This Society (the Canadian Paediatric Society - CPS) parrots the age old “safe and effective” canards to attempt to consolidate the gains made in the incredibly stupid and misguided practice of artificial water fluoridation. The selected references are fallaciously used and misquoted ad nauseam to lull the uninitiated and innocent reader into believing their erroneous statements and pronoucements. All can be easily refuted as support for the termination of artificial water fluoridation continues to mount accross North America. Stay tuned, since they say that this position statement is a “Revision in progress” as of “February 2009.”
The use of fluoride in infants and children
Nutrition Committee, Canadian Paediatric Society (CPS)
Paediatric Child Health 2002;7(8):569-72
Reference No. N02-01 (Formerly N95-02)
Revision in progress February 2009
Healthy teeth for children
Index of position statements from the Nutrition and Gastroenterology Committee
The Canadian Paediatric Society gives permission to print single copies of this document from our website. Visit the index of position statements to see which are available as pdf files. For permission to reprint or reproduce multiple copies, please submit a detailed request to firstname.lastname@example.org.
The introduction of fluoride to drinking water in 1958
resulted in a dramatic reduction of dental caries.1 Subsequently, fluoride
supplements were advocated for children whose water was not fluoridated, and now
almost all toothpaste contains fluoride. The result is that multiple sources of
fluoride, such as fluoridated toothpastes, fluoride supplements (drops and
lozenges) and naturally occurring fluoride, have contributed to an increase in
the incidence of fluorosis. The challenge is to provide the right amount of
fluoride in a reliable and safe manner. Fluoride has been found to be effective
in preventing caries but there have been no controlled studies to evaluate the
The recommendations on fluoride use in a 1995 statement by
the Canadian Paediatric Society (CPS) 2 differed substantially from those of
the Canadian Dental Association (CDA). The position of the CDA3 was that,
apart from fluoride in water, the main source of fluoride should be fluoridated
toothpaste, and that supplements should not be used in children younger than
three years of age. The CPS position was that proper tooth brushing, especially
in high risk populations, may be difficult to implement; that delaying
supplementation until three years of age would result in higher caries rates;
and that supplements should be started at six months of age.2 More recent
studies of the actions of fluoride resulted in the modification of these two
positions. The position outlined in the present statement follows the principles
agreed on at the 1997 Canadian Consensus Conference on fluoride use.4
Dental fluorosis, a condition associated with abnormal
enamel development, was first noted in communities with high levels of naturally
occurring fluoride in the drinking water, but has since appeared in individuals
ingesting fluoride from other sources.
This condition, occurring mainly in children younger than
seven years of age, is associated with impaired biosynthesis of dental matrix.
Manifestations can vary from minimal changes (Toxic Effect [TF] of 1),
comprising 80% to 90% of the cases, and noted only by close dental examination;
to rarer, florid, unsightly mottling and pitting of the teeth, enamel
striations, and in severe cases, ‘snow-capped cusps’ and chalky-white teeth
(TF of 2 or more), which may be unsightly and require cosmetic treatment.
Secondary teeth are at the greatest risk for fluorosis at 15 to 24 months of age.5
The prevalence of fluorosis has increased since 1945,6
paralleling the increase in possible sources of fluoride, including water,
toothpaste, foods and drinks made with fluoridated water, and fluoride
supplements such as drops, mouthwashes and lozenges. Fluorosis prevalence varies
inversely with caries control. In a large study of 18,755 children by Heller et
al,77, the sharpest decline in decayed, missing, filled surfaces occurred with
increasing drinking water concentrations of fluoride from 0 to 0.7 ppm, with
little additional benefit above this concentration. The prevalence of fluorosis
increased with increasing water fluoride concentration, from 13.5% in children
exposed to water containing less than 0.3 ppm of fluoride to 41.4% when they
were exposed to greater than 1.2 ppm. The use of supplements added to the effect
and was associated with a further lowering of caries at the cost of increased
fluorosis. A suitable trade-off between caries and fluorosis occurred at around
0.7 ppm of fluoride (7). Other studies (8-10) have also found fluorosis
prevalence of greater than 40% with increasing fluoride exposure, although only
a small proportion of dental changes due to fluorosis are noticeable enough for
treatment to be considered. A recent study of fluorosis among 2435 children aged
seven to 13 years in Toronto, Ontario (11) found dental fluorosis of moderate
degree (Tooth Surface Index of 2 – fluorosis of moderate severity) in 14% of
seven-year-olds, 12.3% of 13-year-olds and 13.2% of the two groups combined, a
prevalence similar to most of the recent studies performed in Toronto.
Mechanism of Action of Fluoride
Fluoride prevents caries mainly by its topical effect (12).
Dental caries result when plaque, a sticky film of bacteria on the surface of
the tooth, feeds on sugar and food residue to produce acid, which dissolves the
surface of the tooth (demineralization). Bathing the surface of the tooth with
as little as 1 ppm of fluoride causes a dramatic decrease in enamel solubility.
Ingested fluoride, on the other hand, has little effect on caries, but
contributes significantly to the development of fluorosis.
Enamel development is characterized by three stages.
- In the secretory stage, a protein matrix is laid down and mineral
- In the transition stage, protein is removed and replaced.
- In the maturation stage, protein is 95% replaced and mineralization is
Fluoride delivered systemically to the tooth affects both
the transition and maturation stages. Enamel development is most sensitive to
systemic fluoride during the transition stage. The matrix becomes porous as
fluoride and other ions accumulate. In the maturation stage, altered mineral
deposition occurs. This effect of fluoride results in interference with crystal
deposition, altered cell modulation and delayed maturation of bone.
Topical fluoride acts in three main ways to prevent dental
- It inhibits plaque. Fluoride may kill or inhibit bacteria and makes them
less able to produce acid from carbohydrates.
- It inhibits demineralization. Fluoride is incorporated into crystals on
the tooth surface, making the surface more resistant to acid.
- It enhances remineralization of enamel. The process of demineralization
and remineralization of enamel is constant. Fluoride increases the speed of this
process and the incorporation of fluoride in the mineral makes it less soluble
Toothpaste is available with or without fluoride.
Toothpaste tubes containing fluoride are now labeled and contain approximately
0.5 mg fluoride per gram of toothpaste. Some tubes suggest covering the bristles
with toothpaste. A ‘pea-sized’ portion weighs approximately 0.75 g and
contains about 0.4 mg of fluoride; a ‘full cover’ portion weighs
approximately 2.25 g and contains about 1.0 mg of fluoride. Thus, brushing twice
a day would deliver 0.8 to 2.0 mg of fluoride, depending on which regimen is
used. If swallowed, the amount of fluoride could be excessive and could
contribute to the development of fluorosis.
- The primary mechanism of the action of fluoride in preventing tooth decay
is topical (evidence level II-3, recommendation B) (11,13,14) (Table 1).
- Water fluoridation is an effective delivery method for topical fluoride
(evidence level II-1, recommendation B) (l).
- Fluoridated toothpaste is an effective delivery method for topical
fluoride (evidence level I, recommendation A) (15).
- The ingestion of more than the recommended daily dose of fluoride is
associated with an increased risk of dental fluorosis (evidence level II-2,
recommendation E) (2,16).
- In the absence of adequate topical fluoride exposure (eg, fluoridated
toothpaste or water), additional fluoride products may be provided in the form
of drops, chewable tablets and lozenges. The effectiveness of these products in
preventing dental caries is low in school-aged children (evidence level II-2,
recommendation C) and has not been evaluated in infants and toddlers (evidence
level II-3, recommendation C).8
- Some individuals may be susceptible to ‘carious challenge’. Because
of either a genetic or an environmental predisposition to a high prevalence of
caries (17-21), topical fluorides alone may be insufficient to prevent caries
among these individuals (ie, additional fluoride may produce no net benefit and
other measures such as antibacterial therapy and diet changes may be required)
(evidence level II-3, recommendation C) (22).
There is no doubt that the use of fluoride decreases dental
caries. On the other hand, it is clear that the ingestion of too much fluoride
can result in varying degrees of fluorosis. Thus, in practice, the
administration of fluoride should strike a balance between the two situations.
- The position outlined in the present statement follows the principles
agreed to at the Canadian Consensus Conference on fluoride held in 1997 (4).
- Fluoride should continue to be added to municipal water supplies where
natural concentrations are less than 0.3 ppm. A suitable trade-off between
dental caries and fluorosis occurs around 0.7 ppm.
- A statement of fluoride concentration should continue to be printed on
the toothpaste tube, and the amount in a ‘pea-sized’ portion of toothpaste
should be indicated.
- Fluoride concentrations should be stated on any foods or drinks
- Children should use only a ‘pea-sized’ amount of toothpaste, and be
encouraged not to swallow the excess.
- Because the action of fluoride is topical, no fluoride should be given
before teeth have erupted.
- Supplemental fluoride should be administered (Table 2) only from the age
of six months, and only if the following conditions prevail:
- the concentration of fluoride in drinking water is less than 0.3 ppm;
- the child does not brush his or her teeth (or have them brushed by a
parent or guardian) at least twice a day; and
- if, in the judgment of a dentist or other health professional, the child
is susceptible to high caries activity (family history, caries trends and
patterns in communities or geographic areas).
- Supplemental fluoride should be given in preparations that maximize the
topical effect, such as mouthwashes or lozenges. Drops, if used, should be
diluted with water and squirted on the teeth.
Levels of evidence of the mechanisms of action of fluoride in preventing tooth decay
Evidence obtained from at least one properly
Evidence obtained from a well-designed
controlled trial without randomization
Evidence obtained from well-designed cohort
or case controlled analytic studies,
preferably from more than one centre of
Evidence obtained from comparisons between
times and places, with or without the
intervention. Dramatic results in uncontrolled
experiments could also be included in this
Opinions of respected authorities, based on
clinical experience, descriptive studies or
reports of expert committees
Recommendations for preventive
There is good evidence to support this
There is fair evidence to support this
There is poor evidence to support this
recommendation, but a recommendation
could be made on other grounds
There is fair evidence to support the
recommendation of exclusion
There is good evidence to support the
recommendation of exclusion
Recommended supplemental fluoride concentrations for
|Age of child
|0 to 6 months
|>6 months to 3 years
|>3 to 6 years
- Newbrun E. Effectiveness of water fluoridation. J Pub Health Dent
However, this study has been refuted by many other researchers in the field of fluoridation
- Canadian Paediatric Society, Nutrition Committee. The use of fluorides in
infants and children. Paediatr Child Health 1996;1:131-4.
- Clark DC. Appropriate uses of fluoride in children: Guidelines from the
Canadian Workshop on the Evaluation of Current Recommendations Concerning
Fluorides. CMAJ 1993;59:272-9.
- Limeback H, Ismail A, Banting D, et al. Canadian Consensus Conference on
the appropriate use of fluoride supplements for the prevention of dental caries
in children. J Can Dent Assoc 1998;64:636-9.
It should be noted that Dr. Hardy Limeback PhD, DDS, has since taken position on artificial water
fluoridation that is now in complete disagreement with that former position. This reference is
therefore currently fraudulent.
- Evans RW, Darvell BW. Refining the estimate of the critical
susceptibility to enamel fluorosis in human maxillary incisors. J Public Health Dent 1995;55:238-49.
- Lewis DW, Banting DW. Water fluoridation, current effectiveness and
dental fluorosis. Comm Dentist Oral Epidemiol 1994;22:153-8.
- Heller KE, Ecklund SA, Burt BA. Dental caries and dental fluorosis at
varying water fluoride. J Public Health Dent 1997;57:136-43.
- Ismail AL. Fluoride supplements: Current effectiveness, side effects, and
recommendations. Comm Dentistry Oral Epidem 1994;22:164-72.
- Riordan PJ, Banks JA. Dental fluorosis and fluoride exposure in Western
Australia. J Dent Res 1991;70:1022-8.
- Ismail AL, Brodeur JM, Kavanagh M, et al. Prevalence of dental caries and
dental fluorosis in students, 11-17 years of age, in fluorinated and
non-fluorinated areas of Quebec. Caries Res 1990;24:290-7.
- Leake J, Goettler F, Stahl-Quinlan B, Stewart H. Has the level of
fluorosis among Toronto children changed? J Can Dent Assoc 2002;68:21-5.
- Shellis RP, Duckworth RM. Studies on the cariostatic mechanisms of
fluoride. Int Dent J 1994;44(Suppl l):263-73.
- Featherstone JDB, Glena R, Shariati M, Shields CP. Dependence of in vitro demineralization of apatite and remineralization
of dental enamel on fluoride concentration. J Dent Res 1990;69:620-5.
- Thylstrup A. Clinical evidence of the role of pre-eruptive fluoride in
caries prevention. J Dent Res 1990;60:742-50.
- Clarkson JE, Ellwood RP. A comprehensive summary of fluoride dentifrices
in clinical trials. Am J Dent 1993;6:59-106.
- Osuji OO, Leake JL, Chipman ML, et al. Risk factors for dental fluorosis
in a fluoridated community. J Dent Res 1988;67:1488-92.
- Driscoll WS, Nowjack-Raymer R, Selwitz RH, et al. A comparison of the
caries-preventing effects of fluoride mouth rinsing, fluoride tablets, and both
procedures combined. J Public Health Dent 1992;52:111-6.
- Canadian Task Force on the Periodic Health Examination. The periodic health examination: 2. 1987 update. CMAJ 1988;138:618-26.
- Hassell TM, Harris EL. Genetic influences in caries and periodontal
disease. Crit Rev Oral Biol Med 1995;6:319-42.
Ozawa Y, Chiba J, Sakamoto S. HLA class II alleles and salivary numbers
of mutans streptococci and lactobacilli among young adults in Japan. Oral
Microbiol Immunol 2001;16:353-7.
- Hassell TM, Harris EL. Genetic influences in caries and periodontal
diseases. Crit Rev Oral Biol Med 1995;6:319-42.
O’Sullivan EA, Curzon ME. Salivary factors affecting dental erosion in
children. Caries Res 2000;34:82-7.
- Seow WK. Prematurity as factor to enamel hypoplasia. Aust Dent J 1997;42:85-91.
Members: Drs Margaret Boland, Children’s Hospital of
Eastern Ontario, Ottawa, Ontario (chair); Robert Issenman, Children’s Hospital
– Hamilton HSC, Hamilton, Ontario (director responsible); Alexander Leung,
Alberta Children’s Hospital, Calgary, Alberta; Valérie Marchand, Hôpital
Sainte-Justine, Montreal, Quebec; Anthony Otley, IWK Health Centre, Halifax,
Consultants: Drs Claude Roy, Hôpital Sainte-Justine,
Montreal, Quebec; Reginald Sauve, University of Calgary, Calgary, Alberta;
Stanley Zlotkin, The Hospital for Sick Children, Toronto, Ontario.
Liaisons: Ms Anne Kennedy, National Institute of Nutrition,
Ottawa, Ontario; Marilyn Sanders, Breastfeeding Committee for Canada, Toronto,
Ontario; Donna Secker, The Hospital for Sick Children, Toronto, Ontario;
Rosemary Sloan, Population and Public Health Branch, Health Canada, Ottawa,
Ontario; Christina Zehaluk, Health Products and Food Branch, Health Canada,
Principal author: Dr John Godel, Heriot Bay, British
Disclaimer: The recommendations in this position statement
do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking
into account individual circumstances, may be appropriate.
Internet addresses are current at the time of publication.
More content available at: Fluoride Action Network | http://www.fluoridealert.org/ | 1-802-338-5577 | email@example.com