預防齲齒-氟化物的添加 Preventive dental care and counseling for infants and young children

(下面所有的氟都是指濃度1000PPM以上)
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。

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].

兒童預防齲齒建議

1. 牙齒有沒有刷乾淨, 與齲齒關聯性不大. 沒刷乾淨的問題是髒, 刷的很乾淨還是可能發生齲齒.
2. 牙齒塗氟是預防齲齒最好的方式. 每天兩次使用含氟牙膏刷牙, 每次兩分鐘以上, 兩次間隔可以很接近(例如隔一小時前後刷兩次)
3. 每天刷兩次牙. 餐前餐後都無妨. 使用含氟牙膏刷牙. 可以不漱口
因此即使嬰幼兒不會吐出漱口水, 還是可以刷牙. 氟化鈉的安全劑量很高, 每天吃兩條牙膏, 連吃兩天才會有過量問題. 吃牙膏是開玩笑的. 但重點是要非常大劑量才會造成氟中毒
4. 兒童牙齒塗氟, 健保給付隨著身分不同有差異. 原住民兒童每三個月可申報一次.
5. 牙膏的選擇, 第一是要含氟化鈉 1000 ppm 以上才有療效. 台灣市售的很多是介於 500-1000 ppm. 目前僅含氟 1000 ppm 以上的才有醫學實症能預防齲齒
6. 何時可以開始幫兒童塗氟?
美國兒童牙醫學會AAPD建議，兒童在長第一顆牙開始，就使用含氟濃度至少1000ppm的牙膏, (也有牙醫師建議四顆以上才開始塗氟)

7. 三歲以下嬰幼兒, 每次使用含氟牙膏的量建議為「米粒大小」，每天需使用兩次，每次推薦至少兩分鐘。且潔牙後不漱口可能可以增加齲齒預防的效果，因此即使不會漱口的嬰兒，家長亦可在刷牙後將多餘的殘渣擦掉即可，米粒大小的牙膏量並不會造成嬰兒身體的長期危害，家長可以安心使用。

8. 而3歲以上兒童可增加為「豌豆大小」的牙膏濃度。另外，氟並不是讓牙膏辣辣的原因，含氟牙膏一樣可以做成水果口味，家長也不必因為口味而不敢選用。

9. 含氟牙膏的品牌不是重點, 含氟濃度超過 1000 ppm 才有保護預防齲齒效過
10. 兒童牙刷選擇便宜的就好. 一個月至三個月更換一次.
11. 每天不要吃超過五餐, 但每一餐是以30分鐘為一單位. 例如吃飯兩小時相當於吃四餐. 因此. 讓小孩吃飯吃越久, 例如小孩一邊玩耍, 家長一邊追著餵食, 不但會增加兒童肥胖的機率, 還會增加發生齲齒機率. 
12. 天然的水果比人工加工過的食物好, 水果再甜也比鹹餅乾好. 鹹餅乾造成齲齒的風險大於甜的天然水果
13. 兩歲以下不要喝飲料. 即使無糖奶茶也會增加齲齒機率(天然的食物優於加工過的食物)
14. 含糖的運動飲料一點也不健康, 是造成齲齒的重要原因之一


參考資料
1. 學會建議但非常規 OFFICIAL BUT UNFORMATTED 氟化物使用政策最新修訂版 2023
縮寫 AAPD：美國兒科牙科學會。NaFV：氟化鈉清漆。ppm：百萬分之一。美國：美國。

目的
美國兒童牙科學會 (AAPD) 確認使用氟化物預防齲齒是安全有效的。AAPD 鼓勵牙醫和牙科專業人員、其他醫療保健提供者、公共衛生官員和家長/護理人員優化氟化物暴露，以降低齲齒風險並增強受影響牙齒的再礦化。

方法
該文件由與其他團體聯絡委員會制定，於 19671 年通過，最後一次修訂於 2018 年 2 。使用以下術語進行電子數據庫搜索：氟化物、氟化、酸化磷酸鹽氟化物、氟化物清漆、氟化物治療和局部氟化物，以製定和更新本政策。當前的更新依賴於系統審查、專家意見和當前最佳實踐。

二胺氟化銀的使用在單獨的 AAPD 政策中得到解決。3

背景
氟化物通過三種重要方式預防齲齒：1
) 通過生成氟磷灰石來強化牙釉質，
2) 通過再礦化牙釉質，以及
3) 通過影響微生物代謝和減少致齲菌產生的酸。4

社區水氟化被認為是二十世紀十大公共衛生成就之一，因為它是一種有益且廉價的基於人群的方法，可以覆蓋整個社區。5根據定義，社區水氟化是將社區供水中的氟化物調整到最佳濃度以預防齲齒的過程。6 最近對社區水氟化的經濟評估進行的系統審查結果顯示，水氟化與較低的牙科治療成本相關。7 當公共水氟化到最佳水平時，乳牙腐爛、缺失和補牙的數量減少 35%，恆牙的腐爛、缺失和補牙的數量減少 26%。8 氟斑牙的發生，引起牙齒美觀問題，據報導，當公共水中氟化物含量為百萬分之 0.7 (ppm) 或毫克每升 (mg/L) 時，氟化物含量為 12%。8 當與其他飲食、口腔衛生和預防措施相結合時，氟化物的使用可以進一步降低齲齒的發生率。當兒童的家庭飲用水不含氟化物時，可以通過根據既定指南攝入每日氟化物補充劑來實現氟化物的防齲功效。6,9-11 在服用補充劑之前，仔細審查所有氟化物的飲食來源（例如，額外的飲用水來源[日托、學校、體育設施、瓶裝水]、其他飲用的飲料、預製食品[包括嬰兒配方奶粉]、牙膏）將有助於確定兒童對氟化物的真實接觸情況。6,12,13 此信息，結合兒童的齲齒風險評估，可用於確定是否需要補充氟化物。美國即食嬰兒配方奶粉的平均氟化物濃度為 0.15 ppm（乳基配方奶粉）和 0.21 ppm（大豆基配方奶粉）。 14 然而，更重要的問題是用氟化水沖調的濃縮或粉狀嬰兒配方奶粉的氟化物含量。當用含有 1 ppm 氟化物的水重構時，重構的粉末或液體濃縮物的氟化物範圍（以 ppm 計）為 0.64 至 1.07。14 14 然而，更重要的問題是用氟化水沖調的濃縮或粉狀嬰兒配方奶粉的氟化物含量。當用含有 1 ppm 氟化物的水重構時，重構的粉末或液體濃縮物的氟化物範圍（以 ppm 計）為 0.64 至 1.07。14 14 然而，更重要的問題是用氟化水沖調的濃縮或粉狀嬰兒配方奶粉的氟化物含量。當用含有 1 ppm 氟化物的水重構時，重構的粉末或液體濃縮物的氟化物範圍（以 ppm 計）為 0.64 至 1.07。14
隨著社區調整市政供水以符合美國衛生與公眾服務部 2015 年建議的 0.7 ppm 氟化物 15 ，用氟化水沖調嬰兒配方奶粉導致氟斑牙的風險降低。使用非處方含氟產品（例如牙膏、外用凝膠和口腔沖洗劑）可顯著達到防齲效果，特別是在沒有氟化飲用水的地區。6,16-20 建議所有兒童每天兩次用適量的含氟牙膏刷牙。 10,21 監測兒童使用外用含氟產品（包括牙膏）的情況，可防止攝入過量的氟化物。21,22 三歲以下兒童適合使用米粒大小的含氟牙膏，而三至六歲兒童建議用量不要超過豌豆大小。22 大量臨床試驗已證實專業外用氟化物治療的防齲效果，其中包括 1.23%酸化氟化磷酸鹽（[APF]；1.23% 氟化物）、5% 氟化鈉清漆（[NaFV]；2.26% 氟化物）、0.9% 二氟矽烷清漆（[DFS]）；0.1% 氟化物）、0.09% 氟化物漱口水和 0.5% 氟化物凝膠/糊劑。23-25 對於六歲以下的兒童，單位劑量中 5% 的 NaFV（通過限制氟化物的可用性來降低潛在傷害）是唯一推薦的專業應用的局部氟化劑。25 專業氟化物產品應由有執照的牙科或醫療保健提供者或在其指導下使用，該提供者熟悉兒童的口腔健康狀況，並可以根據完整的齲齒風險評估確定使用的需要和頻率。25 一些家長和看護者擔心他們的孩子接受氟化物，並且可能拒絕氟化物治療，儘管氟化物是安全有效的。26 這與反對社區水加氟類似。27 局部氟化物的拒絕和耐藥性可能是一個日益嚴重的問題，這反映了醫學上拒絕接種疫苗的趨勢。


政策聲明
AAPD： • 認識到每天兩次飲用氟化水和使用氟化牙膏刷牙是減少兒童齲齒患病率的最有效方法。• 鼓勵所有兒童每天兩次使用適量的含氟牙膏刷牙。• 認可並鼓勵在可行的情況下將公共飲用水供應中的氟化物含量調整至最佳水平（0.7 ppm）。• 鼓勵對所有有齲齒風險的個人進行專業氟化物治療。• 支持在全面的口腔檢查和齲齒風險評估後，根據牙醫的處方或命令，或在進行牙科篩查和齲齒風險評估後，根據醫生的處方或命令，將局部氟化物應用授權給輔助牙科人員或其他經過培訓的專職醫療人員。• 當城市飲用水中的氟化物水平不理想時，並考慮膳食氟化物的來源和兒童的齲齒風險後，根據美國牙科協會9、美國兒科學會10 和AAPD11 的建議，認可使用氟化物補充劑。• 鼓勵牙科服務提供者與家長討論氟化物的好處，並通過椅旁教育主動解決對氟化物的疑慮。• 鼓勵牙科團隊成員尋找機會提供循證社區教育，宣傳通過市政水氟化來安全且經濟地預防齲齒的益處。• 鼓勵美國食品和藥物管理局要求食品和飲料的營養標籤包含氟化物含量。與此同時，AAPD 鼓勵所有飲料和嬰兒配方奶粉的製造商在食品標籤上的營養成分中註明氟化物濃度。• 鼓勵牙科專業人士告知醫療同行，在牙釉質成熟之前攝入過量氟化物可能會導致氟斑牙。官方但未格式化 • 鼓勵繼續研究安全有效的氟化物產品 美國食品和藥物管理局要求食品和飲料的營養標籤包含氟化物含量。與此同時，AAPD 鼓勵所有飲料和嬰兒配方奶粉的製造商在食品標籤上的營養成分中註明氟化物濃度。• 鼓勵牙科專業人士告知醫療同行，在牙釉質成熟之前攝入過量氟化物可能會導致氟斑牙。官方但未格式化 • 鼓勵繼續研究安全有效的氟化物產品 美國食品和藥物管理局要求食品和飲料的營養標籤包含氟化物含量。與此同時，AAPD 鼓勵所有飲料和嬰兒配方奶粉的製造商在食品標籤上的營養成分中註明氟化物濃度。• 鼓勵牙科專業人士告知醫療同行，在牙釉質成熟之前攝入過量氟化物可能會導致氟斑牙。官方但未格式化 • 鼓勵繼續研究安全有效的氟化物產品 • 鼓勵牙科專業人士告知醫療同行，在牙釉質成熟之前攝入過量氟化物可能會導致氟斑牙。官方但未格式化 • 鼓勵繼續研究安全有效的氟化物產品 • 鼓勵牙科專業人士告知醫療同行，在牙釉質成熟之前攝入過量氟化物可能會導致氟斑牙。官方但未格式化 • 鼓勵繼續研究安全有效的氟化物產品


OFFICIAL BUT UNFORMATTED Policy on Use of FluorideLatest Revision2023
Abbreviations AAPD: American Academy Pediatric Dentistry. NaFV: sodium fluoride varnish. ppm: parts per million. U.S.: United States.

Purpose
The American Academy of Pediatric Dentistry (AAPD) affirms that the use of fluoride in the prevention of caries is safe and effective. The AAPD encourages dentists and dental professionals, other health care providers, public health officials, and parents/caregivers to optimize fluoride exposures to reduce the risk for caries and to enhance the remineralization of affected teeth.

Methods
This document was developed by the Liaison with Other Groups Committee, adopted in 19671 , and last revised in 2018 2 . An electronic database search using the terms: fluoride, fluoridation, acidulated phosphate fluoride, fluoride varnish, fluoride therapy, and topical fluoride was conducted to develop and update this policy. The current update relied upon systematic reviews, expert opinions, and best current practices.

The use of silver diamine fluoride is addressed in a separate AAPD policy.3 Background Fluoride acts in three important ways to prevent caries:
1) by strengthening enamel through the creation of fluorapatite,
2) by remineralizing enamel, and
3) by affecting microbial metabolism and reducing acid production by cariogenic bacteria.4

Community water fluoridation is recognized as one of the ten greatest public health achievements of the twentieth century because it is a beneficial and inexpensive population-based approach that can reach the entire community.5 By definition, community water fluoridation is the process of adjusting the fluoride in community water supplies to optimal concentration for preventing caries. 6 Results from a recent systematic review on the economic evaluation of community water fluoridation reveal fluoridation of water is associated with fewer dental treatment costs.7 When public water is fluoridated to an optimal level, there is a 35 percent reduction in decayed, missing, and filled primary teeth and 26 percent fewer decayed, missing, and filled permanent teeth. 8 The occurrence of dental fluorosis, causing dental esthetic concerns, has been reported to be 12 percent when public water contains 0.7 parts per million (ppm) or milligrams per liter (mg/L) fluoride. 8 When combined with other dietary, oral hygiene, and preventive measures6 , the use of fluorides can further reduce the incidence of caries. When a child's home drinking water supply does not contain fluoride, the caries-preventive benefits of fluoride can be achieved through the intake of daily fluoride supplements according to established guidelines. 6,9-11 Before supplements are prescribed, careful review of all dietary sources of fluoride (e.g., additional sources of drinking water [daycare, school, sports facilities, bottled water], other consumed beverages, prepared foods [including infant formula], toothpaste) will help establish the child’s true exposure to fluoride. 6,12,13 This information, along with the child’s assessed caries risk, can be used to determine a need for fluoride supplementation. The mean fluoride concentration of ready-to-feed infant formulas in the United States (U.S.) is 0.15 ppm for milk-based formulas and 0.21 ppm for soy-based formulas.14 The more important issue, however, is the fluoride content of concentrated or powdered infant formula when reconstituted with fluoridated water. The range of fluoride (in ppm) for reconstituted powdered or liquid concentrate when reconstituted with water containing one ppm fluoride is 0.64 to 1.07. 14
As communities adjust their municipal water supplies to align with the U.S. Department of Health and Human Services’ 2015 recommendation of 0.7 ppm fluoride 15 , the risk of dental fluorosis due to reconstituting infant formula with fluoridated water is decreased. Significant cariostatic benefits can be achieved by the use of over-the-counter fluoride-containing products such as toothpastes, topically-applied gels, and oral rinses, especially in areas without fluoridated drinking water.6,16-20 Toothbrushing with appropriate amounts of fluoride toothpaste twice daily is recommended for all children. 10,21 Monitoring children’s use of topical fluoride-containing products, including toothpaste, may prevent ingestion of excessive amounts of fluoride.21,22 A grain-ofrice-sized amount of fluoridated toothpaste is appropriate for children less than three years of age, while no more than a pea-sized amount is recommended for children ages three to six years.22 Numerous clinical trials have confirmed the anti-caries effect of professional topical fluoride treatments, including 1.23 percent acidulated phosphate fluoride ([APF]; 1.23 percent fluoride), five percent sodium fluoride varnish ([NaFV]; 2.26 percent fluoride), 0.9 percent difluorosilane varnish ([DFS]); 0.1 percent fluoride), 0.09 percent fluoride mouthrinse, and 0.5 percent fluoride gel/paste. 23-25 For children under the age of six years, five percent NaFV in unit doses (which reduces the potential for harm by limiting fluoride availability) is the only recommended professionally-applied topical fluoride agent.25 Professional fluoride products are intended for application by, or under the direction of, a licensed dental or medical care provider who is familiar with the child’s oral health status and can determine the need and frequency for application based upon a completed a caries risk assessment. 25 Some parents and caregivers are concerned about their child receiving fluoride and may refuse fluoride treatment even though fluoride is safe and effective. 26 This is similar to opposition to community water fluoridation. 27 Topical fluoride refusal and resistance may be a growing problem and mirror trends seen with vaccination refusal in medicine. Oral health promotion through patient education resources and social media may assist in addressing parental reluctance or misinformation about fluoride.


Policy statement
The AAPD: • recognizes that drinking fluoridated water and brushing with fluoridated toothpaste twice daily are the most effective methods in reducing dental caries prevalence in children. • encourages toothbrushing with appropriate amounts of fluoride toothpaste twice daily for all children. • endorses and encourages the adjustment of fluoride content of public drinking water supplies to an optimal level (0.7 ppm) where feasible. • encourages professionally-applied fluoride treatments for all individuals at risk for dental caries. • supports the delegation of topical fluoride application to auxiliary dental personnel or other trained allied health professionals by prescription or order of a dentist after a comprehensive oral examination and caries-risk assessment or by a physician after a dental screening and caries-risk assessment have been performed. • endorses the use of fluoride supplements according to established American Dental Association9 , American Academy of Pediatrics10, and AAPD11 recommendations when fluoride levels in municipal drinking water are suboptimal and after consideration of sources of dietary fluoride and the caries risk of the child. • encourages dental providers to talk to parents about the benefits of fluoride and to proactively address fluoride hesitance through chairside education. • encourages dental team members to seek opportunities to provide evidence-based community education on the safe and economical dental caries-preventive benefits of fluoride through municipal water fluoridation. • encourages the U.S. Food and Drug Administration to require food and beverage nutrition labels to include fluoride content. In the meantime, AAPD encourages manufacturers of all beverages and infant formula to include fluoride concentration with the nutritional content on food labels. • encourages dental professionals to inform medical peers of the potential of dental fluorosis when excess fluoride is ingested prior to enamel maturation. OFFICIAL BUT UNFORMATTED • encourages continued research on safe and effective fluoride products

塗氟-- 學會建議但非醫療常規.
摘要
該最佳實踐為從業人員提供了有關使用氟化物輔助預防和控制兒童牙科患者齲齒的信息。這些建議涉及全身氟化物（水氟化、膳食氟化物補充劑）、通過專業應用的局部氟化物輸送（酸化磷酸鹽氟化物凝膠或泡沫、氟化鈉清漆、氟化二胺銀）和家用產品（牙膏、漱口水）以及氟化物的相關風險。社區水氟化物的標準水平（氟化物為百萬分之 0.7）有助於平衡齲齒風險和牙齒發育早期因攝入過量氟化物而導致氟斑牙的可能性。針對 6 個月至 16 歲兒童膳食補充氟化物的具體建議是基於飲用水中的氟化物含量、其他膳食氟化物來源、氟化牙膏的使用以及齲齒風險。每個患者的具體需求決定了全身和局部氟化產品的適當使用，無論是在專業臨床還是家庭環境中提供。氟化物已被證明是降低嬰兒、兒童、青少年和有特殊需要的人齲齒患病率的有效療法。通過美國兒科牙科學會臨床事務和科學事務委員會的共同努力，


Fluoride Therapy OFFICIAL BUT UNFORMATTED Latest Revision 2023
Abbreviations CaF: Calcium fluoride. F: Fluoride. FSIQ: Full scale intelligent quotient. IQ: Intelligence quotient. mg: milligram(s). mg/kg: milligrams per kilogram. NaFV: Sodium fluoride varnish. ppm F: parts per million fluoride. SDF: Silver diamine fluoride. U.S.: United States. :302-5.
Abstract This best practice provides information for practitioners regarding the use of fluoride as an aid in preventing and controlling dental caries in pediatric dental patients. These recommendations address systemic fluoride (water fluoridation, dietary fluoride supplements), topical fluoride delivery via professional application (acidulated phosphate fluoride gel or foam, sodium fluoride varnish, silver diamine fluoride), and home-use products (toothpastes, mouthrinses) as well as the associated risks of fluoride agents. The standard level for community water fluoridation (0.7 parts per million fluoride) helps balance the risk of caries and the possibility of dental fluorosis from excessive fluoride ingestion during the early years of tooth development. Specific recommendations for dietary supplementation of fluoride for children ages six months through 16 years are based on fluoride levels in the drinking water, other dietary sources of fluoride, use of a fluoridated toothpaste, and caries risk. The specific needs of each patient determine the appropriate use of systemic and topical fluoride products, whether delivered in a professional clinical or a home setting. Fluoride has proven to be an effective therapy in reducing the prevalence of dental caries in infants, children, adolescents, and persons with special needs. Through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and Scientific Affairs, this best practice was revised to offer updated information and recommendations to assist healthcare practitioners and parents in using fluoride therapy for management of caries risk in pediatric patients.