'The Use of Dietary Fluoride Supplements for the Prevention of Dental Caries By William S.Lgriscoll, 0.0.5., M.P.H. Community rograms ection Caries Prevention and Research Branch National Caries Program V \LA 3 , National Institute of Dental Research??- “*< National Institutes of Health Public Health Service /;f ‘,r Bethesda, Maryland 20014 LQQflQ%£a#Lw fiL4?9£3ng ’W‘fw m 0 ,f We firm? ”I 0 Prepared for oral presentation at the "International Workshop on Fluorides and Dental Caries Reductions," held April 28-May 1, l974 in Baltimore, MD. / /”” m‘ r".\ Ha; _,,,—,,_——-—le .1r1.1,- , 11 11 11111111 ,1111 1,1111111 111 [1,,1, 11 1,1, 1, 11,111 1,1, 11111"11111 1111'11‘111111111111 ,,,,.,111111111,,,,,-1111 '1‘1"‘1‘11 ‘1“ H‘ '1“ ,111,1,‘-1"'1‘1‘1,1,111‘1 1,1,11,11,11,11,11‘,11,11,11 1,111,111,111, 1, ‘1 ,1,,,11,1,1,11,1,1,1,,,11,.,1,1111,11 1,1,1,1,, 1 ,1,11,11,1,1,1, , 1,1111, 1 1,,1, ,11,1,1,1,,1,1,1 111111,11,11,1,11,111111,11,11‘,11‘11 11 1111,11‘, 1,1,1111,11,111‘,11,1‘,1‘,11,r1‘11,11,11,1,1,1,1 1| ' H 1:1,‘111,",‘,11H1111H‘ 111“1,11111 1 1‘1‘,1‘,111 ,111111 11,11,111 11111 ,1,1,11,1,1,1,1,111 ,1,1, 11,11,111, ,11 11111' 1 '11,"1'1‘1"1,‘1,"1‘1 ,,1,'1‘1 1“1'1,‘1 1 1 11 ‘1 1111111.‘1‘1‘1‘1‘1‘1‘1"1‘1‘1'1‘1‘ 111111,14,11111,1,1,1,1,11,, 1,,1111, 11,11,1 1,,,1,111 1,111,. 1,111 111 11111 11,1,,1.,11,1,11,1,1 ,1,,11,11.,1,1,,11, 1,1,1111 1,11111111,1,,,,1,1,1,11 1‘1 ,1111111,1 1,1,1,1,1,1,1,1,,1,1‘1,, ,‘,11,‘1,1,1,1,1111‘1, 1. 1.11.11,11111,1,1,111.,1,,,1,1, ,,1, I. Introduction The purpose of this paper is to review the current status of the use of fluoride tablets for the prevention of dental caries. An attempt has been made to identify those areas that appear to need further re- search to establish efficacy definitively or to develop the procedure to its maximum potential. Salient data of selected clinical studies have been summarized in one or more of four tables contained in the back of the position paper that has been distributed to the attendees of this workshop. The paper will also consider several specific subjects in- cluding dosage, mode of action, retained benefits and the practical aspects of administering a fluoride tablet program. II. Effect of Fluoride Tablets on Deciduous Teeth Table l contains data from eighteen studies that have investigated the cariostatic effects of fluoride tablets on deciduous teeth. Dosage generally ranged from 0.25 mg. to l.0 mg. of fluoride per day depending upon the ages of the subjects. The average initial ages of the partici- pants was about four years or less in all studies. In the majority of studies, fluorides were administered for periods from two to six years. Caries reductions, expressed as percentages, are shown in the final column of the table. There appears to be little doubt that fluoride tablets are effective in reducing dental caries in deciduous teeth. 52’65’83 of the eighteen studies. Percentage reductions in the studies reporting benefits ranged Positive findings were reported in all but three widely from l3 percent in Schutzmannsky's study82 in a group of children receiving fluoride only prenatally to 93 percent in the study by Hoskova49 for children who received fluoride prenatally as well as four years post- natally. The eighteen studies have been arranged according to the initial ages of the study participants. It is evident that the benefits generally were greater in those studies in which the initial ages of the children averaged near two years or younger. Also, results from these studies were consis- tently positive. In contrast, each of the three studies that reported 52,65,83 no benefits, used children aged three years or older at the com— mencement of tablet administration. In summary, the data indicate that 8891 caries reductions in the approximate range of 50-80 percent may be achieved in deciduous teeth when fluoride administration is begun before about two years of age and is continued for a minimum of three to four years. III. Effect of Fluoride Tablets on Permanent Teeth Data from twenty—eight studies that have investigated the cariostatic effects of fluoride tablets on permanent teeth are presented in Table 2. Dosage generally ranged from 0.25 mg. to l.0 mg. of fluoride per day, depending upon the ages of the study participants. In l3 of the studies (indicated by asterisks) it was stated that the supplements were given only on school days. In the majority of studies, fluoride administration did not commence until the children were at least five years of age. In most instances the average period of administration was within a range of 2—4 years. Collectively, the data lead to the conclusion that fluoride tablet administration reduces dental caries in the permanent dentition. The findings, however, were not invariably positive in all the studies; in seven investigations, either no reductions or marginal reductions were reported_l2,24,50,52,60,82,84 Among those studies showing benefits, percentage reductions in about three-quarters of the instances fall within the approximate range of 20 to 40 percent. The results of studies on permanent teeth also were looked at according to the initial ages of the study participants. There is an indication that children who began fluoride ingestion at younger ages de- rived greater benefits than children who were older at the start of the study. However, the relationship is not as well defined as it was with deciduous teeth. In summary, the majority of studies have reported caries reductions in permanent teeth of approximately 20 to 40 percent among children initially between 5 and 9 years of age who had consumed fluoride tablets for periods of two to four years. IV. Effect of Prenatal Use of Fluoride Tablets Clinical data on the caries-preventive effects of fluoride tablets used prenatally are limited. A review of the literature revealed four per- tinent studies, which are summarized in Table 3. Hoskova49 reported a I caries reduction of 93 percent in the deciduous teeth of a group of children who had received fluoride tablets daily beginning at four months in utgrg and continuing for four years after birth, compared with a 54 percent re- duction in another group of children who received tablets for four years 51 found an 82 percent reduction beginning shortly after birth. Kailis et al. in def teeth among Australian children who consumed fluoride supplements prenatally and for 4-6 years postnatally compared with a 56 percent reduction for children who received the supplements only postnatally. The difference between these two reductions was statistically significant. In another Australian study, Prichard77 reported reductions in def teeth of 70 percent and 40 percent, respectively, following prenatal plus postnatal use and postnatal use only of fluoride supplements. The most recent study on the subject, conducted in l97l by Schutzmannsky,82 is particularly interesting for two reasons: it included a group that received only prenatal fluoride supplements and evaluations were made of six-year molars. Because of the age of the children when examined (9 years old) the evaluation of deciduous teeth was limited to cuspids and molars. A small but statistically sig- nificant reduction in dmft of l3 percent was found in the group that re- ceived fluoride only prenatally. An almost identical (l4 percent) reduction was found among children who consumed supplements for nine years, beginning at birth. The highest percentage reduction for deciduous teeth (30 percent) occurred in the group receiving both prenatal and postnatal exposure. With regard to permanent teeth, no benefit was found for the six—year molars of children who received only prenatal exposure. In contrast, however, statistically significant reductions in caries in these teeth of 43 percent and 39 percent, respectively, following prenatal plus postnatal use and postnatal use only, were detected. The similarity of benefits in these two groups plus the lack of benefit in the group receiving only prenatal fluo- ride suggest that prenatal fluorides are of no value in preventing caries in permanent teeth. In summary, the clinical studies with fluoride tablets tend to sup- port the efficacy of prenatal fluoride ingestion for deciduous teeth. How— ever, the studies with tablets are few in number and, in some instances, the significance of the apparent additional benefit from prenatal exposure is not clear. Collectively, the data presented indicate that more proof of efficacy is needed before dietary supplements of fluoride can be re- commended for gravid women as a sound public health measure. The data further suggest that if any benefits do result from the procedure, they would accrue only to deciduous teeth. There appears to be no reason from the standpoint of safety of the mother or the developing fetus to contra- indicate further research on prenatal fluorides.32 V. Effect of Fluoride-Vitamin Combinations Nine clinical studies in which fluoride-vitamin combinations have been used are presented in Table 4. Sodium fluoride was used in all these studies. The vitamin component varied from study to study and encompassed vitamins A, B complex, C, D and E. Dosages varied from 0.25 to l mg. of fluoride per day depending, in most instances, upon the ages of the children. In the study reported in l97l by Hennon, Stookey and Muhler,45 the dosage of 0.5 mg. of fluoride derived from the supplement was in addition to that derived from consuming 0.6—0.8 ppm fluoride from the com- munity drinking water supply. These water fluoride levels were considered by the investigators to be sub—optimal for the geographic area. In most of the studies the average initial ages of the children ranged from birth to two years. The period of fluoride ingestion ranged among the studies from two to six years, the notable exception being the study conducted by Aasenden and Peebles2 in which supplements were ingested for an average of almost ten years. The nine studies were unanimous in reporting caries-preventive benefits from the ingestion of fluoride-vitamin supplements. Benefits were parti- cularly impressive in those studie52’39’44’45’46’66 in which the average starting age of the children was approxiamtely two years or younger. In these studies reductions in caries for deciduous teeth ranged from about 50 percent to 80 percent. Findings on permanent teeth were reported in only three studies. Pollak76 and Minoguchi and his co-workers68 found similar reductions of 38 percent and 36 percent, respectively, in DMFT with widely differing study conditions. Considerably larger reductions of about 80 percent in DFS were reported in the long-term study by Aasenden and Peebles.2 In summary, there appears to be little question that fluoride-vitamin supplements are effective in reducing dental caries, and that the degree of effectiveness is comparable to that achieved by regular use of fluoride supplements without vitamins. The determining factor in choosing a fluo- ride-vitamin combination should be whether there is a clear indication that a vitamin supplement is needed. If this need does not exist, then a fluoride supplement without vitamins should be provided. In those cases where vitamins as well as fluorides are indicated, it would be advantageous, for reasons of convenience, to prescribe a combined fluoride-vitamin sup— plement. VI. Comments on Specific Aspects of Fluoride Tablet Administration A. Mode of Action Fluoride supplements are frequently thought of as being essentially systemic therapeutic agents that provide venefits only until the time of eruption of the teeth. This belief is unfortunate because there is consi- derable evidence to demonstrate that teeth already erupted when fluoride supplementation begins derive topical benefits from the procedure. For example, several studies presented in Table 1 reported moderate to sub- stantial benefits in deciduous teeth of children who were about two years of age or older when the procedure was initiated.42’43’46’56’63’76’9] Sufficient data also are available to demonstrate a topical effect on per- manent teeth. It is difficult to quantify systemic benefits from use of fluoride tablets because, in most studies, the teeth that received systemic exposure also received varying periods of post—eruptive exposure. Furthermore, the few studies in which systemic benefits can be separated from topical benefits do not permit one to estimate the total potential of systemic exposure, because in no instance was fluoride ingested from the earliest stages of calcification of the teeth. However, from collective data one can conclude that systemically derived benefits are afforded by the use of fluoride tablets. In summary, the collective data from clinical studies of fluoride sup- plementation suggest that both pre-eruptive and post-eruptive exposure are important in imparting cariostatic benefits to the teeth. In order to take advantage 0f the potential for post-eruptive topical benefits, it is im- portant to instruct children to dissolve or chew the supplement in the ¥ mouth before swallowing. B. Age at Initiation Considering the preceding discussion, fluoride administration ideally should begin at an age young enough to assure that the teeth will be ex- posed to fluoride before eruption. One question often raised, however, is when during pre-eruption should fluoride administration begin for maximal benefits to be obtained. Findings on this subject from studies of water fluoridation have been inconsistent. It also appears that the issue has not been resolved definitively for dietary fluoride supplements. From a practical standpoint, however, the lack of definitive information may not be of great concern if the objective is to impart maximal benefits to deciduous as well as permanent teeth. Because the deciduous incisors be- gin erupting at 6—7 months of age and essentially all of the deciduous teeth are erupted before two years of age,58 there is little flexibility in starting time for providing fluoride systemically to these teeth. However, if program limitations require that efforts be directed primarily toward protecting the permanent teeth from caries, then the de- termination of the optimal period of pre-eruptive exposure may be more important. Unfortunately, there are only limited data on which to deter- mine the best age to begin fluoride supplementation for maximal protection to permanent teeth. One of the most important conclusions that can be made from the clinical data in regard to age at initiation is that definite caries re— ductions can be attained when fluoride supplementation is commenced at school—age and is given only on days of school attendance (about lSO-ZOO days per year). Table 2 contains results of nine studies (indicated by asterisks) in which children received fluoride supplements only on school days. Overall percentage reductions for permanent teeth in most of these studies range between about 20 and 35 percent after two or more years of fluoride ingestion. Several investigators reported that the caries re- ductions experienced by teeth erupting after fluoride administration was initiated were larger than those for teeth present at the beginning of the study. In addition to providing caries-preventive benefits to perma- nent teeth, the administration of fluoride supplements in school may also confer post-eruptive benefits to deciduous teeth. In summary, the data suggest that fluoride exposure should begin shortly after birth in order to provide maximal benefits to deciduous and permanent teeth combined. Additional studies are needed to determine the appropriate starting age for conferring optimal systemic benefits solely to the permanent teeth. Important reductions in caries can be achieved by commencing fluoride administration at school-age and by giving the supplements only on days of school attendance. C. Discontinuation of Fluoride Supplementation The Council on Dental Therapeutics of the American Dental Association3 has recommended that administration of fluoride supplements should be con— tinued until about l2 to l4 years of age. A similar recommendation has been made by Nikiforuk and Fraser72 in their review on the use of fluoride supplements. Only limited data are available with regard to benefits retained after discontinuation of dietary fluoride administration. The results of a few of the studies reviewed suggest that the benefits derived from fluoride tablets gradually decrease after treatment is stopped. However, it is clear that additional, more definitive information is needed. Until more definitive information is available, it appears that fluoride treatment should not cease at l2 to l4 years of age. Because of their proven topical effect, fluoride supplements in tablet or liquid form could continue to be used. However, if a daily procedure is not feasible at this age, it may be possible to sustain the benefits derived from fluoride supplements by less frequent exposure to more concentrated fluoride agents. D. Dosage for Fluoride Supplementation The Council on Dental Therapeutics of the American Dental Association3 has recommended the following dosage schedule to be followed in an area where there is essentially no natural fluoride in the drinking water: (l) Up to two years of age-—add one fluoride tablet containing l mg. of fluoride to each quart of water used for drinking and preparing food; (2) two to three years of age—-one mg. of fluoride every other day or 0.5 mg. every day; (3) after three years of age--one mg. of fluoride daily. This dosage schedule has been developed essentially from estimates of the amount of fluoride ingested from drinking water that is optimally fluoridated at 1 ppm. Dosage recommendations derived in this manner must be considered as being tentative inasmuch as both animal and human studies have shown that the metabolic response to fluoride supplements taken once a day does 41 Whether the difference in the metabolic patterns produced by the two fluoride vehicles not duplicate that produced by drinking fluoridated water. has an effect on the magnitude of caries-preventive benefits is unknown. It is also not known if the difference in metabolic patterns is of any importance with respect to the occurrence of dental fluorosis. A perusal of the clinical studies of dietary fluoride supplements indicates that several different dosage regimens have been used. It is difficult, because of the many variables among the studies, to reach any definitive conclusions with regard to optimal dosage. Among the studies, there are only five in which fluoride administration began at or soon after birth and continued until permanent teeth could be evaluated for caries. Only three of these studies included findings on dental fluorosis. 39 it was re— In the studies by Arnold and his co-workers5 and by Hamberg, ported that the children showed no signs of dental fluorosis. The most striking cariostatic benefit, about an 80 percent reduction, was reported by Aasenden and Peebles2 who used a daily dosage of 0.5 mg. of fluoride for children under three years of age and 1.0 mg. thereafter. The benefit received by these children was greater than that derived by a comparable group of children who consumed fluoridated water. However, these inves- tigators reported an unprecedented high prevalence of fluorosis among the children who consumed the supplement. The fluorosis was limited in all but a few children to the milder types. However, the investigators concluded that the dosages_of fluoride given during the first years of life were at the borderline of the tolerable limit. Except for the period from birth to two years of age, the dosage schedule used in this study is identical to that recommended by the ADA's Council on Dental Therapeu- tics. It may be possible to obtain greater benefits in school-age children by increasing the dosage of fluoride to levels greater than one milligram without causing undue risk of fluorosis. Additional research is needed, however, to elucidate the relationship between stage of calcification and susceptibility to fluorosis. Another important factor in a school program is that the supplements are ingested intermittently for an equivalent of about one-half of the calendar year. It may, therefore, be especially desirable to increase the dosage under these circumstances. Data from a limited number of blood and urinary studies suggest that enhanced cariostatic benefits may result from giving fluoride supplements in divided dosages during the day. Several of the clinical studies pre- sented in Tables l and 2 used anywhere from two to four tablets to achieve the total daily dosage. However, it is not possible from these studies to draw definitive conclusions about the efficacy of the procedure. Another mechanism for possibly providing enhanced systemic benefits is through the use of controlled—release fluoride compounds. Laboratory studies have shown that these types of compounds are capablgsof sustaining ’ Thus, they may duplicate more closely the metabolic effects seen with fluoridated elevated blood fluoride levels for long periods of time. water. One drawback with this type of vehicle is that it may not be pos- sible to use it in a manner that can provide post-eruptive (topical) benefits. If this is true, then the system may be self-defeating. In summary, it is clear that there is a lack of definitive knowledge with respect to what constitutes an optimal dosage for fluoride supple- mentation. At the present time it appears premature to suggest that the dosage schedule recommended by the ADA's Council on Dental Therapeutics should be altered, although additional long-term evaluations of this regimen are indicated. A fluoride dosage of one milligram appears to be well tolerated by school—age children and the possibility of increasing this dosage, parti- cularly if the tablets are being given only on days of school attendance, should be considered. The possibility that enhanced benefits may be pro- duced by using controlled—release type vehicles or by giving the supple— ments in divided dosages should be further researched. When fluoride supplements are being given, it is important to be aware of and to make appropriate dosage adjustments for naturally-occurring fluoride in the drinking water supply. Because optimal water fluoride levels vary from one geographic area to another, depending on mean maximum daily temperature,28 it is also advisable to take this variation into account when adjusting for natural fluorides. 10 E. Practical Aspects of Fluoride Tablet Administration In organizing a program for the administration of dietary fluoride supplements, the following approaches may be considered: administration on a full-time basis at home, administration in school on days of school attendance or a combination of home and school administration. With regard to full-time administration at home, the degree of suc— cess depends upon the cooperation that can be obtained from the parents and the child in following the consistent and continuous regimen required. Strong motivation and a clear realization of the need for careful regula- tion of the daily intake are essential. These demands tend to severely restrict the effectiveness of home use of fluoride administration as a wide-scale measure for preventing dental caries. There have been several reports indicating that public health programs in which fluoride supple- ments have been distributed to families have met with little success.25’70’77'79 Although these reports suggest that full-time home use of fluoride supple- ments holds little promise of being successful as a wide-scale public health measure, the procedure still should be recommended for selected situations where the necessary motivation can be achieved. The second approach, that of administering fluoride supplements in school, appears to be a more suitable choice for wide-scale use in public health programs. Because the supplements can be administered and super- vised by classroom teachers, control of the regimen is better than that normally expected for a home-use program. The procedure of distributing tablets in school, however, is still not an ideal public health measure. The regimen requires the continued enthusiasm and cooperation of school officials, teachers and students. The cooperation of students becomes increasingly important as they advance in age and begin to exert their independence. Thus, it may not be possible to continue fluoride tablet administration in school beyond age l2 to 14. The third approach involves a combination of the two approaches pre- viously discussed. The combination could be derived by giving tablets at home until school age and then giving them only in school, or by giving tablets in school on school days and at home on weekends and during vaca- tions. However, the advantages of this approach are questionable. If administration can be carried out conscientiously at home from birth until five years of age, it probably could be continued successfully at home ll for several more years. The other combination in which fluoride supple- ments would be provided for home use on non—school days does not seem to be practical. The intermittent use of supplements at home is likely to be subject to more neglect and abuse than is full-time use at home. Furthermore, it is not clear from the available data that greater benefits are derived by giving the supplements to children of school age on a full- time basis rather than only on school days. Related to the practicality of fluoride tablet programs is the pro- cedure of giving fluoride supplements in divided dosages. In the study by Driscoll and his co-workers,42 in which one study group receives one fluoride tablet in the morning and another tablet in the afternoon, it has been found that many teachers have not remembered to give the tablet in the afternoon, or have given it intermittently because of their reluc- tance to interrupt their schedules a second time during the day. The same problem undoubtedly would occur if fluoride tablets were being given in divided dosages at home. With regard to the cost of administering a fluoride tablet program, estimates received from the manufacturer indicate that EDQEiElEE (APF) tablets would cost $l8.00 per lOOO tablets and Luride (neutral NaF) tab- lets would cost $8.00 per lOOO for large quantities used in public health programs.37 Using these figures, the annual cost per child for the sodium fluoride tablets would be $2.92 for full—time administration and $1.44 for administration on school days (l80 days). The corresponding figures for the APF tablets are $6.57 and $3.24. In summary, the most practical approach to fluoride tablet adminis- tration in public health programs appears to be that of administering the supplements in school on days of school attendance. To derive maximum benefit from the procedure, administration should begin in the earliest grades. Because of its outstanding caries-preventive potential, full- time use of fluoride supplements at home should be encouraged in selected situations where the necessary motivation can be achieved. The difficulty of giving fluoride supplements in divided dosages at separate times during the day tends to restrict the feasibility of that procedure. It appears 12 that the cost per child for administering fluoride tablet programs is not unreasonable. However, analyses must be carried out to establish the cost-benefit ratios for dietary fluoride administration and these ratios must be compared with those of other caries-preventive procedures. The various shortcomings associated with fluoride tablet administration clearly indicate that the procedure is not a feasible substitute in com- munities where water fluoridation can be implemented. Table l Caries—Preventive Effects of Fluoride Tablets on Deciduous Teeth: A Summary F Com- Daily Initial No. of Years Caries Study pound Dosage Age of Subjects of F Reduction (mg) Subjects Intake In Years Arnold et NaF 0.5—1 Birth—6 121 1—12 "Comparable to al. 1960 water F" (deft) [3] Pollak NaF+v+ 1 3 100 2 80% (dmft) [3] 1960 NaF+V 1 4 111 2 20% (dmft) [3] Ziemnowicz- NaF 0.8* ¢ 3 139 2 26% (dmfs) [1] Glowaka 1960 (4x0.2) Lutomska & NaF 0.6 3—4 154 2 "No significant Koninska 1962 (3x0.2) effect" [3] Kamocka et NaF 0.75* 3 64 3 0% (dmft) [2] a1. 1964 (3x0.25) NaF 0.75* 4 79 3 0% (dmft) [2] (3x0.25) Leonhardt NaF+V 1* 3 ? 2 38% (dmft) [3] 1965 (liquid) NaF+V 1* 4 ? 2 30% (dmft) [3] (liquid) Hennon et NaF+V 0.5-1 Birth—5% 85 3 63% (dmfs) [1] a1. 1966, NaF+V 0.5-1 Birth-5% 54 4 68% (dmfs) [1] 1967, 1970 NaF+V 0.5-1 Birth-5% 6O 5 66% (dmfs) [1] Margolis et NaF+V 0.5—1 Birth 91 5 70% (deft) [3] a1. 1967 Hoskova NaF 0.25—1 Prenatal 78 4 93% (deft) [1] 1968 (1-4x0.25) NaF 0.25—1 Birth-l 151 4 54% (deft) [1] (1—4x0.25) Kailis et NaF ? Prenatal 50 4-6 82% (deft) [1] al' 1968 NaF 2 Birth 92 4—6 56% (deft) [1] Stolte ? l 3 130 3 11% (dmft) [3] 1968 Prichard NaF ? Prenatal 176 6—8 70% (deft) [l] 1969 NaF ? Birth 282 6—8 40% (deft) [1] Table 1 (Continued) . Caries-Preventive Effects of Fluoride Tablets on Deciduous Teeth: A Summary F Com— Daily Initial No. of Years Caries Study pound Dosage Age of Subjects of F Reduction (mg) Subjects Intake In Years Hamberg NaF+V 0.5 Birth 342 3 57% (decayed [3] 1971 (drops) teeth) NaF+V 0.5 Birth 342 6 49% (decayed [3] (drOPS) . teeth) Hennon et NaF+V 0.5 <1 458 3 78% (defs) [3] al. 1971 Kraemer CaF2 l 4 170 2 22% (dmft) [3] 1971 0an 1 5 82 2 18% (dmft) [3] Schutzmannsky NaF l Prenatal 100 4. 13% (dmft) [l] 1971 NaF 0.25—1 Prenatal 100 9 30% (dmft) [1] (l—4x0.25) NaF 0.25-1 Birth 100 9 14% (dmft) [1] (1-4x0.25) Hennon et NaF+V 1 12-3 182 1 57% (defs) [1] al' 1972‘ NaF 1 115—3 165 1 55% (defs) [1] NaF+V 1 1%-3 95 2 66% (defs) [1] NaF 1 12-3 91 2 63% (defs) [1] Aasenden & NaF+v++ 0.5—1 Birth 87 8—11 80% (dfs, 2nd [1] Peebles 1974 molars) + V=Vitamins [1] Statistically significant T? A NaF+V combination was given up [2] Not statistically significant to 3 years of age. Beyond this [3] No statistical test reported age some children received NaF+V while others received only NaF. * Tablets given only on school days. ¢ Four 0.2 mg. F tablets given daily. Table 2 Caries—Preventive Effects of Fluoride Tablets on Permanent Teeth: A Summary F Com— Daily Initial No. of Years Caries Study pound Dosage Age of Subjects of F Reduction (mg) Subjects Intake in Years Stones et NaF 1.5 6-14 125 2 0% (caries [2] a1. 1949 intensity) Bibby et NaF 1 5-14 133 l Tentative find- [3] a1. 1955 (pill) ing: no reduction (new carious areas) NaF 1 5—14 119 1 Tentative find- [3] (lozenge) ing: possible reduction (new carious areas) Niedenthal NaF 1* ¢ 6—7 251 3 22% (DMFT) [3] 1957 (2x0.5) Wrzodek NaF 1* 6-9 8381 21% (DMFT) [3] 1959 NaF 1* 6-9 13585 222 (mm) [3] Arnold et NaF 0.5-1 Birth-6 121 1—15 "Comparable to [3] a1. 1960 water F" (DMFT) Krusic CaF2 ? 8-15 480 1-3 70% (?) [3] 1960 Pollak NaF+V+ 1 6-7 300 2 38% (DMFT) [3] 1960 Ziemnowics- NaF 0.8* 3-6 704 2 33% (DMFS) [1] Glowaka (4x0.2) NaF 0.8* 5—6 204 3 28% (DMFS) [1] (4x0.2) Jez CaF2 '2 7-11 7200 2*: oz (:7) [3] 1962 Krychalska- NaF ? grammar 134 4 5% (DMFS) [3] Karwan & school Laskowska 1963 Minoguchi et NaF+V 0.25 Birth—6 75 6 36% (DMFT) [3] a1. 1963 Binder NaF 1* 6 ? 4 35% (DMFT) [3] 1964, 1967 Table 2 {Continued) Caries-Preventive Effects of Fluoride Tablets on Permanent Teeth: A Summary F Com— Daily Initial No. of Years Caries Study pound Dosage Age of Subjects of F Reduction (mg) Subjects Intake in Years Grissom et NaF 1* 6—11 178 2 34% (DMFS) [1] a1. 1964 Kamocka et NaF 0.75* 3 64 3 17% (DMFT) [2] al. 1964 (3x0.25) NaF 0.75* 4 79 3 60% (DMFT) [1] (3x0.25) Leonhardt NaF 6 398 32% (DMFT) [3] 196‘ NaF 7 429 25% (DMFT) [3] Hippchen ? 1 6 500 3 32% (DMFT) [3] .1965 Schutzmannsky NaF 0.75* 6 580 4 25% (DMFS) [3] 1965 (3x0.25) NaF 0.75* 6 197 6 27% (DMFS) [3] (3x0.25) Berner et NaF 0.5—1* 5-7 105 3 84% (DMFS, except a1. 1967, lst molar) 1968 33% (DMFS, lst [3] molar) NaF 1* 7—9 158 4 16% (DMFT) [3] NaF 1* 7—9 160 20% (DMFT) [3] NaF 1* 7-9 109 24% (DMFT) [3] DePaola & APF 1* 6—8 130 2 23% (DFS) [l] Lax 1968 Girardi— NaF 1 lst grade ? 3 31% (?) [3] Vogt 1968 Stolte ? 1 3 150 3 69% (DMFT) [3] 1968 Marthaler NaF 0.5—1* 6—7 450 1—8 36% (DMFT) 1969 (2—4x0.25) 47% (DMF sites) [1] Hamberg NaF+V 0.5 Birth 342 7 70% (decayed [3] 1971 (drops) teeth) Table 2 gContinued) Caries—Preventive Effects of Fluoride Tablets on Permanent Teeth: A Summary F Com— Daily Initial No. of Years Caries Study pound Dosage Age of Subjects of F Reduction (mg) Subjects Intake in Years Schutzmannsky NaF 1 Prenatal 100 4. 6% (DMFT) [2] 1971 NaF 0.25—1 Prenatal 100 9 43% (DMFT) [l] (1-4x0.25) NaF 0.25—1 Birth 100 9 39% (DMFT) [1] (l—4x0.25) Aasenden et APF 1* 8—11 109 3 30% (DFS) [1] a1. 1972 (liquid) NaF 1* 8-11 114 3 27% (DFS) [1] (liquid) Plasschaert & NaF l 7 190 2 32% (DMFS) [l] Konig 1973 Assenden & NaF+V++ 0.5-1 Birth 100 8-11 80% (DFS, all Peebles 1974 teeth) 77% (DFS, lst [1] molars) Driscoll et , APF 1* 6-7 202 2b2 6% (DMFS) [2] 31' 197“ APF 2* 6—7 197 292 27% (DMFS) [1] (2x1) f V=Vitamins [l] Statistically significant ++ A NaF+V combination was given up to 3 years of age. Beyond this age some children received NaF+V while others received only NaF. * Tablets given only on school days ¢ Two 0.5 mg. F tablets given daily [2] [3] Not statistically significant No statistical test reported Table 3 Caries—Preventive Effects of Fluoride Tablets Used Prenatally: A Summary F Com— Daily Initial No. of Years Caries Study pound Dosage Age of Subjects of F Reduction (mg) Subjects Intake in Years Hoskova NaF 0.25—l ¢ Prenatal 78 4 93% (deft) [1] 1968 (l—4x0.25) NaF 0.25—1 Birth—l 151 4 54% (deft) [l] (l-4x0.25) Kailis et NaF ? Prenatal 50 4—6 82% (deft) [1] al' 1968 NaF 2 Birth 92 4—6 56% (deft) [1] Prichard NaF 7 Prenatal 176 6—8 70% (deft) [1] 1969 NaF ? Birth 282 6—8 40% (deft) [1] Schutzmannsky NaF l Prenatal 100 4. 13% (dmft) [1] 1971 6% (DMFT) [2] NaF 0.25-l Prenatal 100 9 30% (dmft) [l] (l—4x0.25) 43% (DMFT) [l] NaF 0.25-l Birth 100 9 14% (dmft) [l] (l—4x0.25) 39% (DMFT) [l] ¢ One to four 0.25 mg. F tablets given daily [1] Statistically significant [2] Not statistically significant Table 4 Caries—Preventive Effects of Fluoride—Vitamin Combinations: A Summary F-Vita- Daily Initial No. of Years Caries Study min Com- Dosage Age of Subjects of F Reduction pound (mg) Subjects Intake in Years Pollak NaF, Vit. 1 3 75 2 80% (dmft) [3] 1960 A,D,E NaF, Vit. 1 4 148 2 20% (dmft) [3] A,D,E NaF, Vit. 1 6-7 300 2 38% (DMFT) [3] A,D,E Minoguchi et NaF, Vit. 0.25 Birth-6 75 6 36% (DMFT) [3] a1. 1963 A,D Leonhardt NaF, Vit. 1* 3 ? 2 38% (dmft) [3] 1965 A,D,E NaF, Vit. 1* 4 ? 2 30% (dmft) [3] A,D,E Hermon et NaF, Vit. 0.5—1 Birth—535 85 3 63% (dmfs) [1] a1. 1966, A,B,C,D 1967’ 1970 NaF, Vit. 0.5—1 Birth—5‘12 54 4 68% (dmfs) [1] A,B,C,D NaF, Vit. 0.5—1 Birth—5% 60 5 66% (dmfs) [1] A,B,C,D Margolis et NaF, Vit. 0.5—1 Birth 91 5 70% (deft) [3] a1. 1967 A,B,C,D Hennon et NaF, Vit. 0.5 4. 458 3 78% (defs) [3] a1. 1971 ? Hamberg NaF, Vit. 0.5 Birth 342 3 57% (deciduous [3] 1971 A,D, (drops) decayed teeth) NaF, Vit. 0.5 Birth 342 6 49% (deciduous [3] A,D (drops) decayed teeth) Hermon et NaF, Vit. 1 1&3 182 1 57% (defs) [1] a1. 1972 A,B,C,D NaF 1L2—3 165 1 55% (defs) [1] NaF, Vit. 1%~3 95 66% (defs) [l] A,B,C,D NaF 1 15-3 91 2 63% (defs) [1] Table 4 Caries—Preventive Effects of Fluoride—Vitamin Combinations: A Summary F—Vita- Daily Initial No. of Years Caries Study min Com— Dosage Age of Subjects of F Reduction pound (mg) Subjects Intake in Years Aasenden & NaF, Vit.++ Birth 87—100 8-11 80% (dfs, 2nd [1] Peebles 1974 C,D molars) 80% (DFS, all [11 teeth) 77% (DFS, lst molars) ++ A NaF+V combination was given up to 3 years of age. Beyond this age some children received NaF+V while others received only NaF. * Tablets given only on school days [1] Statistically significant [3] No statistical test reported 10. 11. 12. BIBLIOGRAPHY Aasenden, R., DePaoTa, P. F. and Brudevo1d, F. 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