drinking water fluoridation and childrens health page

By John Sullivan, MD





Dental and gum disease is totally preventable, and is can cause lifetime pain, ill health, disability, and gets worse and more expensive to treat the longer it goes on.  Resources for treatment are limited; this is especially true for people with low income, without good dental insurance, seniors on public benefits, young children, and disabled people unable to participate easily for office exams and treatment.  Statewide, the scarcity of providers and funding is not expected to improve any time soon. Simple advice to brush and avoid sweets is unfortunately insufficient to promote dental health especially in high-risk populations

PREGNANCY: Get dental and gum disease treated and practice good dental care before you get pregnant to prevent medical complications for you and baby.

INFANCY:  Try to avoid passing your dental germs to your baby (especially if you have decay- prone teeth, you probably still have specific decay-causing germs in your mouth that may be passed on to him or her).  Try not to share spoons, lick pacifiers, etc.  Try to breast-feed.  Try to get the baby in the habit of falling asleep without the nipple in the mouth especially if formula feeding.  Avoid bottle propping.  When teeth erupt start cleaning them regularly (begin by wiping the infant’s gums with a cloth and when you begin to us a toothbrush, use a soft brush). Go easy on sweets, especially sticky ones, when introducing solids.  Avoid excessive juice in bottles.  Try to wean your baby from bottle to cup early as possible.

TODDLERHOOD and PRESCHOOLERS: Gradually let the child get accustomed to you touching her around the mouth, then inside.   Brush teeth regularly with a soft brush- toothpaste is not necessary at first, but some kids prefer it.  Replace brush when worn or old.  Use toothpaste without fluoride if the child does not rinse and spit well.  Then use a pea-sized amount of fluoridated toothpaste when she is old enough to not to swallow it.  Allow child to “help” brush or “pre-brush” when interested, but teach her that adult needs to finish up. Begin getting your child used to floss when there are many teeth especially if crowded. Floss holders may help for small mouths.
Prepare your child behaviorally for dental exams—for example, you may want to read books, play with dolls and toy instruments, visiting the dental office without exam, parent touching mouth and putting brush inside.  Think about how you talk about the dentist to generate positive expectations.  Medical provider should carefully examine teeth with well child checkups and may recommend dental referral or professionally applied topical fluoride in high risk cases.  Get a child in for a medical examination if you suspect decay as it may take a while to schedule your child with a dentist who sees young children.   Go ahead and get on a waiting list for the dentist as it could take many months to get in. Your medical provider, the Child Health and Disability Prevention Program, or Headstart program may be able to help with appointments; be patient and persistent. Make the first visits to dentist comfortable and positive and communicate to the dental office staff how your child does the best.

 Ensure your child’s diet is adequate in calcium. Ensure child is getting adequate fluoride after 12 months of age. If you live where there is community water fluoridation, your child will receive fluoride from drinking and food preparation water. If you are unsure if your water is fluoridated, telephone your water district. If you live in a community with non-fluoridated water, your child’s medical provider or dentist can prescribe the correct dose of supplement as drops or chewable tablet. Chewable tablets are more effective when chewed than swallowed whole.  If you move, find out if your new water contains fluoride or not.  If your child spends a long time in daycare with fluoridated water, decrease at home supplement.  Keep supplements (like medications, or iron containing vitamins) out of reach to avoid accidental overdose. It takes about 80 fluoride tablets for a 20-pound toddler to overdose.

  Try to get your child used to treats that are non-sugary. Try to set an example yourself as children copy what you do.  Get the child used to limited juice and rare sodas, and to accept water if thirsty.  Try to get in the habit of giving sweets, especially sticky ones, seldom.  Give sweets with meals not between and not around bedtime.

Dental fluorosis or spotting occurs during pre-eruption tooth mineralization.  In the case of permanent front teeth visible to the public, this is before age 6 or 8.  It is caused by excessive intake of fluoride from naturally or supplemental fluoridated water, prescribed supplements, prepared foods and beverages made with high fluoride water, certain foods, or from swallowing fluoridated toothpaste. In the US in people consuming water at 0.7 to 1.0 ppm fluoride (as in fluoride supplemented community water), one can occasionally see white spots on strong, decay-resistant teeth, although it is rare to see cosmetically significant white spots on front teeth.  This becomes more common when concentrations exceed 4 ppm (upper limit set by EPA for drinking water), and brown stains and pitting become a problem in naturally fluoridated water about 10 ppm, as does medically significant skeletal fluorosis.

Preventing excessive intake of fluoride in the first 6 years of life can minimize significant dental fluorosis.  Breast milk contains minimal fluoride and breast fed infants have less fluorosis.  Formula concentrates which are now required to be made with low concentrations of fluoride, can be prepared with non-fluoridated water.  Oral supplements should be given only as directed and not if the child drinks fluoridated water and possibly in lower doses if the child drinks many prepared beverages made with fluoridated water.  Children should not swallow fluoridated toothpaste. 

 SCHOOL CHILDREN:  Continue to reinforce proper brushing at least twice a day (especially after last food before bed) with fluoridated toothpaste when your children are old enough to spit it out instead of swallowing it. To be sure to brush all teeth, brush front, back, upper, lower, right, left, inside and outside; this method should take about 3 minutes, a timer may be useful. Invest in a new toothbrush every couple months or when the bristles are worn or frayed.  Some children are educated or motivated by trying “disclosing tablets” which color teeth until well brushed. The disclosing tablet shows clearly areas that child is missing when brushing. Some hygienists like child to show them how she brushes at home.  Promote flossing.   Find treats that are the least sticky and sugary you can. Make sodas a very occasional treat. Get child used to sugarless gum only.  Talk to your school about snacks and meals they provide, and “fundraisers” and vending machines.  Think again about eating that you are modeling. Xylitol gum or chewables are mildly protective especially at times when child is unlikely to brush.   Get regular dental checkups.  If on supplemental fluoride by mouth, ensure children are taking it as directed, and keep asking for refills till at least 11 years old.

 TEENS:  Adolescents need to be encouraged to practice good habits and to continue to get regular dental care. Discourage smoking or chewing tobacco, encourage use of mouth guards for sports activities. Ensure that they get established with regular dental care after leaving home. Make good dental care a lifetime habit.

SPECIAL RISK FACTORS:  Some children are at higher risk for dental disease and require even more diligence and monitoring.  Examples:  children in families with low income, members of disadvantaged minorities, immigrants, children adopted from adverse circumstances, children with behavioral, medical, or developmental obstacles to maintaining good oral hygiene and/or cooperating with exams and treatment, children requiring supplemental (usually sweet) formulas after infancy, people requiring tube feeding with little oral intake, children with gastroesophageal reflux, children with dental or medical conditions associated with decay prone teeth, children chronically  taking medications which reduce saliva such as antihistamines and some psychiatric drugs, children with reduced access or participation in medical or dental care.
Some parents find it is easier to get the teeth well cleaned using an electric brush (e.g., small mouth, limited dexterity of caregiver, child cooperative only very briefly for brushing, child is orally sensitive and vibration is easily tolerated, child is more prone to use electric brush than manual).

 ADVOCACY:  Currently in California, Denti-cal funding is very limited. There are several disincentives for dentists to accept Denti-cal patients. Dental provider reimbursement in many cases is below the cost of providing care and paper work and requirements for authorization are high. Covered restorative treatment is in many cases adequate, but in others below what most dentists would prefer to provide. Additionally provider supply and reimbursement issues severely restrict access to hospital dentistry. 

Few specialists in pediatric dentistry are being trained and are especially scarce in rural areas.  Many general dentists feel inadequately trained or uncomfortable treating young children or adults who have difficulty cooperating. There is a scarcity of dental hygienists.

In response to limited reimbursement and scarcity of providers, the medical system has made increasing use of mid-level providers to increase efficiency; this process is in a very early stage in dentistry.

Public Health, medical, dental, educational, and early childhood educational professionals are collaborating on many community measures (education, health promotion, enhanced access to care, obtaining grant funding, etc) to promote dental health in Humboldt County. 

The media relentlessly bombards children with millions of dollars worth of messages to eat unhealthily including foods promoting dental disease and obesity. In the US, most children, even toddlers, watch way too much TV.  Older kids need to know how to be informed consumers of media messages and information.

While it is only one component of dental health promotion, community water fluoridation is the single most effective and cost- effective preventative dental public health measure. This is especially for those in high-risk groups who have the majority of dental decay and the least access and resources for treatment.  In the last half-century community water fluoridation has made a major difference in dental health in the US. Currently 140 million people are served by fluoride naturally occurring in ground water, or by community water supplies supplemented with fluoride to a concentration sufficient to cut down substantially on decay. The careful supplementing of fluoride to community water has minimized risks of cosmetic dental fluorosis and made medically significant skeletal or dental fluorosis nearly unheard of. Community water fluoridation continues to confer additional protection even in people with reasonable dental hygiene who use topical fluoride, and benefits the elderly who are at risk for root caries as their gums recede. Community water fluoridation has a long record of safety and effectiveness. Public health and dental scholars, government, and international agencies rightly periodically review water fluoridation in view of new circumstances and research.  In the past, California was one of the states with the least fraction of people served with community water fluoridation, but recently enacted legislation requires water systems with more than 10,000 hookups to provide fluoride supplementation. 


“The fact is that I started out as somewhat skeptical and cautious about fluoridation. But then I became a firm believer as proof was assembled by scientists that fluoridation of a water supply will reduce the production of tooth cavities (our most prevalent disease) by 60%, and, just as important, that no disease or defect is caused by this procedure. What particularly allayed my early doubts about adding a chemical to public water supplies was learning that fluoride has always occurred naturally in water supplies.” Dr. Benjamin Spock
childrens health and fluoride
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