Canadian Medical Association Journal 1996; 154: 1007
There has been concern since the early 1980s that fluoride supplementation, combined with the use of fluoride toothpaste and the consumption of fluoride in food prepared in fluoridated areas, has led to high fluoride-consumption levels that cause fluorosis in the teeth of some children. [full text] [4] In most of those affected, fluorosis is mild and not noticeable in social situations. In a few, fluorosis is moderate and noticeable, but it is a cosmetic problem only, posing no health risk. Severe fluorosis can damage teeth but has rarely been observed.4 The concern about fluorosis prompted the 1986 revision of the CPS supplementation recommendations. Since full eruption of adult teeth is required to identify and classify fluorosis, the effects of the changes in these recommendations are not yet fully documented because the children have not yet reached the required age.[5]
Despite this uncertainty concerning the effects of the 1986 reduction in recommended supplementation levels, the Canadian Dental Association (CDA) developed guidelines recommending further reduction in supplementation levels and restriction of supplementation to children in high-risk or "targeted" populations, although the term "targeted" was undefined.4 The Canadian Task Force on the Periodic Health Examination, in its review of the evidence concerning the effectiveness of supplementation (at the levels recommended by the CPS), provided readers with only the CDA recommendations, noting that the new, lower dosage levels had not been evaluated in clinical practice.3 Both the CPS and CDA statements were made widely available to Canadian physicians through publication in CMAJ. The CPS Nutrition Committee reviewed the evidence in 1995 and tried to make a judgement, given the insufficient epidemiologic evidence, that balanced the risks of fluorosis and dental caries. The resulting statement,5 endorsed by the CPS Board, increased the age at which supplementation begins from the "first few months of life" to 6 months and increased the age at which dosages increase from those recommended in the 1986 CPS recommendations (Table 1). The CPS statement is endorsed by the Canadian Association of Pediatric Dentistry. Unfortunately, the CPS statement has not yet been published, but it can be obtained from the CPS at 401 Smyth Rd., Ottawa ON K1H 8L1, tel. 613 737-2728, fax 613 737-2794.
The American Dental Association (ADA) has produced identical guidelines[6] (and Dr. Clifford Wall, Director of Product Evaluation, ADA: personal communication, 1996). The ADA guidelines are endorsed by the American Academy of Pediatrics, the American Association of Pediatric Dentistry and the American Dietetic Association.[7]
After serious consideration of the issues and evidence available, the Drugs and Therapeutics Subcommittee feels that the CPS statement represents the best balance of the risks, benefits and values of aesthetic concerns and health. The subcommittee stresses, as do the CPS and the CDA, that children receiving supplements must be advised to use very small amounts of fluoridated toothpaste, to avoid swallowing, to spit out and to rinse thoroughly after brushing. It also stresses that research is needed on fluorosis and caries rates among children receiving supplements according the 1986 and 1995 CPS recommendations and the CDA recommendations.
Ivan Kowalchuk, MD
Chair
Subcommittee on Drugs
and Therapeutics
CMA Council on Health Care
and Promotion
Winnipeg, Man.