Dental Fluorosis

• Overview
• What is dental fluorosis?
• Who develops dental fluorosis?
• What does dental fluorosis look like?
• What causes dental fluorosis?
• What are the common sources of fluoride?
• What accounts for most of the fluoride intake?
• In which communities can dental fluorosis be found?
• What parents and caregivers can do to reduce the occurrence of dental fluorosis
• What health care and public health professionals can do to reduce the occurrence of dental fluorosis
• What consumer product industries and health agencies can do to reduce the occurrence of dental fluorosis

Overview

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What is dental fluorosis?

Dental fluorosis is a change in the appearance of the tooth’s enamel. These changes can vary from barely noticeable white spots in mild forms to staining and pitting in the more severe forms. Dental fluorosis only occurs when younger children consume too much fluoride, from any source, over long periods when teeth are developing under the gums.

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Who develops dental fluorosis?

Only children aged 8 years and younger can develop dental fluorosis because this is when permanent teeth are developing under the gums.

•  Once the teeth erupt through the gums and are in the mouth, they can no longer develop fluorosis.
•  The teeth of children older than 8 years, adolescents, and adults cannot develop dental fluorosis.

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What does dental fluorosis look like?

•  Very mild and mild forms of dental fluorosis—teeth have scattered white flecks, occasional white spots, frosty edges, or fine, lacy chalk-like lines. These changes are barely noticeable and difficult to see except by a dental health care professional.
•  Moderate and severe forms of dental fluorosis—teeth have larger white spots and, in the rare, severe form, rough, pitted surfaces.

Normal	Questionable	Very mild
Mild	Moderate	Severe

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What causes dental fluorosis?

Dental fluorosis is caused by taking in too much fluoride over a long period when the teeth are forming under the gums. Only children aged 8 years and younger are at risk because this is when permanent teeth are developing under the gums. The severity of the condition depends on the dose (how much), duration (how long), and timing (when consumed) of fluoride intake.

Increases in the occurrence of mostly mild dental fluorosis were recognized as more sources of fluoride became available to prevent tooth decay. These sources include drinking water with fluoride, fluoride toothpaste—especially if swallowed by young children—and dietary prescription supplements in tablets or drops (particularly if prescribed to children already drinking fluoridated water).

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What are the common sources of fluoride?

•  Toothpaste (if swallowed by young children).
•  Drinking water in fluoridated communities.
•  Beverages and food processed with fluoridated water.
•  Dietary prescription supplements that include fluoride (e.g., tablets or drops).
•  Other professional dental products (e.g., mouth rinses, gels, and foams).

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What accounts for most of the fluoride intake?

In the United States, water and processed beverages (e.g., soft drinks and fruit juices) can provide approximately 75% of a person's fluoride intake. Inadvertent swallowing of toothpaste and inappropriate use of other dental products containing fluoride can result in greater intake than desired. For this reason the CDC recommends parents supervise the use of fluoride toothpaste by children under the age of 6 to encourage them to spit out excess toothpaste. Also avoid the use of fluoride mouth rinses in children who are younger than 6 years old because the mouth rinse could be repeatedly swallowed.

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In which communities can dental fluorosis be found?

Dental fluorosis occurs among some persons in all communities, even in those with a low natural concentration of fluoride in the drinking water.

What parents and caregivers can do to reduce the occurrence of dental fluorosis—

Know the fluoride concentration of your drinking water

You should know the fluoride concentration in your primary source of drinking water, especially if you have young children. This information should help with decisions about using other fluoride products, particularly fluoride tablets or drops that your physician or dentist may prescribe for your young child. Fluoride tablets or drops should not be used at all if your drinking water has the recommended fluoride concentration of 0.7 mg/L or higher.

If you live in a state that participates in CDC’s My Water's Fluoride, you can find out your water system’s fluoridation status online. If you are on a community water system, you can call the water utility company and request a copy of the utility’s most recent Consumer Confidence Report.

For very young children, less than 2 years old:

Do not use fluoride toothpaste unless advised to do so by your doctor or dentist. You should clean your child’s teeth as soon as the first tooth appears by brushing without toothpaste with a small, soft-bristled toothbrush and plain water.

For children aged 2 to 6 years, apply no more than a pea-sized amount of fluoride toothpaste to the brush and supervise their toothbrushing, encouraging the child to spit out the toothpaste rather than swallow it. Until about age 6, children have poor control of their swallowing reflex and frequently swallow most of the toothpaste placed on their brush.

See Brush Up on Healthy Teeth for further guidance.

Use an alternative source of water for children aged 8 years and younger if your primary drinking water contains greater than 2 mg/L of fluoride

In some regions of the United States, community water systems and private wells contain a natural fluoride concentration of more than 2 mg/L, and at this concentration, children 8 years and younger have a greater chance for developing dental fluorosis, including the moderate and severe forms.

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What health care and public health professionals can do to reduce the occurrence of dental fluorosis—

Counsel parents and caregivers regarding use of fluoride toothpaste by young children
Parents or caregivers should be counseled on the use of fluoride toothpaste by young children, especially those younger than 2 years. There is an increased chance for dental fluorosis for children younger than 6 years, and especially for those younger than 2 years, because they are more likely to swallow the toothpaste than older children.

For children younger than 2 years, you should consider the fluoride level in the community drinking water, other sources of fluoride, and factors likely to affect susceptibility to tooth decay when weighing the risk and benefits of using fluoride toothpaste. When assessing the risks and benefits, determine if the child may be at high risk for tooth decay because of factors such as poor hygiene, poor diet, or history of decay in the child, and in their siblings or parents.

Target mouth rinses to children at high risk for developing tooth decay

Because fluoride mouth rinses have resulted in only limited reductions in tooth decay among children, especially as their exposure to other sources of fluoride has increased, their use should be targeted to individuals and groups at high risk for decay.

Children younger than 6 years should not use a fluoride mouth rinse without parents first consulting a dentist or physician because there is a possibility for dental fluorosis if these rinses are repeatedly swallowed.

Prescribe fluoride supplements judiciously

Fluoride supplements can be prescribed for children at high risk for tooth decay and whose primary source of drinking water has a low fluoride level. If the children are younger than 6 years, however, then the dentist or physician should weigh the risks for developing decay without supplements with the possibility of developing dental fluorosis. Other sources of fluoride, especially drinking water, should be considered when determining this balance. Parents and caregivers should be informed of both the benefits and risks of fluoride supplements.

Fluoride supplements can be prescribed for persons as appropriate or used in school-based programs. When practical, supplements should be prescribed as chewable tablets or lozenges to maximize the topical effects of fluoride.

The prescription dosage of fluoride supplements should be consistent with the schedule* established by the American Dental Association (ADA) Council on Scientific Affairs.

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What consumer product industries and health agencies can do to reduce the occurrence of dental fluorosis—

Label the fluoride concentration of bottled water
Producers of bottled water should label the fluoride concentration of their products. Such labeling would allow consumers to make informed decisions.

Promote the use of a small amount of fluoride toothpaste for children younger than 6 years
Labels and advertisements for fluoride toothpaste should promote using only a pea-sized amount (0.25g) of toothpaste on a child-sized toothbrush for children younger than 6 years. Parents and caregivers should be encouraged to supervise their children’s toothbrushing to reduce the swallowing of excess toothpaste.

Collaborate
Professional health care organizations, public health agencies, and suppliers of oral care products should collaborate to educate health care professionals and the public.

Related Links

Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States

My Water's Fluoride

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Date last reviewed: October 22, 2012
Date last modified: October 22, 2012
Content source: Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion