1. 所有長牙的兒童, 每天使用少量含氟牙膏刷牙兩次
2. 三歲以下. 每次使用一個米粒大小的牙膏, 用塗的, 不用刷的
3. 三歲以上, 學齡前(5-6歲)每次使用一個豌豆大小的牙膏
4. 年齡較大的學齡前兒童可以使用略多於“豌豆大小”的量
5. 六至18歲的兒童——至少每週使用0.09%氟化物漱口水；每天兩次或 0.5% 氟化物凝膠或糊劑，直至風險水平降低
5. 家用局部氟化劑（濃度高達百萬分之 5000）建議使用在六歲以上且患齲齒風險較高的患者
6. 美國公共衛生服務部門建議預防齲齒的最佳社區飲用水濃度為 0.7 mg/L
參考資料 Preventive dental care and counseling for infants and young children
下面內容來自 uptodate 網站.
中文部分先使用GOOGLE翻譯
氟化物
使用氟化物是所有年齡段預防齲齒的主要方法。然而，兒童過量接觸氟化物會導致氟斑牙，氟斑牙通常表現為恆牙釉質中的白色條紋。因此，兒童應謹慎使用氟化物，特別是在牙釉質成熟的關鍵幾個月（最多 48 個月），此時正在發育的前恆牙最容易受到過量氟化物的影響，從而導致氟中毒 [90 ]。對於日常使用的氟化產品尤其如此，例如氟化牙膏。
氟化物牙膏 — 我們建議所有長牙的兒童每天使用少量含氟牙膏刷牙兩次，每次兩分鐘。嬰幼兒（三歲以下）牙膏的適量用量為“塗抹”（一層非常薄的牙膏，覆蓋兒童牙刷刷毛表面不到一半的面積（圖4））或米粒大小[ 12,39,91 ]。牙膏量應增加到不超過“豌豆大小”（圖5) 三歲時的金額；年齡較大的學齡前兒童可以使用略多於“豌豆大小”的量。向護理人員提供諮詢以確保使用適量的牙膏非常重要；一項全國調查（2013 年至 2016 年）顯示，近 40% 的 3 至 6 歲兒童使用的牙膏數量超過了推薦量 [ 92 ]。為了避免吞嚥含氟牙膏，幼兒刷牙後不應用水沖洗[ 12 ]。對觀察性研究的系統回顧發現，有限的證據表明，儘管攝入超過豌豆大小的含氟牙膏與氟中毒風險增加相關[ 93]，大多數與含氟牙膏相關的氟中毒病例都是輕微的，並不被認為沒有吸引力[ 94-96 ]。
關於何時開始使用含氟
牙膏，兒科和牙科團體尚未達成明確共識[ 97 ]。美國兒科學會 (AAP) 和美國牙科協會 (ADA) 推薦“所有有牙齒的兒童”使用氟化物牙膏 [ 12,91 ]，而美國兒科牙科學會 (AAPD) 建議“為有齲齒風險的兩歲以下兒童”使用氟化物牙膏 [98 ]。ADA 提供了牙膏清單符合 ADA 安全性和有效性標準。所有三個組織都同意，護理人員應密切監督氟化物牙膏的使用，並且嬰兒和幼兒應使用極少量的氟化物牙膏，以降低恆牙氟中毒的風險。考慮到治療幼兒齲齒的成本和復雜性，以及缺乏在該人群中經過驗證的齲齒風險評估工具，我們建議所有有牙的兒童都應該每天用父母或看護者配發的少量含氟牙膏刷牙。
氟化物的使用牙膏可以降低兒童患齲齒的風險。一項系統評價包括一項隨機試驗（998 名受試者），比較含氟牙膏和不含氟化物的牙膏刷牙在減少齲齒增量（即乳牙列腐爛和填充表面相對基線的變化）方面的情況[ 99]。含氟牙膏將齲齒增量從 4.73 降低至 2.87（平均差為 -1.86，95% CI -2.5 至 -1.2）。在另一項系統評價中，對八項觀察性和隨機研究（4187 名患者）進行匯總分析，發現使用含氟牙膏刷牙與患齲齒高風險的 6 歲以下兒童的齲齒風險小幅降低相關（標準化平均差 -0.25，95% CI -0.36 至 -0.14）[97 ]。
最佳氟化物濃度尚不確定，但美國幾乎所有含氟牙膏的濃度約為百萬分之 1000 (1000PPM)。在對 81 項研究進行的網絡薈萃分析中，百萬分之 1000 至 1500 的濃度比無氟牙膏具有更好的效果；在間接比較中，1450 至 1500 ppm 濃度和 1700 至 2000 ppm 濃度的結果相似[ 99 ]。納入的試驗均未報告氟中毒。為了最大限度地發揮含氟牙膏的益處並最大限度地降低其風險，我們建議三歲以下的兒童在牙齒長出後立即開始使用含氟牙膏刷牙，但只使用“塗抹”牙膏。
局部應用氟化物 — 我們建議按處方強度局部應用氟化物應根據齲齒風險評估的結果（表 2 ）提供氟化物，而不是從乳牙萌出時開始普遍使用局部氟化物。處方強度的家用局部氟化劑（濃度高達百萬分之 5000）僅適用於 6 歲以上且患齲齒風險較高的患者[100 ]。患齲齒風險較低的患者可以通過氟化水和非處方氟化牙膏獲得足夠的氟化物。
對於齲齒風險較高的兒童，可以通過多種方式局部使用氟化物[ 100 ]：
●由醫療保健從業者專業使用（例如，牙醫、牙科保健員、醫師、護士或醫療助理，具體取決於國家實踐法案）[12]： •對於6歲以下的兒童 – 至少每三至六個月使用2.26％的氟化物清漆 •對於6至18歲的兒童 – 至少每三至六個月使用1.23％的酸化磷酸鹽氟化物泡沫或凝膠四分鐘；或至少每三到六個月使用 2.26% 的氟化物清漆 與初級保健實踐中氟化物清漆應用相關的信息和資源可通過AAP獲得。
●在家自行塗抹（憑處方）
•對於6至18歲的兒童——至少每週使用0.09%氟化物漱口水；每天兩次或 0.5% 氟化物凝膠或糊劑，直至風險水平降低（表 2）
系統評價和薈萃分析發現，非處方氟化物漱口水（0.05% 氟化物 [百萬分之 230]）可能有助於預防高危兒童（> 6 歲）的齲齒，但對於低齲齒風險兒童而言，除了氟化物牙膏之外，沒有任何益處 [101,102 ]。專業團體對於通用或基於風險的局部氟化物
缺乏共識應用。ADA 和 AAPD 建議基於風險的應用，以避免對齲齒風險低的兒童不必要地使用資源 [ 100,103 ]。美國預防服務工作組 (USPSTF) 和 AAP 建議從乳牙萌出開始一直持續到五歲 (USPSTF) 或建立牙科之家 (AAP) 普遍使用氟化物清漆，以避免錯過預防齲齒的機會 [12,104 ]。儘管我們建議採用基於風險的方法，但我們認識到進行個性化齲齒風險評估並不總是可行。
參考資料 Preventive dental care and counseling for infants and young children
下面內容來自 uptodate 網站.
中文部分先使用GOOGLE翻譯
氟化物
使用氟化物是所有年齡段預防齲齒的主要方法。然而，兒童過量接觸氟化物會導致氟斑牙，氟斑牙通常表現為恆牙釉質中的白色條紋。因此，兒童應謹慎使用氟化物，特別是在牙釉質成熟的關鍵幾個月（最多 48 個月），此時正在發育的前恆牙最容易受到過量氟化物的影響，從而導致氟中毒 [90 ]。對於日常使用的氟化產品尤其如此，例如氟化牙膏。
氟化物牙膏 — 我們建議所有長牙的兒童每天使用少量含氟牙膏刷牙兩次，每次兩分鐘。嬰幼兒（三歲以下）牙膏的適量用量為“塗抹”（一層非常薄的牙膏，覆蓋兒童牙刷刷毛表面不到一半的面積（圖4））或米粒大小[ 12,39,91 ]。牙膏量應增加到不超過“豌豆大小”（圖5) 三歲時的金額；年齡較大的學齡前兒童可以使用略多於“豌豆大小”的量。向護理人員提供諮詢以確保使用適量的牙膏非常重要；一項全國調查（2013 年至 2016 年）顯示，近 40% 的 3 至 6 歲兒童使用的牙膏數量超過了推薦量 [ 92 ]。為了避免吞嚥含氟牙膏，幼兒刷牙後不應用水沖洗[ 12 ]。對觀察性研究的系統回顧發現，有限的證據表明，儘管攝入超過豌豆大小的含氟牙膏與氟中毒風險增加相關[ 93]，大多數與含氟牙膏相關的氟中毒病例都是輕微的，並不被認為沒有吸引力[ 94-96 ]。
關於何時開始使用含氟
牙膏，兒科和牙科團體尚未達成明確共識[ 97 ]。美國兒科學會 (AAP) 和美國牙科協會 (ADA) 推薦“所有有牙齒的兒童”使用氟化物牙膏 [ 12,91 ]，而美國兒科牙科學會 (AAPD) 建議“為有齲齒風險的兩歲以下兒童”使用氟化物牙膏 [98 ]。ADA 提供了牙膏清單符合 ADA 安全性和有效性標準。所有三個組織都同意，護理人員應密切監督氟化物牙膏的使用，並且嬰兒和幼兒應使用極少量的氟化物牙膏，以降低恆牙氟中毒的風險。考慮到治療幼兒齲齒的成本和復雜性，以及缺乏在該人群中經過驗證的齲齒風險評估工具，我們建議所有有牙的兒童都應該每天用父母或看護者配發的少量含氟牙膏刷牙。
氟化物的使用牙膏可以降低兒童患齲齒的風險。一項系統評價包括一項隨機試驗（998 名受試者），比較含氟牙膏和不含氟化物的牙膏刷牙在減少齲齒增量（即乳牙列腐爛和填充表面相對基線的變化）方面的情況[ 99]。含氟牙膏將齲齒增量從 4.73 降低至 2.87（平均差為 -1.86，95% CI -2.5 至 -1.2）。在另一項系統評價中，對八項觀察性和隨機研究（4187 名患者）進行匯總分析，發現使用含氟牙膏刷牙與患齲齒高風險的 6 歲以下兒童的齲齒風險小幅降低相關（標準化平均差 -0.25，95% CI -0.36 至 -0.14）[97 ]。
最佳氟化物濃度尚不確定，但美國幾乎所有含氟牙膏的濃度約為百萬分之 1000 (1000PPM)。在對 81 項研究進行的網絡薈萃分析中，百萬分之 1000 至 1500 的濃度比無氟牙膏具有更好的效果；在間接比較中，1450 至 1500 ppm 濃度和 1700 至 2000 ppm 濃度的結果相似[ 99 ]。納入的試驗均未報告氟中毒。為了最大限度地發揮含氟牙膏的益處並最大限度地降低其風險，我們建議三歲以下的兒童在牙齒長出後立即開始使用含氟牙膏刷牙，但只使用“塗抹”牙膏。
局部應用氟化物 — 我們建議按處方強度局部應用氟化物應根據齲齒風險評估的結果（表 2 ）提供氟化物，而不是從乳牙萌出時開始普遍使用局部氟化物。處方強度的家用局部氟化劑（濃度高達百萬分之 5000）僅適用於 6 歲以上且患齲齒風險較高的患者[100 ]。患齲齒風險較低的患者可以通過氟化水和非處方氟化牙膏獲得足夠的氟化物。
對於齲齒風險較高的兒童，可以通過多種方式局部使用氟化物[ 100 ]：
●由醫療保健從業者專業使用（例如，牙醫、牙科保健員、醫師、護士或醫療助理，具體取決於國家實踐法案）[12]： •對於6歲以下的兒童 – 至少每三至六個月使用2.26％的氟化物清漆 •對於6至18歲的兒童 – 至少每三至六個月使用1.23％的酸化磷酸鹽氟化物泡沫或凝膠四分鐘；或至少每三到六個月使用 2.26% 的氟化物清漆 與初級保健實踐中氟化物清漆應用相關的信息和資源可通過AAP獲得。
●在家自行塗抹（憑處方）
•對於6至18歲的兒童——至少每週使用0.09%氟化物漱口水；每天兩次或 0.5% 氟化物凝膠或糊劑，直至風險水平降低（表 2）
系統評價和薈萃分析發現，非處方氟化物漱口水（0.05% 氟化物 [百萬分之 230]）可能有助於預防高危兒童（> 6 歲）的齲齒，但對於低齲齒風險兒童而言，除了氟化物牙膏之外，沒有任何益處 [101,102 ]。專業團體對於通用或基於風險的局部氟化物
缺乏共識應用。ADA 和 AAPD 建議基於風險的應用，以避免對齲齒風險低的兒童不必要地使用資源 [ 100,103 ]。美國預防服務工作組 (USPSTF) 和 AAP 建議從乳牙萌出開始一直持續到五歲 (USPSTF) 或建立牙科之家 (AAP) 普遍使用氟化物清漆，以避免錯過預防齲齒的機會 [12,104 ]。儘管我們建議採用基於風險的方法，但我們認識到進行個性化齲齒風險評估並不總是可行。
2021 年對比較氟化物的隨機試驗進行薈萃分析在安慰劑或不治療的情況下，使用局部氟化物（主要是氟化物清漆）在兩年內可使表面蛀牙減少約 1 次（蛀牙、缺失或填充的乳牙表面增量的平均差異為 -0.94，95% CI -1.74 至 -0.34；13 項試驗，5733 名受試者）[105 ]。此外，在高風險人群或環境中，局部氟化物可降低發生齲齒的可能性（絕對風險差 -7%，相對風險 0.80，95% CI 0.66-0.95），主要是在 ≤2 歲的兒童中。表明特定頻率（例如，每三個月與每六個月）或方案（例如，單次施用與兩週內多次施用）優於另一個的證據是有限的[25,106-108 ]。
局部使用氟化物似乎是安全的。在一項對四項隨機試驗（414 名受試者）進行的薈萃分析中，將氟化物清漆與安慰劑或不治療進行比較，發現氟中毒和其他不良事件的發生率相似 [105 ]。此外，在一項針對 6 名幼兒（12 至 15 個月大）的藥代動力學研究中，在使用 5% 氟化鈉（2.26% 氟化物）清漆後 5 小時內測量尿氟化物，平均估計殘留氟化物為 20 mcg/kg，遠低於 5 mg/kg 的“可能中毒劑量”[109,110 ]。
儘管有強有力的證據表明存在氟化物由於氟化物的安全性和有效性，美國有一小部分人幾十年來一直反對使用氟化物，特別是水氟化物[ 111 ]。此外，患者不願意接受診室局部氟化物應用似乎是一個日益嚴重的問題[ 112 ]。儘管“氟化猶豫”的原因尚不清楚，但幼兒家長拒絕局部塗氟的理由包括：他們的孩子沒有患齲齒的風險，氟化物無效，其他預防齲齒的方法（例如減少糖的攝入）更可取，以及氟化物有害[113 ]。
補充氟化物 —氟化物如果根據氟化物攝入量和齲齒風險（表 2）表明需要補充，則應從六個月大時開始（表 3）[ 104,114 ]。僅當孩子患齲齒的風險較高，其他含氟媒介（例如含氟牙膏、漱口水、清漆、凝膠）已被證明不足，並且家庭使用非氟化水、瓶裝水或加工水或不含氟化物的井水時，才需要補充氟化物[12,115,116 ]。在美國，疾病控制和預防中心提供有關社區水氟化的信息[ 117]。美國公共衛生服務部門建議預防齲齒的最佳社區飲用水濃度為 0.7 mg/L [ 118 ]。
大多數瓶裝水產品的氟化物含量可以忽略不計，儘管含量各不相同[ 119 ]。除非製造商添加了氟化物，否則標籤上不包含氟化物含量[ 12 ]。
飲用前的水處理可能會影響氟化物濃度。使用反滲透系統和蒸餾裝置的水龍頭濾水器可大幅降低氟化物含量[ 120-122 ]。大多數使用活性炭過濾器的“傾倒”裝置不會減少氟化物[12,120,122,123 ]。水軟化器系統不會改變氟化物含量[ 122,124,125 ]。
氟中毒 — 過量攝入氟化物（通常每天超過 0.05 mg/kg）可導致氟中毒或牙釉質礦化不足[ 126 ]。氟斑牙只有在牙齒發育過程中氟化物濃度過高時才會發生——通常持續到 48 個月大[ 90 ]。根據全國健康與營養調查的數據，1999年至2002年間，6歲至39歲人群氟中毒患病率為23%[127 ]。
輕度氟中毒的牙齒影響僅限於表面外觀（圖6）。2010 年的一項系統回顧發現，輕度氟中毒不是一個美容問題 [ 96 ]。輕度氟中毒表現為牙釉質出現白色斑點或花邊；中度氟中毒外觀呈不透明白色（圖7）；嚴重的氟中毒表現為棕色變色。嚴重氟中毒比輕度氟中毒少見，但它會使牙齒更容易磨損和斷裂[ 128 ]。過量氟化物消耗導致氟中毒的機制似乎是直接影響成釉細胞礦物質形成的速度，導致牙釉質基質破壞[ 129]。氟中毒的嚴重程度通常會在青春期和成年早期減輕，尤其是較輕微的氟中毒[ 130 ]。可以通過在生命早期限製過量氟化物消耗（例如通過吞嚥氟化牙膏或漱口水）和適當補充氟化物來預防氟中毒。
自來水可用於沖調粉狀或濃縮嬰兒配方奶粉[ 12,131 ]。儘管在一項前瞻性研究中使用最佳氟化水沖調嬰兒配方奶粉與氟斑牙風險增加相關[132] ，但兒童可能會接觸多種氟化物來源在嬰儿期（例如，復原果汁、含氟牙膏），很難確定某一特定來源的貢獻[ 131 ]。
FLUORIDE
Use of fluorides is the primary means of preventing dental caries across all age groups. However, excessive fluoride exposure in children can cause dental fluorosis, which typically presents as white streaks in the enamel of permanent teeth. Thus, fluoride should be used judiciously in children, particularly during the critical months of enamel maturation (up to 48 months), when the developing anterior permanent teeth are most vulnerable to excessive fluoride that can cause fluorosis [90]. This is especially true for daily-use fluoride products, such as fluoride toothpaste.
Fluoride toothpaste — We suggest that all children with teeth have their teeth brushed twice daily for two minutes with small amounts of fluoride-containing toothpaste. The appropriate amount of toothpaste for infants and toddlers (younger than three years) is a "smear" (a very thin layer of toothpaste that covers less than half of the bristle surface of a child-size toothbrush (picture 4)) or the size of a grain of rice [12,39,91]. The amount of toothpaste should be increased to no more than a "pea-sized" (picture 5) amount at age three years; older preschoolers can use slightly more than a "pea-sized" amount. It is important to provide counseling to caregivers to ensure that the appropriate amount of toothpaste is used; in a national survey (2013 to 2016), nearly 40 percent of children age three to six years used more toothpaste than recommended [92]. To avoid swallowing fluoride toothpaste, young children should not be given water to rinse after brushing [12]. A systematic review of observational studies found limited evidence that although ingesting more than a pea-sized amount of fluoride-containing toothpaste is associated with increased risk of fluorosis [93], most cases of fluorosis associated with fluoride toothpaste are mild, and not considered unattractive [94-96].
There is no clear consensus among pediatric and dental groups as to when use of fluoride toothpaste should be initiated [97]. The American Academy of Pediatrics (AAP) and the American Dental Association (ADA) recommend fluoride toothpaste "for all children with teeth" [12,91], whereas the American Academy of Pediatric Dentistry (AAPD) recommends fluoride toothpaste "for children less than two years of age at risk for dental caries" [98]. The ADA provides a list of toothpastes that meet ADA criteria for safety and effectiveness. All three organizations agree that use of fluoride toothpaste should be closely supervised by caregivers and that very small amounts should be used for infants and toddlers to reduce the risk of fluorosis in the permanent teeth. Given the cost and complexity of treating caries in young children and the lack of caries risk assessment tools that have been validated in this population, we suggest that all children with teeth should have their teeth brushed daily with small amounts of fluoride toothpaste dispensed by the parent or caregiver.
Use of fluoride toothpaste reduces the risk of dental caries in children. A systematic review included one randomized trial (998 participants) that compared toothbrushing with fluoride-containing toothpaste and toothpaste without fluoride in reducing the caries increment (ie, the change from baseline in decayed and filled surfaces of the primary dentition) [99]. Fluoride-containing toothpaste reduced the caries increment from 4.73 to 2.87 (mean difference of -1.86, 95% CI -2.5 to -1.2). In another systematic review, pooled analysis of eight observational and randomized studies (4187 patients), brushing with fluoride-containing toothpaste was associated with a small reduction in caries risk in children younger than six years who were at high risk of developing caries (standardized mean difference -0.25, 95% CI -0.36 to -0.14) [97].
The optimal concentration of fluoride is uncertain, but nearly all fluoride toothpaste in the United States has concentrations of approximately 1000 parts per million. In a network meta-analysis of 81 studies, concentrations of 1000 to 1500 parts per million (ppm) were associated with better outcomes than nonfluoride toothpaste; in indirect comparisons, outcomes were similar for concentrations of 1450 to 1500 ppm and concentrations of 1700 to 2000 ppm [99]. None of the included trials reported on fluorosis. To maximize the benefits and minimize the risks of fluoride toothpaste, we suggest that children younger than three years begin brushing with fluoride toothpaste as soon as they develop teeth but that they use only a "smear" of toothpaste.
Topical fluoride application — We suggest that prescription-strength topical fluoride be provided based on the results of a caries risk assessment (table 2) rather than universal application of topical fluoride beginning at primary tooth eruption. Prescription-strength home-use topical fluoride agents (up to 5000 parts per million) are indicated only for patients ≥6 years old who are at increased risk of developing dental caries [100]. Patients at low risk of developing caries can receive sufficient fluoride through fluoridated water and over-the-counter fluoridated toothpaste.
For children at increased risk of dental caries, topical application of fluoride can be achieved in a number of ways [100]:
●Professionally applied by health care practitioners (eg, dentist, dental hygienist, physician, nurse, or medical assistant depending on state practice acts) [12]:
•For children <6 years – 2.26 percent fluoride varnish applied at least every three to six months
•For children 6 to 18 years old – 1.23 percent acidulated phosphate fluoride foam or gel for four minutes at least every three to six months; or 2.26 percent fluoride varnish at least every three to six months
Information and resources related to fluoride varnish application in primary care practice are available through the AAP.
●Self-applied at home (by prescription)
•For children 6 to 18 years old – 0.09 percent fluoride mouth rinse at least weekly; or 0.5 percent fluoride gel or paste twice daily until the risk level is reduced (table 2)
Systematic reviews and meta-analyses have found that over-the-counter fluoride mouth rinse (0.05 percent fluoride [230 parts per million]) may be beneficial in preventing caries in children (>6 years) at high risk but does not provide any benefit beyond that of fluoride toothpaste for children at low risk of caries [101,102].
There is a lack of consensus among professional groups regarding universal or risk-based topical fluoride application. The ADA and the AAPD recommend risk-based application to avoid unnecessary use of resources in children who are at low risk of dental caries [100,103]. The United States Preventive Services Task Force (USPSTF) and the AAP recommend universal application of fluoride varnish beginning at primary tooth eruption and continuing through age five years (USPSTF) or establishment of a dental home (AAP) to avoid missed opportunities for caries prevention [12,104]. Although, we suggest a risk-based approach, we recognize that it is not always practical to perform individualized caries risk assessments.
In a 2021 meta-analysis of randomized trials comparing fluoride with placebo or no treatment, the use of topical fluoride (mainly fluoride varnish) resulted in approximately one less surface tooth decay over a two-year period (mean difference in the increment of decayed, missing, or filled primary tooth surfaces of -0.94, 95% CI -1.74 to -0.34; 13 trials, 5733 participants) [105]. In addition, in higher-risk populations or settings, topical fluoride reduced the likelihood of incident caries (absolute risk difference -7 percent, relative risk 0.80, 95% CI 0.66-0.95), predominantly in children ≤2 years of age. Evidence suggesting that a particular frequency (eg, every three versus every six months) or regimen (eg, single application versus multiple applications over a two-week period) is superior to another is limited [25,106-108].
Topical fluoride application appears to be safe. In a meta-analysis of four randomized trials (414 participants) comparing fluoride varnish with placebo or no treatment, the rates of fluorosis and other adverse events were similar [105]. In addition, in a pharmacokinetic study in six toddlers (12 to 15 months of age) in whom urinary fluoride was measured for five hours after application of 5 percent sodium fluoride (2.26 percent fluoride) varnish, the average estimated retained fluoride was 20 mcg/kg, well below the "probable toxic dose" of 5 mg/kg [109,110].
Despite strong evidence of fluoride's safety and effectiveness, small groups of people in the United States have opposed fluoride use – particularly water fluoridation – for decades [111]. In addition, patient reluctance to accept in-office topical fluoride applications appears to be a growing problem [112]. Although the reasons for "fluoride hesitancy" are unclear, reasons provided by parents of young children for refusing topical fluoride application include that their children are not at risk for caries, that fluoride is not effective, that other means of caries prevention (eg, reduced sugar consumption) are preferable, and that fluoride is harmful [113].
Fluoride supplementation — Fluoride supplementation, if indicated based upon fluoride intake and caries risk (table 2), should begin at six months of age (table 3) [104,114]. Fluoride supplementation is only necessary if the child is at high risk for caries, other fluoride vehicles (eg, fluoride toothpaste, mouth rinse, varnish, gel) have proved to be inadequate, and the family is using nonfluoridated water, bottled or processed waters, or well water that does not contain fluoride [12,115,116]. In the United States, the Centers for Disease Control and Prevention provide information about community water fluoridation [117]. The United States Public Health Service recommends an optimal community drinking water concentration of 0.7 mg/L to prevent dental caries [118].
Most bottled water products contain negligible levels of fluoride, although the content varies [119]. The fluoride content is not included on the label unless fluoride has been added by the manufacturer [12].
The treatment of water before drinking may affect the fluoride concentration. Faucet water filters that use reverse osmosis systems and distillation units substantially reduce the fluoride content [120-122]. Most "pour through" devices using activated carbon filters do not reduce fluoride [12,120,122,123]. Water softener systems do not alter fluoride content [122,124,125].
Fluorosis — Excess fluoride consumption (generally greater than 0.05 mg/kg per day) can cause fluorosis or hypomineralization of the dental enamel [126]. Dental fluorosis occurs only when there is excessive fluoride concentration during tooth development – generally up to 48 months of age [90]. According to data from the National Health and Nutrition Examination Survey, the prevalence of fluorosis among persons aged 6 to 39 years was 23 percent during 1999 to 2002 [127].
The dental effect of mild fluorosis is limited to surface appearance (picture 6). A 2010 systematic review found that mild fluorosis is not a cosmetic concern [96]. Mild fluorosis is indicated by a white flecked or lacy appearance to the enamel; moderate fluorosis has an opaque white appearance (picture 7); severe fluorosis is indicated by a brown discoloration. Severe fluorosis is much less common than mild fluorosis, but it can make the teeth more susceptible to wear and breakage [128]. The mechanism by which excessive fluoride consumption causes fluorosis appears to be a direct effect on the rate of mineral formation by ameloblasts, resulting in disruption of the enamel matrix [129]. Fluorosis severity often diminishes during adolescence and young adulthood, particularly in its milder forms [130]. Fluorosis can be prevented by limitation of excessive fluoride consumption (eg, through the swallowing of fluoridated toothpaste or mouth rinses) early in life and appropriate fluoride supplementation.
Tap water may be used to reconstitute powdered or concentrated infant formula [12,131]. Although use of optimally fluoridated water to reconstitute powdered infant formula was associated with an increased risk of dental fluorosis in a prospective study [132], children may be exposed to multiple sources of fluoride during infancy (eg, reconstituted fruit juice, fluoride-containing toothpaste) and it is difficult to determine the contribution of one particular source [131].
局部使用氟化物似乎是安全的。在一項對四項隨機試驗（414 名受試者）進行的薈萃分析中，將氟化物清漆與安慰劑或不治療進行比較，發現氟中毒和其他不良事件的發生率相似 [105 ]。此外，在一項針對 6 名幼兒（12 至 15 個月大）的藥代動力學研究中，在使用 5% 氟化鈉（2.26% 氟化物）清漆後 5 小時內測量尿氟化物，平均估計殘留氟化物為 20 mcg/kg，遠低於 5 mg/kg 的“可能中毒劑量”[109,110 ]。
儘管有強有力的證據表明存在氟化物由於氟化物的安全性和有效性，美國有一小部分人幾十年來一直反對使用氟化物，特別是水氟化物[ 111 ]。此外，患者不願意接受診室局部氟化物應用似乎是一個日益嚴重的問題[ 112 ]。儘管“氟化猶豫”的原因尚不清楚，但幼兒家長拒絕局部塗氟的理由包括：他們的孩子沒有患齲齒的風險，氟化物無效，其他預防齲齒的方法（例如減少糖的攝入）更可取，以及氟化物有害[113 ]。
補充氟化物 —氟化物如果根據氟化物攝入量和齲齒風險（表 2）表明需要補充，則應從六個月大時開始（表 3）[ 104,114 ]。僅當孩子患齲齒的風險較高，其他含氟媒介（例如含氟牙膏、漱口水、清漆、凝膠）已被證明不足，並且家庭使用非氟化水、瓶裝水或加工水或不含氟化物的井水時，才需要補充氟化物[12,115,116 ]。在美國，疾病控制和預防中心提供有關社區水氟化的信息[ 117]。美國公共衛生服務部門建議預防齲齒的最佳社區飲用水濃度為 0.7 mg/L [ 118 ]。
大多數瓶裝水產品的氟化物含量可以忽略不計，儘管含量各不相同[ 119 ]。除非製造商添加了氟化物，否則標籤上不包含氟化物含量[ 12 ]。
飲用前的水處理可能會影響氟化物濃度。使用反滲透系統和蒸餾裝置的水龍頭濾水器可大幅降低氟化物含量[ 120-122 ]。大多數使用活性炭過濾器的“傾倒”裝置不會減少氟化物[12,120,122,123 ]。水軟化器系統不會改變氟化物含量[ 122,124,125 ]。
氟中毒 — 過量攝入氟化物（通常每天超過 0.05 mg/kg）可導致氟中毒或牙釉質礦化不足[ 126 ]。氟斑牙只有在牙齒發育過程中氟化物濃度過高時才會發生——通常持續到 48 個月大[ 90 ]。根據全國健康與營養調查的數據，1999年至2002年間，6歲至39歲人群氟中毒患病率為23%[127 ]。
輕度氟中毒的牙齒影響僅限於表面外觀（圖6）。2010 年的一項系統回顧發現，輕度氟中毒不是一個美容問題 [ 96 ]。輕度氟中毒表現為牙釉質出現白色斑點或花邊；中度氟中毒外觀呈不透明白色（圖7）；嚴重的氟中毒表現為棕色變色。嚴重氟中毒比輕度氟中毒少見，但它會使牙齒更容易磨損和斷裂[ 128 ]。過量氟化物消耗導致氟中毒的機制似乎是直接影響成釉細胞礦物質形成的速度，導致牙釉質基質破壞[ 129]。氟中毒的嚴重程度通常會在青春期和成年早期減輕，尤其是較輕微的氟中毒[ 130 ]。可以通過在生命早期限製過量氟化物消耗（例如通過吞嚥氟化牙膏或漱口水）和適當補充氟化物來預防氟中毒。
自來水可用於沖調粉狀或濃縮嬰兒配方奶粉[ 12,131 ]。儘管在一項前瞻性研究中使用最佳氟化水沖調嬰兒配方奶粉與氟斑牙風險增加相關[132] ，但兒童可能會接觸多種氟化物來源在嬰儿期（例如，復原果汁、含氟牙膏），很難確定某一特定來源的貢獻[ 131 ]。
FLUORIDE
Use of fluorides is the primary means of preventing dental caries across all age groups. However, excessive fluoride exposure in children can cause dental fluorosis, which typically presents as white streaks in the enamel of permanent teeth. Thus, fluoride should be used judiciously in children, particularly during the critical months of enamel maturation (up to 48 months), when the developing anterior permanent teeth are most vulnerable to excessive fluoride that can cause fluorosis [90]. This is especially true for daily-use fluoride products, such as fluoride toothpaste.
Fluoride toothpaste — We suggest that all children with teeth have their teeth brushed twice daily for two minutes with small amounts of fluoride-containing toothpaste. The appropriate amount of toothpaste for infants and toddlers (younger than three years) is a "smear" (a very thin layer of toothpaste that covers less than half of the bristle surface of a child-size toothbrush (picture 4)) or the size of a grain of rice [12,39,91]. The amount of toothpaste should be increased to no more than a "pea-sized" (picture 5) amount at age three years; older preschoolers can use slightly more than a "pea-sized" amount. It is important to provide counseling to caregivers to ensure that the appropriate amount of toothpaste is used; in a national survey (2013 to 2016), nearly 40 percent of children age three to six years used more toothpaste than recommended [92]. To avoid swallowing fluoride toothpaste, young children should not be given water to rinse after brushing [12]. A systematic review of observational studies found limited evidence that although ingesting more than a pea-sized amount of fluoride-containing toothpaste is associated with increased risk of fluorosis [93], most cases of fluorosis associated with fluoride toothpaste are mild, and not considered unattractive [94-96].
There is no clear consensus among pediatric and dental groups as to when use of fluoride toothpaste should be initiated [97]. The American Academy of Pediatrics (AAP) and the American Dental Association (ADA) recommend fluoride toothpaste "for all children with teeth" [12,91], whereas the American Academy of Pediatric Dentistry (AAPD) recommends fluoride toothpaste "for children less than two years of age at risk for dental caries" [98]. The ADA provides a list of toothpastes that meet ADA criteria for safety and effectiveness. All three organizations agree that use of fluoride toothpaste should be closely supervised by caregivers and that very small amounts should be used for infants and toddlers to reduce the risk of fluorosis in the permanent teeth. Given the cost and complexity of treating caries in young children and the lack of caries risk assessment tools that have been validated in this population, we suggest that all children with teeth should have their teeth brushed daily with small amounts of fluoride toothpaste dispensed by the parent or caregiver.
Use of fluoride toothpaste reduces the risk of dental caries in children. A systematic review included one randomized trial (998 participants) that compared toothbrushing with fluoride-containing toothpaste and toothpaste without fluoride in reducing the caries increment (ie, the change from baseline in decayed and filled surfaces of the primary dentition) [99]. Fluoride-containing toothpaste reduced the caries increment from 4.73 to 2.87 (mean difference of -1.86, 95% CI -2.5 to -1.2). In another systematic review, pooled analysis of eight observational and randomized studies (4187 patients), brushing with fluoride-containing toothpaste was associated with a small reduction in caries risk in children younger than six years who were at high risk of developing caries (standardized mean difference -0.25, 95% CI -0.36 to -0.14) [97].
The optimal concentration of fluoride is uncertain, but nearly all fluoride toothpaste in the United States has concentrations of approximately 1000 parts per million. In a network meta-analysis of 81 studies, concentrations of 1000 to 1500 parts per million (ppm) were associated with better outcomes than nonfluoride toothpaste; in indirect comparisons, outcomes were similar for concentrations of 1450 to 1500 ppm and concentrations of 1700 to 2000 ppm [99]. None of the included trials reported on fluorosis. To maximize the benefits and minimize the risks of fluoride toothpaste, we suggest that children younger than three years begin brushing with fluoride toothpaste as soon as they develop teeth but that they use only a "smear" of toothpaste.
Topical fluoride application — We suggest that prescription-strength topical fluoride be provided based on the results of a caries risk assessment (table 2) rather than universal application of topical fluoride beginning at primary tooth eruption. Prescription-strength home-use topical fluoride agents (up to 5000 parts per million) are indicated only for patients ≥6 years old who are at increased risk of developing dental caries [100]. Patients at low risk of developing caries can receive sufficient fluoride through fluoridated water and over-the-counter fluoridated toothpaste.
For children at increased risk of dental caries, topical application of fluoride can be achieved in a number of ways [100]:
●Professionally applied by health care practitioners (eg, dentist, dental hygienist, physician, nurse, or medical assistant depending on state practice acts) [12]:
•For children <6 years – 2.26 percent fluoride varnish applied at least every three to six months
•For children 6 to 18 years old – 1.23 percent acidulated phosphate fluoride foam or gel for four minutes at least every three to six months; or 2.26 percent fluoride varnish at least every three to six months
Information and resources related to fluoride varnish application in primary care practice are available through the AAP.
●Self-applied at home (by prescription)
•For children 6 to 18 years old – 0.09 percent fluoride mouth rinse at least weekly; or 0.5 percent fluoride gel or paste twice daily until the risk level is reduced (table 2)
Systematic reviews and meta-analyses have found that over-the-counter fluoride mouth rinse (0.05 percent fluoride [230 parts per million]) may be beneficial in preventing caries in children (>6 years) at high risk but does not provide any benefit beyond that of fluoride toothpaste for children at low risk of caries [101,102].
There is a lack of consensus among professional groups regarding universal or risk-based topical fluoride application. The ADA and the AAPD recommend risk-based application to avoid unnecessary use of resources in children who are at low risk of dental caries [100,103]. The United States Preventive Services Task Force (USPSTF) and the AAP recommend universal application of fluoride varnish beginning at primary tooth eruption and continuing through age five years (USPSTF) or establishment of a dental home (AAP) to avoid missed opportunities for caries prevention [12,104]. Although, we suggest a risk-based approach, we recognize that it is not always practical to perform individualized caries risk assessments.
In a 2021 meta-analysis of randomized trials comparing fluoride with placebo or no treatment, the use of topical fluoride (mainly fluoride varnish) resulted in approximately one less surface tooth decay over a two-year period (mean difference in the increment of decayed, missing, or filled primary tooth surfaces of -0.94, 95% CI -1.74 to -0.34; 13 trials, 5733 participants) [105]. In addition, in higher-risk populations or settings, topical fluoride reduced the likelihood of incident caries (absolute risk difference -7 percent, relative risk 0.80, 95% CI 0.66-0.95), predominantly in children ≤2 years of age. Evidence suggesting that a particular frequency (eg, every three versus every six months) or regimen (eg, single application versus multiple applications over a two-week period) is superior to another is limited [25,106-108].
Topical fluoride application appears to be safe. In a meta-analysis of four randomized trials (414 participants) comparing fluoride varnish with placebo or no treatment, the rates of fluorosis and other adverse events were similar [105]. In addition, in a pharmacokinetic study in six toddlers (12 to 15 months of age) in whom urinary fluoride was measured for five hours after application of 5 percent sodium fluoride (2.26 percent fluoride) varnish, the average estimated retained fluoride was 20 mcg/kg, well below the "probable toxic dose" of 5 mg/kg [109,110].
Despite strong evidence of fluoride's safety and effectiveness, small groups of people in the United States have opposed fluoride use – particularly water fluoridation – for decades [111]. In addition, patient reluctance to accept in-office topical fluoride applications appears to be a growing problem [112]. Although the reasons for "fluoride hesitancy" are unclear, reasons provided by parents of young children for refusing topical fluoride application include that their children are not at risk for caries, that fluoride is not effective, that other means of caries prevention (eg, reduced sugar consumption) are preferable, and that fluoride is harmful [113].
Fluoride supplementation — Fluoride supplementation, if indicated based upon fluoride intake and caries risk (table 2), should begin at six months of age (table 3) [104,114]. Fluoride supplementation is only necessary if the child is at high risk for caries, other fluoride vehicles (eg, fluoride toothpaste, mouth rinse, varnish, gel) have proved to be inadequate, and the family is using nonfluoridated water, bottled or processed waters, or well water that does not contain fluoride [12,115,116]. In the United States, the Centers for Disease Control and Prevention provide information about community water fluoridation [117]. The United States Public Health Service recommends an optimal community drinking water concentration of 0.7 mg/L to prevent dental caries [118].
Most bottled water products contain negligible levels of fluoride, although the content varies [119]. The fluoride content is not included on the label unless fluoride has been added by the manufacturer [12].
The treatment of water before drinking may affect the fluoride concentration. Faucet water filters that use reverse osmosis systems and distillation units substantially reduce the fluoride content [120-122]. Most "pour through" devices using activated carbon filters do not reduce fluoride [12,120,122,123]. Water softener systems do not alter fluoride content [122,124,125].
Fluorosis — Excess fluoride consumption (generally greater than 0.05 mg/kg per day) can cause fluorosis or hypomineralization of the dental enamel [126]. Dental fluorosis occurs only when there is excessive fluoride concentration during tooth development – generally up to 48 months of age [90]. According to data from the National Health and Nutrition Examination Survey, the prevalence of fluorosis among persons aged 6 to 39 years was 23 percent during 1999 to 2002 [127].
The dental effect of mild fluorosis is limited to surface appearance (picture 6). A 2010 systematic review found that mild fluorosis is not a cosmetic concern [96]. Mild fluorosis is indicated by a white flecked or lacy appearance to the enamel; moderate fluorosis has an opaque white appearance (picture 7); severe fluorosis is indicated by a brown discoloration. Severe fluorosis is much less common than mild fluorosis, but it can make the teeth more susceptible to wear and breakage [128]. The mechanism by which excessive fluoride consumption causes fluorosis appears to be a direct effect on the rate of mineral formation by ameloblasts, resulting in disruption of the enamel matrix [129]. Fluorosis severity often diminishes during adolescence and young adulthood, particularly in its milder forms [130]. Fluorosis can be prevented by limitation of excessive fluoride consumption (eg, through the swallowing of fluoridated toothpaste or mouth rinses) early in life and appropriate fluoride supplementation.
Tap water may be used to reconstitute powdered or concentrated infant formula [12,131]. Although use of optimally fluoridated water to reconstitute powdered infant formula was associated with an increased risk of dental fluorosis in a prospective study [132], children may be exposed to multiple sources of fluoride during infancy (eg, reconstituted fruit juice, fluoride-containing toothpaste) and it is difficult to determine the contribution of one particular source [131].
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