Canadian Consensus Conference On the Appropriate Use Of Fluoride Supplements For the Prevention Of Dental Caries In Children 

[ Background | Scientific Presentations | Development Of More Appropriate Fluoride Recommendations | Modification Of the New Recommendations and the Consensus Building Process | Conference Recommendations For Daily Fluoride Supplements | Algorithm For Fluoride Supplement Usage | Acknowledgements | References ] 

Background

Dental fluorosis is an early sign that children have ingested more than optimum amounts of fluoride. Water fluoridation has been in use for more than 50 years. In most developed countries, the prevalence of dental caries has dramatically decreased among the population, from the levels seen in the first six decades of this century. The decline has occurred in both fluoridated and non-fluoridated areas and there is a consensus among experts that the widespread availability of fluoride in water, toothpaste, gels, mouth rinses and other products has had a significant role in causing this decline.

The decline in the prevalence and severity of dental caries has also occurred in Canada, where there is evidence that dental caries are more prevalent in Canadians with low education status (less than 12 years of education) than those with high education status (college or university education). The shift and clustering of dental caries and the increase in the prevalence of dental fluorosis in Canadian children, led some experts to question the rationale for the routine and universal application of fluoride products.

An April 1992 conference, co-chaired by Drs. Chris Clark and Hardy Limeback, involving fluoride experts from Canada and the United States, resulted in the proposal of several new guidelines for the appropriate use of fluoride products. A major recommendation called for the severe restriction of fluoride supplements associated with the development of dental fluorosis.

The 1992 revision of the Canadian recommendation for fluoride supplements was proposed for the following reasons: widespread use of fluoridated toothpastes in Canada and evidence that young children ingest approximately one-third of the paste placed on the toothbrush; increased availability of fluoride in bottled soft drinks and other fluids in Canada; weak scientific evidence supporting the effectiveness of fluoride supplements; the finding that children of highly educated parents have multiple exposures to fluoride products early in life; and the observation that the daily use of fluoride supplements is difficult to follow by population groups who have high prevalence of dental caries. It is believed that fluoride supplements taken in single daily doses, in tablet or lozenge form, increase the risk of dental fluorosis more than fluoridated water because the tissues forming tooth enamel are highly sensitive to fluoride levels in the serum or the bone.

The 1992 Canadian fluoride conference resulted in a more conservative fluoride supplement schedule. This schedule was subsequently approved by the Canadian Dental Association (CDA). The CDA recommended that fluoride tablets not be given to babies and toddlers (birth to 3 years) and that 3 to 5-year-old children living in areas where the fluoride in the drinking water is less then 0.3 parts per million, should receive 0.25 mg of fluoride per day (or 0.5 mg of fluoride per day if fluoridated toothpaste is not used regularly). While most health care professionals accepted this new schedule, others, including some in the dental profession, continued to recommend the American Dental Association (ADA) fluoride schedule to Canadian residents.

This has raised a number of legal and academic questions, the main one being: should fluoride supplements in tablet form continue to be recommended for small children whose front teeth are susceptible to dental fluorosis, and if so, what fluoride schedule is most appropriate? Thus, despite a five-year period of adjustment after the CDA endorsed the recommendations of the 1992 fluoride conference, the confusion about which fluoride supplement schedule was most appropriate for Canadians was still not resolved. Early in 1997, CDA invited Dr. Hardy Limeback to organize a follow-up international conference to examine the current literature and determine if any further modification should be made to existing fluoride recommendations.

Prominent clinical scientists were invited to thoroughly re-examine the evidence for and against the use of fluoride supplements, present their findings in comprehensive reviews (to be published elsewhere), and develop new and more appropriate recommendations, with a particular focus on fluoride supplements. Additionally, the CDA involved representatives from various dental, medical and pharmaceutical organizations in a consensus building process. The ADA was invited but declined to send a representative. The pediatric medical specialists (Canadian Pediatric Society) were represented at this conference but the Canadian Medical Association was unable to send a representative.

The following is a summary of the conference held in Toronto on November 28 and 29, 1997. Brief explanations of the agenda and the recommendations that resulted from the conference are presented in this Journal article. Full conference proceedings will be published in an upcoming issue of Community Dentistry and Oral Epidemiology.

[ Top ]

Scientific Presentations

These participants were charged with developing new guidelines for fluoride use, in Canada, based on their analysis of the current evidence.

1. John Featherstone
A review of how daily low doses of fluoride from fluoride supplements (and fluoridated water) work to prevent and control dental caries.

2. Pamela DenBesten
A review of how the biological mechanism of low daily doses of fluoride causes dental fluorosis.

3. Amid Ismail
A review of the clinical evidence showing fluoride supplements are a primary risk factor for dental fluorosis in non-fluoridated areas.

4. David Banting
A review of the fluoride supplement recommendations in countries outside North America.

5. Hardy Limeback (Conference Chair)
A re-examination of the pre-eruptive and post-eruptive mechanism of the anti-caries effects of fluoride.

First, ask the following question: Does the child brush his or her teeth (or have teeth brushed by parent or guardian) using fluoridated toothpaste at least twice a day?

If the answer is NO, then supplemental topical fluoride exposure should be provided according to Table II.
If the answer is YES, then answer the following question: In your judgment, is the child susceptible to high dental caries activity?

If your answer is NO, then fluoride supplements are NOT required.
If your answer is YES, then supplemental topical fluoride exposure should be provided according to Table II.

[ Top ]

[ Top ]

Acknowledgements

The authors thank Benoit Soucy for co-organizing the conference, Richard McCoy, Anne Bauer and Brian Henderson for staff support and John O’Keefe for moderating the second day of the conference. A web site dedicate to this conference (with additional information) can be found at http://www.interlog.com/~hardyl

Reprint requests to: Dr. Hardy Limeback, Head of Preventive Dentistry, Faculty of Dentistry, University of Toronto, 124 Edward St., Toronto, ON M5G 1G6.

[ Top ]

[ Top ]