Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Suhyun Rue Date: 8/23/2017
Associations between fluorosis of permanent incisors and fluoride intake from infant formula, other dietary sources and dentifrice during early childhood
Steven M. Levy; Barbara Broffitt, Teresa A. Marshall; Julie M. Eichenberger-Gilmore; John J. Warren
Journal of American Dental Association
Associations between dental fluorosis and fluoride intakes, with an emphasis on intake from fluoride in infant formula
Type of Article: case control cohort study
1- Describe associations between fluorosis in the permanent maxillary incisors and fluoride consumed during infancy and early childhood.
2- Estimate risks associated with using substantial amounts of powdered infant formula reconstituted with fluoridated water.
- - Fluoride can be ingested from both dietary and nondietary sources. The primary source of dietary fluoride is water. The primary sources of nondietary fluoride are oral health products aimed at caries prevention, such as dentifrices, mouth rinses and gels.
- -The critical period for development of fluorosis in permanent maxillary central incisors, the most prominent teeth esthetically, is during the period from birth through age 4 years.
- -Other researchers showed that consumption of infant formula was associated with increased risk of at least some detectable level of enamel fluorosis.
- - The authors administered periodic questionnaires to parents (n=630) to assess children’s early fluoride intake sources from beverages, selected foods, dentifrice and supplements (1.5, 3, 6, 9, 12, 16, 20, 24, 28,32 and 36 months).
- -The examiners used the Fluorosis Risk Index (FRI) to assess dental fluorosis (FRI score 2 and 3). -Exclusion criteria: 1-Cervical zones / 2-One central incisor involvement.
-Case participants: if they had fluorosis on two or more permanent maxillary incisors / control participants: if they had no fluorosis on maxillary incisors.
- The authors determined effects associated with fluoride in reconstituted powdered infant formulas, along with risks associated with intake of fluoride from dentifrice and other sources.
- -Fluoride intake from ages 3 to 9 months: Participants with fluorosis had significantly greater fluoride intake from powdered infant formula and other beverages with added water than those without fluorosis.
- - Fluoride intake from ages 16 to 36 months: Participants with fluorosis had significantly higher fluoride intake from dentifrice ingestion than those without fluorosis.
- -In a model combining both the 3 to 9 months and 16 to 36 months age groups, the significant variables were fluoride intake from powder concentrate formula and other beverages with added water ( for participants at ages 3-9 months) and dentifrice ingestion (for participants at ages 16-36 months).
- - Median total formula intakes were about 8 percent higher in children with fluorosis, but median fluoride intakes from infant formulas were 80 percent higher. Thus, fluorosis was not associated with the quantity of formula consumed but rather associated with the amount of fluoride in the formula
- - Fluoride intake from selected food sources prepared with water at home was slightly higher with fluorosis than in those without fluorosis. This suggests that fluoride intake associated with food preparation had less effect on fluorosis risk than did the intake from beverages
- -97% of the fluorosis in this study was mild. A recent review of the effect of mild dental fluorosis on oral health-related quality of life concluded that the effect of mild fluorosis was not adverse and could even be favorable. This suggests that concerns about mild dental fluorosis may be exaggerated. Thus,
T no general recommendations to avoid use of fluoridated water in reconstituting infant formula are warranted.
- - At younger ages ( 3-9 months), fluoride intakes from the fluoride in formula reconstituted with water and the fluoride in tap water added to beverages; at older ages ( 16 to 36 months), it was from dentifrice ingestion.
- For those concerned about reducing risk of developing mild fluorosis, dentist or physician should provide recommendations to use water with lower fluoride levels and to use small ( smear or pea-sized) amounts of fluoridated dentifrice with proper supervision of the child’s tooth brushing.
Assessment of Article: Level of Evidence/Comments: Level II Cohort study