children’s toothpaste, discouraging the use of fluoride toothpaste by children less than 2 years old, avoiding flavored children’s toothpastes, encouraging the use of very small amounts of toothpaste, encouraging rinsing and expectorating (rather than swallowing) after brushing, and recommending careful parental supervision (e.g., Szpunar and Burt 1990; Levy and Zarei-M 1991; Simard et al. 1991; Burt 1992; Levy et al. 1992, 1993, 1997, 2000; Naccache et al. 1992; Newbrun 1992; Levy 1993, 1994; Bentley et al. 1999; Rojas-Sanchez et al. 1999; Warren and Levy 1999; Fomon et al. 2000).

Topical applications of fluoride in a professional setting can lead to ingestion of 1.3-31.2 mg (Levy and Zarei-M 1991). Substantial ingestion of fluoride also has been demonstrated from the use of fluoride mouth rinse and self-applied topical fluoride gel (Levy and Zarei-M 1991). Heath et al. (2001) reported that 0.3-6.1 mg of fluoride (5-29% of total applied) was ingested by young adults who used gels containing 0.62-62.5 mg of fluoride.

Levy et al. (2003a) found that two-thirds of children had at least one fluoride treatment by age 6 and that children with dental caries were more likely to have had such a treatment. Their explanation is that professional application of topical fluoride is used mostly for children with moderate to high risk for caries. In contrast, Eklund et al. (2000), in a survey of insurance claims for more than 15,000 Michigan children treated by 1,556 different dentists, found no association between the frequency of use of topical fluoride (professionally applied) and restorative care. Although these were largely low-risk children, for whom routine use of professionally applied fluoride is not recommended, two-thirds received topical fluoride at nearly every office visit. The authors recommended that the effectiveness of professionally applied topical fluoride products in modern clinical practice be evaluated.

Exposures from topical fluorides during professional treatment are unlikely to be significant contributors to chronic fluoride exposures because they are used only a few times per year. However, they could be important with respect to short-term or peak exposures.

Heath et al. (2001) found that retention of fluoride ion in saliva after the use of dentifrice (toothpaste, mouthrinse, or gel) was proportional to the quantity used, at least for young adults. They were concerned with maximizing the retention in saliva to maximize the topical benefit of the fluoride. Sjögren and Melin (2001) were also concerned about enhancing the retention of fluoride in saliva and recommend minimal rinsing after toothbrushing. However, fluoride in saliva eventually will be ingested, so enhancing the retention of fluoride in saliva after dentifrice use also enhances the ingestion of fluoride from the dentifrice.

Fluoride supplements (NaF tablets, drops, lozenges, and rinses) are intended for prescriptions for children in low-fluoride areas; dosages generally range from 0.25 to 1.0 mg of fluoride/day (Levy 1994; Warren and Levy

Front matter (R1-R22)

Summary (1-12)

1 Introduction (13-22)

2 Measures of Exposure to Fluoride in the United States (23-88)

3 Pharmacokinetics of Fluoride (89-102)

4 Effects of Fluoride on Teeth (103-130)

5 Musculoskeletal Effects (131-180)

6 Reproductive and Developmental Effects of Fluoride (181-204)

7 Neurotoxicity and Neurobehavioral Effects (205-223)

8 Effects on the Endocrine System (224-267)

9 Effects on the Gastrointestinal, Renal, Hepatic, and Immune Systems (268-303)

10 Genotoxicity and Carcinogenicity (304-339)

11 Drinking Water Standards for Fluoride (340-353)

References (354-410)

Appendix A Biographical Information on the Committee on Fluoride in Drinking Water (411-415)

Appendix B Measures of Exposure to Fluoride in the United States: Supplementary Information (416-438)

Appendix C Ecologic and Partially Ecologic Studies in Epidemiology (439-441)

Appendix D Comparative Pharmacokinetics of Rats and Humans (442-446)

Appendix E Detailed Information on Endocrine Studies of Fluoride (447-508)