) describe the recommendations for choosing
the appropriate fluoride modalities for patients; and g) list the risk factors for enamel fluorosis.
To receive continuing education credit, please answer all of the following questions.
1. Which of the following statements are true? (
Indicate all that apply.
)
A. The U.S. Environmental Protection Agency requires all community water systems
to provide each customer an annual report that includes the fluoride concentration
of their water.
B. Fluoridated community drinking water and toothpaste containing fluoride are the
most common sources for fluoride in the United States.
C. A person at high risk for dental caries will not require more frequent exposure to
fluoride than persons at low risk.
D. Water and other beverages provide <50% of a person’s fluoride intake in the United
States.
2. Which of the following persons are believed to be at greater risk for dental caries?
(
Indicate all that apply.
)
A. Persons who do not seek dental treatment on a regular basis.
B. Persons with dental insurance.
C. Persons living in families with incomes below the poverty level.
D. Children with an older brother/sister having a history of high levels of dental decay.
3. Which of the following are risk factors for enamel fluorosis for children aged <6 years?
(
Indicate all that apply.
)
A. Taking fluoride supplements in an area with fluoridated drinking water.
B. Not being allowed to deliberately swallow toothpaste.
C. Using a pea-sized amount of toothpaste no more than twice a day.
D. Ingesting too much fluoride from any source during critical periods of tooth
development.
4. What is the most cost-effective measure to prevent dental caries in the United States?
A. Fluoridation of individual school water systems.
B. Use of a pea-sized amount of fluoride toothpaste twice a day.
C. Adding fluoride to the community water system.
D. Giving fluoride supplements to schoolchildren.
Vol. 50 / No. RR-14 MMWR CE-3
5. Which of the following statements regarding effective fluoride use are true? (
Indicate all
that apply.
)
A. Community water fluoridation should be continued as a safe and inexpensive
method to prevent dental caries.
B. Parents and caregivers should be provided information on use of fluoride
toothpaste for children aged <6 years.
C. Other fluoride modalities (e.g., mouthrinse and professionally applied gels) should
be targeted to patients at high risk for dental caries.
D. Fluoride supplements should be provided to children whose primary drinking water
has a low fluoride concentration and who are at high risk for dental caries.
6. Enamel fluorosis is . . .
A. hypermineralization of the dentin.
B. hypomineralization of the enamel.
C. demineralization of the enamel.
D. demineralization of the dentin.
7. At what age should a fluoride supplement first be prescribed to a child at high risk for
dental caries living in a community where the level of fluoride is below the optimal level?
A. Birth.
B. 3 months.
C. 6 months.
D. 9 months.
8. For which children at high risk should fluoride mouthrinses be used?
A. Those aged >2 years.
B. Those attending Head Start programs.
C. Those aged >6 years.
D. Those aged >2 years living in rural areas.
9. Currently, how many persons in the United States have access to fluoridated water in
their communities?
A. 104 million.
B. 114 million.
C. 134 million.
D. 144 million.
10. What is the optimal concentration of fluoride in community water systems in the United
States?
A. 0.7 parts per million (ppm).
B. 0.7–0.9 ppm.
C. 0.7–1.0 ppm.
D. 0.7–1.2 ppm.
CE-4 MMWR August 17, 2001
11. Indicate your work setting.
A. State/local health department.
B. Other public health agency.
C. Hospital clinic/private practice.
D. Managed care organization.
E. Academic institution.
F. Other.
12. Which best describes your professional activities?
A. Family practice.
B. Pediatrics.
C. Nursing.
D. General dentistry.
E. Pediatric dentistry.
F. Dental hygiene.
13. I plan to use these recommendations as the basis for . . . (
Indicate all that apply.
)
A. health education materials.
B. insurance reimbursement policies.
C. local practice guidelines.
D. public policy
E. other.
14. Each month, approximately how many patients do you counsel regarding fluoride use?
A. None.
B. 1–5.
C. 6–15.
D. 16–24.
E. 25.
15. How much time did you spend reading this report and completing the exam?
A. 2–2.5 hours.
B. More than 2.5 hours but fewer than 3 hours.
C. 3–3.5 hours.
D. More than 3.5 hours but fewer than 4 hours.
E. More than 4 hours.
16. After reading this report, I am confident I can list the factors used in the decision to
prescribe fluoride supplements.
A. Strongly agree.
B. Agree.
C. Neither agree or disagree.
D. Disagree.
E. Strongly disagree.
Vol. 50 / No. RR-14 MMWR CE-5
17. After reading this report, I am confident I can describe the recommendations for
counseling patients on the use of fluoride products in oral self-care practices, especially
for children aged <6 years.
A. Strongly agree.
B. Agree.
C. Neither agree or disagree.
D. Disagree.
E. Strongly disagree.
18. After reading this report, I am confident I can list the sources for determining the current
level of fluoride delivered by a community water system.
A. Strongly agree.
B. Agree.
C. Neither agree or disagree.
D. Disagree.
E. Strongly disagree.
19. After reading this report, I am confident I can identify the factors used to assess caries
risk.
A. Strongly agree.
B. Agree.
C. Neither agree or disagree.
D. Disagree.
E. Strongly disagree.
20. After reading this report, I am confident I can explain how fluoride prevents dental
caries.
A. Strongly agree.
B. Agree.
C. Neither agree or disagree.
D. Disagree.
E. Strongly disagree.
21. After reading this report, I am confident I can describe the recommendations for
choosing the appropriate fluoride modalities for patients.
A. Strongly agree.
B. Agree.
C. Neither agree or disagree.
D. Disagree.
E. Strongly disagree.
22. After reading this report, I am confident I can list the risk factors for enamel fluorosis.
A. Strongly agree.
B. Agree.
C. Neither agree or disagree.
D. Disagree.
E. Strongly disagree.
CE-6 MMWR August 17, 2001
23. The objectives are relevant to the goal of this report.
A. Strongly agree.
B. Agree.
C. Neither agree nor disagree.
D. Disagree.
E. Strongly disagree.
24. The figures, tables, and boxes are useful.
A. Strongly agree.
B. Agree.
C. Neither agree nor disagree.
D. Disagree.
E. Strongly disagree.
25. Overall, the presentation of the report enhanced my ability to understand the material.
A. Strongly agree.
B. Agree.
C. Neither agree nor disagree.
D. Disagree.
E. Strongly disagree.
26. These recommendations will affect my practice.
A. Strongly agree.
B. Agree
C. Neither agree nor disagree.
D. Disagree.
E. Strongly disagree.
27. How did you learn about this continuing education activity?
A. Internet.
B. Advertisement (e.g., fact sheet,
MMWR
cover, newsletter, or journal).
C. Coworker/supervisor.
D. Conference presentation.
E.
MMWR
subscription.
F. Other.
Correct answers for questions 1–10
1. A,B; 2. A,C, D; 3. A,D; 4. C; 5. A,B,C,D; 6. B; 7. C; 8. C; 9. D; 10. D.
Vol. 50 / No. RR-14 MMWR CE-7
MMWR
Response Form for Continuing Education Credit
August 17, 2001/Vol. 50/No. RR-14
Recommendations for Using Fluoride to Prevent and Control Dental Caries
in the United States
To receive continuing education credit, you must
1. provide your contact information;
2. indicate your choice of CME, CEU, or CNE credit;
3. answer all of the test questions;
4. sign and date this form or a photocopy;
5. submit your answer form by August 17, 2002.
Failure to complete these items can result in a delay or rejection of
your application for continuing education credit.
Detach or photocopy.
Last Name First Name
Street Address or P.O. Box
Apartment or Suite
City State ZIP Code
Phone Number Fax Number
E-Mail Address
Fill in the appropriate blocks to indicate your answers. Remember, you must answer all of the questions to receive
continuing education credit!
1.[ ] A[ ] B[ ] C[ ] D 15.[ ] A[ ] B[ ] C[ ] D[ ] E
2.[ ] A[ ] B[ ] C[ ] D 16.[ ] A[ ] B[ ] C[ ] D[ ] E
3.[ ] A[ ] B[ ] C[ ] D 17.[ ] A[ ] B[ ] C[ ] D[ ] E
4.[ ] A[ ] B[ ] C[ ] D 18.[ ] A[ ] B[ ] C[ ] D[ ] E
5.[ ] A[ ] B[ ] C[ ] D 19.[ ] A[ ] B[ ] C[ ] D[ ] E
6.[ ] A[ ] B[ ] C[ ] D 20.[ ] A[ ] B[ ] C[ ] D[ ] E
7.[ ] A[ ] B[ ] C[ ] D 21.[ ] A[ ] B[ ] C[ ] D[ ] E
8.[ ] A[ ] B[ ] C[ ] D 22.[ ] A[ ] B[ ] C[ ] D[ ] E
9.[ ] A[ ] B[ ] C[ ] D 23.[ ] A[ ] B[ ] C[ ] D[ ] E
10.[ ] A[ ] B[ ] C[ ] D 24.[ ] A[ ] B[ ] C[ ] D[ ] E
11.[ ] A[ ] B[ ] C[ ] D[ ] E[ ] F 25.[ ] A[ ] B[ ] C[ ] D[ ] E
12.[ ] A[ ] B[ ] C[ ] D[ ] E[ ] F 26.[ ] A[ ] B[ ] C[ ] D[ ] E
13.[ ] A[ ] B[ ] C[ ] D[ ] E 27.[ ] A[ ] B[ ] C[ ] D[ ] E[ ] F
14.[ ] A[ ] B[ ] C[ ] D[ ] E
Check One
c
CME Credit
c
CEU Credit
c
CNE Credit
Signature Date I Completed Exam
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