Fluoride – The Magic Mineral
Sharee Clough, RDH, MS Ed
In the spirit of National Public Health Week, let’s turn our attention to a public health achievement that occurred three quarters of a century ago. That achievement was the introduction of community fluoridated water. It was on January 25, 1945 that Grand Rapids, Michigan became the first city in the U.S. to fluoridate its public water supply. Seventy-six years later, a little over 205 million people in the U.S. receive fluoridated water.
In Illinois, Evanston began community water fluoridation in 1946. Today over 11.5 million Illinois residents receive fluoridated water.
Thanks goes to Dr. Frederick McKay for first noticing that individuals who had brown stained teeth were extraordinarily resistant to tooth decay. He also discovered that brown stained teeth was prevalent in other areas of the U.S. including New Mexico, Texas, California, Idaho, Arizona and Virginia. He suspected that too little or too much of something in the drinking water was causing brown staining on people’s teeth.
With the help of Dr. G.V. Black, a dentist from Morgan County, IL, it was discovered that high levels of natural fluoride in the local water supply was causing the brown staining. In the 1930’s Dr. Trendley Dean found that determining the appropriate amount of fluoride in water could prevent brown staining while still making teeth resistant to decay. The U.S. Public Health Service (USPHS) recommends 0.7 ppm as the optimum level of fluoride in drinking water for reducing the risk of tooth decay, while at the same time remaining low enough to reduce the risk of enamel fluorosis, a staining of the teeth.
Today, in addition to fluoridated water, fluoride is available from such sources as fluoride toothpaste, mouth rinses and fluoride supplements. Despite this general availability of fluoride, studies show that water fluoridation is still effective in reducing tooth decay by 25%. It is important to note that water fluoridation not only reduces tooth decay for children, it also reduces tooth decay in adults. For younger children (under 8 years old), fluoride strengthens permanent (adult) teeth that are not erupted (under the gums). For adults, community fluoridated water supports the structure of tooth enamel making teeth stronger and healthier.
According to information from the Association of State and Territorial Dental Directors, fluoride is the 13th most plentiful element in the earth’s crust. Small amounts of fluoride are present in all natural water sources. The amount of fluoride in natural water sources varies upon the water source. The amount of natural fluoride in water can range from being barely detectable to being as much as 1.2 to 1.4 ppm in ocean water. In most cases, the deeper the natural water source, the higher the fluoride level since the water has had an opportunity to dissolve more fluoride as it passes down through rocks and soil.
The use of community fluoridated water in the U.S. is widespread. Approximately 65% of the U.S. population drinks community fluoridated water. On a state level, the percentage of community water systems that are fluoridated range from less than 25% to almost 100%. In Illinois, 98.5% of community water systems are fluoridated.
Based on these facts, it’s easy to see that fluoride provides a lifetime of benefits for both children and adults. In addition to reducing tooth decay, fluoride reduces the severity of cavities If they do occur. Accordingly, there is less need for complex and emergency dental care. Preventing dental disease and forestalling urgent dental treatment needs is the best thing we in oral health can do to improve health outcomes especially when a public health emergency such as pandemic strikes and dental offices and clinics are forced to shut down and or drastically reduce access to any care.
Because of its disease preventive properties, community fluoridated water is cost-effective – it saves money for both the public and for the health care system because it reduces the need for restorative care. Whether a community is large or small, CFW saves cost. As would be expected, the return on investment is greater for large communities as compared to smaller communities because in a larger community, the per capita cost of administering a CFW program is spread across more people.
Dental decay is one of the most prevalent diseases in the U.S. Community water fluoridation has played a significant role in helping to keep teeth cavity free while being safe and cost effective. There are also other types of fluoride which help prevent tooth decay - fluoride toothpaste, fluoride mouth rinses and topical fluoride treatments, to name a few.
Silver Diamine Fluoride
One type of fluoride that has not yet been mentioned is silver diamine fluoride (SDF). SDF can be used as a preventive agent; however, what makes it unique is that it also can be used as a medicament to treat active decay. This medicament is applied to cavitated lesions (active decay) of teeth with the intent to arrest decay. The silver acts as an antimicrobial and the fluoride helps to rebuild the enamel by remineralizing it.
SDF has been used in other countries for many years. In the U.S., the use of SDF for tooth hypersensitivity was approved by the Food and Drug Administration in 2013 and for off-label use for caries (tooth decay) treatment in 2016. The product, Advantage Arrest was designated by the FDA as a revolutionary therapy to stop active decay in children and adults. This classification signifies that SDF has the capacity to address a current unmet medical need.
SDF has many benefits. It is a low-cost medicament. Application is quick and easy. Treatment is done without pain and without local anesthetic. Since drilling the tooth is not necessary, there is no concern about aerosols – an important consideration during this time of COVID 19. SDF can be used for a wide age range of patients – from children to the elderly. For adults, SDF is effective in stopping root decay. When applied to a tooth with active decay, SDF not only arrests the decay on the affected tooth, it also has been shown to prevent decay on the adjacent teeth. As you can see, the benefits of SDF for preventing and tooth decay are numerous. Are your dentists and dental hygienists embracing the use of SDF?
SDF is beneficial when factors exist that can limit access to care for children with severe disease or patients with behavioral issues. In these cases, sedation or general anesthesia may be required to allow treatment. These methods can be costly and increase the risk of negative outcomes for dentist and patient. For elderly patients, treatment can be challenging due to mobility issues and/or health issues. SDF allows an option for treatment where traditional treatment would be difficult, costly or traumatic.
It is important to note that silver particles in SDF will stain teeth where there is active dental decay. It also will cause temporary staining of unprotected soft tissues. Accordingly, patients and parents/caretakers need to be informed of the potential for staining. Moreover, providers need to be appropriately trained in the indication, use and application of SDF.
Fluoride has come a long way since 1945 when Grand Rapids, Michigan became the first community to offer community fluoridated water (CFW). While it still plays an important role in the prevention of tooth decay, other fluoride products also play a role. With SDF, dental providers have a tool that can be used to prevent tooth decay or arrest active decay. Its use is especially beneficial for patients with factors that can limit access to care. SDF is an easy, quick, painless and cost-effective method to address decay.
A final word - fluoride is not effective, unless it’s used! Whether you are a dental or medical professional, social worker, health educator or work with patients in some other capacity, take note that your patient may be telling you (maybe not verbally), “They’re my teeth! You need to help me take care of them!” Educate patients about the dental health benefits of fluoride. Remind patients who have access to CFW that they should be drinking the fluoridated water rather than bottled water. Instruct patients on the appropriate use of fluoride toothpaste and fluoride mouth rinses. For patients who have dental decay, whether a child or adult, and have limited access to dental care or where restorative care might be difficult, consider the use of SDF where indicated. If you are a medical provider, refer the patient to a dentist for care. Referral is an important step in developing a dental home that provides patients with consistent oral health care. Working together, we can keep smiles healthy!
- American Academy of Pediatric Dentistry. Policy on the use of silver diamine fluoride for pediatric dental patients. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2020:66-9.
- American Dental Association Oral Health Topics, “Silver Diamine Fluoride.” Available from: https://www.ada.org/en/member-center/oral-health-topics/silver-diamine-fluoride. Accessed on March 15, 2021.
- Association of State and Territorial Dental Directors. “Fact Sheet Natural Fluoride in Drinking Water.” Available from https://www.astdd.org/docs/natural-fluoride-fact-sheet-9-14-2016.pdf. Accessed on March 15, 2021.
- Association of State and Territorial Dental Directors. “Silver Diamine Fluoride (SDF) Fact Sheet.” March 2017 Amended July 2017. Available from https://www.astdd.org/www/docs/sdf-fact-sheet-09-07-2017.pdf. Accessed on March 20, 2021.
- Centers for Disease Control and Prevention. Community Water Fluoridation. Fluoridation Basic. Available from https://www.cdc.gov/fluoridation/basics/index.htm. Accessed on March 10, 2021.
- Centers for Disease Control and Prevention. Community Water Fluoridation. Community Water Fluoridation Data and Statistics.” 2018 Fluoridation Statistics”. Available from https://www.cdc.gov/fluoridation/statistics/2018stats.htm. Accessed on March 23, 2021.
- Horst, Jeremy A et al. “UCSF Protocol for Caries Arrest Using Silver Diamine Fluoride: Rationale, Indications and Consent.” Journal of the California Dental Association 44,1 (2016): 16-28.
- S. Department of Health and Human Services Federal Panel on Community Water Fluoridation. “U.S. Public Health Service Recommendation for Fluoride Concentration in Drinking Water for the Prevention of Dental Caries.” Public health reports (Washington, D.C.; (1974)vol. 130,4 (2015): 318-31. doi:10.1177/003335491513000408
- Crystal, Yasmi O, and Richard Niederman. “Evidence-Based Dentistry Update on Silver Diamine Fluoride.” Dental clinics of North America 63,1 (2019): 45-68. doi:10.1016/j.cden.2018.08.011.