Module 4: Prevention of Oral Disease
Special Care- Prevention of Oral Disease

4.1 Fluorides

Fluoride is a natural element found in soil and water. Its optimization in children’s diets is a major factor in the decline of prevalence and severity of dental caries in the United States and other countries. It prevents dental caries in the following two ways:

  • Systemically—When ingested, fluoride concentrates in developing teeth, helping to strengthen enamel in primary and permanent teeth before eruption.
  • Topically—Applied to erupted primary and permanent teeth, topical fluoride inhibits the metabolism of the decay-producing bacteria in plaque, stabilizes minerals in the teeth, and helps remineralize teeth that have been affected by early carious attack. Topical fluoride is most effective when delivered at low doses many times a day through water, foods containing fluoride, and fluoridated toothpaste.

Systemic Fluorides

Community Water Fluoridation

Community water fluoridation is one of the best evidence-based public health measures to prevent tooth decay. Children with special health care needs may be dependent on others for their water intake. Adequate water intake is important for oral health and overall health. If the water is not fluoridated, then other sources of topical fluoride should be used.

Fluoride Supplements

Fluoride supplements are recommended only for infants and children at high risk for developing dental caries who drink water that does not contain the optimal amount of fluoride. Determination of dietary fluoride before prescribing supplements can help reduce intake of excess fluoride. Sources of dietary fluoride may include drinking water from home, child care, and school; beverages such as infant formula, juice, and sugar-sweetened beverages, prepared foods, and toothpaste. For infants and children at low risk for developing caries, dietary fluoride supplements are not recommended, and other sources of fluoride should be considered as a caries-prevention intervention. Risk-assessment forms from the American Academy of Pediatric Dentistry can help clinicians determine risk. 1

Fluoride supplements are available in several forms: tablets, lozenges, and drops. Tablets are intended to be chewed or sucked to maximize the topical effects. Fluoride drops may be easier to use than tablets or lozenges for infants (ages 6 months or older) and for children with oral motor problems, since drops can be placed directly in the mouth. If prescribing liquid supplements, oral health professionals should ensure that parents understand the difference between “a dropperful” and “a drop.” Parents also need to understand that fluoride in large doses can be harmful.

The following table provides fluoride dosage schedules for children at high risk for developing caries as recommended by the American Dental Association. 2


Dietary Fluoride Supplementation Schedule for Children and Adolescents at High Risk for Developing Caries

  Fluoride Ion Level in Drinking Water a
Age < 0.3 ppm 0.3–0.6 ppm > 0.6 ppm
Newborn–6 months None None None
6 months–3 years 0.25 mg/day b 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

a  1.0 ppm = 1 mg/L.
b  2.2 mg sodium fluoride contains 1 mg fluoride ion.

Reproduced with permission from the American Dental Association from ADA Guide to Dental Therapeutics (2nd ed.).


Topical Fluorides

Toothpaste with Fluoride

Parents should read toothpaste labels to determine if the toothpaste contains fluoride and to evaluate other benefits the toothpaste may claim to have (e.g., tooth-whitening, anti-plaque, tartar-control properties). Parents should brush the child’s teeth at least twice a day. For children under age 3, a smear of fluoridated toothpaste should be used; for children between ages 3 and 6, a pea-size amount should be used. After age 6 the amount of toothpaste used is not critical even if a child cannot spit out the toothpaste. For children who cannot spit, let them drool into a cup.

Fluoride Rinses

Fluoride rinses are generally not recommended for children.

Fluoride Varnish

Professionally applied fluorides also are used to prevent dental caries. Fluoride varnish has gained wide acceptance within the oral health and medical communities as a preventive agent, especially for CSHCN. Fluoride varnish is usually applied with a brush that is attached to the single-dose applicator. The child can eat and drink after application, but the teeth should not be brushed until at least 12 hours later. Fluoride varnish should be applied every 3 to 6 months in children who are at increased risk for dental caries.

Fluoride varnish may be applied in physicians’ offices, at community-based programs such as Head Start or WIC, and at university centers of excellence for developmental disabilities.

Silver Diamine Fluoride

Silver diamine fluoride (SDF) has been used extensively outside the United States for many years for caries control. 3 SDF arrests active carious lesions without local anesthetic, as long as the teeth are asymptomatic. This intervention can be applied to teeth as soon as caries is detected. SDF is effective in treating people who are unable to access oral health treatment or tolerate conventional oral health care, including young “pre-cooperative” children, persons with intellectual or developmental disabilities, or older adults. 4

SDF darkens active dental caries and temporarily stains unprotected soft tissues, which may be a concern for parents or children. It does not stain sound enamel. Some people report a transient metallic taste after application of SDF. 4