SCIENCE POLICY

• Community Water Fluoridation
• Impact of Tobacco Use on Oral Health
• Oral Disease Related to Tobacco Use
• Sealants
• Temporomandibular Disorders (TMD)
• Topical Fluorides
• Use of Animals in Research
• Use of Fluoride Supplements
• Use of Stem Cells in Dental Research
• Use of Tobacco

COMMUNITY WATER FLUORIDATION

AADR supports community water fluoridation as a safe and effective, evidence-based intervention for the prevention of dental caries. While fluoride occurs naturally in water, fluoridation is the controlled addition of fluoride to community water systems to the level recommended for caries prevention. The practice of adding fluoride to community water supplies began after Dr. H. Trendley Dean – the first director of what later became the National Institute of Dental and Craniofacial Research – observed that residents of communities who drank from naturally fluoridated water supplies experienced less tooth decay than those living in communities without naturally fluoridated water.  What began as a small trial of the controlled addition of fluoride to water in Grand Rapids, Michigan has now reached 75% of the United States population who drink from a community water system and has resulted in a significant decrease in dental caries.^{1, 2}

Dental caries – the destruction of dental hard tissues – can result in pain, infection and tooth loss. Caries is caused by acidic byproducts produced from bacterial fermentation of sugar. ^{5, 6} Dental caries is a very common disease that affects both adults and children. Over one-third of children ages 2-8 experience caries in their primary teeth. One in 5 children ages 6-11 and over half of adolescents ages 12-19 experience caries in their permanent teeth. On average older adults can expect at least one new decayed tooth surface per year. Children with poor oral health are more likely to miss school and suffer academically. Parents may also accrue absences from school or work to seek treatment for their children. Both children and adults with caries may experience embarrassment, exhibit withdrawal, have difficulty eating and sleeping, and limit facial expressions and behaviors that facilitate social interaction. ^3-9

Many studies point to the effectiveness of community water fluoridation in decreasing dental caries. A systematic review of 20 studies by Cochrane, an independent group that reviews medical research to inform evidence-based policies and health guidelines, showed that water fluoridation decreased tooth decay in both the primary and permanent teeth of children and increased the number of children free of decay in primary and permanent teeth.^{10, 11 *} Another review by the Community Preventive Services Task Force (CPSTF), an independent panel of public health experts appointed by the Director of the Centers for Disease Control and Prevention (CDC), found that starting water fluoridation decreased caries in children ages 4-17 by 30-50% and that stopping water fluoridation increased caries by 18%. ^12> Furthermore, reducing childhood caries experience and severity may have benefits into adulthood by halting disease progression that can result in adult tooth loss. Lifelong exposure to fluoridated water has been associated with reduced tooth decay in adults.^{13, 14}

Community water fluoridation is a cost-effective method of delivering caries prevention to a large population. A systematic review by the CPSTF compared the cost of fluoridation to the money saved on dental restorations in communities that drink from fluoridated water sources. CPSTF found that water fluoridation is cost saving. In other words, the savings from fewer dental restorations are greater than the cost of fluoridation for communities of greater than 1,000 people, and the larger the community, the greater the cost saving.¹⁵ A 2016 analysis confirmed this finding.¹⁶

Community water fluoridation may also reduce oral health disparities. Children and adults from socioeconomically disadvantaged backgrounds are more likely to suffer from dental caries and are less likely to be treated for the disease.^{6, 17}  When added to drinking water, fluoride can be delivered to community residents regardless of socioeconomic status or ability to access dental services. Some studies have shown decreased inequalities in caries in communities that drink from a fluoridated community water source, revealing  that children of a lower socioeconomic status who have access to a fluoridated water source have less severe tooth decay and require less expensive care than children of lower socioeconomic status who do not drink fluoridated water. More research is needed to determine the circumstances in which water fluoridation reduces disparities, as not all fluoridated communities show reduced disparities.^{10, 18}

Community water fluoridation is a safe method of delivering fluoride on a population level. There have been numerous systematic reviews on claims of the potential adverse health effects of water fluoridation. None has concluded that there is a significant or consistent association between water fluoridation and the outcomes examined, including neurologic conditions, cancer or osteoporosis.^19-23  Dental fluorosis resulting in tooth discoloration is the only known adverse health effect of water fluoridation. Teeth are only at risk of fluorosis until about age 8 during enamel formation. The United States Public Health Service recommends a concentration of 0.7 milligrams of fluoride per liter of water to achieve caries prevention while minimizing the risk of dental fluorosis.²⁴ While people who drink from fluoridated water sources are at greater risk of dental fluorosis, most people who drink fluoridated water do not develop dental fluorosis.  The cases of dental fluorosis that do develop are very mild, such that discoloration is not usually visible to the naked eye and does not affect the function of the teeth. Severe cases of dental fluorosis are rare. Some studies have shown that Black/African-American and Mexican-American children are at greater risk of developing dental fluorosis. However, this has not been clearly linked to fluoridated water and may be due to cumulative fluoride intake from various sources, such as toothpaste, supplements and food and beverages prepared with fluoridated water.^{10, 17, 25}

Community water fluoridation is supported by various groups, including the American Association of Public Health Dentistry, the American Public Health Association, the American Dental Association and the American Academy of Pediatrics, among others. Additionally, in 1999, the CDC identified community water fluoridation as one of 10 great public health achievements of the 20^th century because of its effectiveness and ability to distribute fluoride equitably and cost-effectively.²⁶ Information about the fluoride concentration of communities participating in water fluoridation can be found on the CDC website “My Water’s Fluoride”.²⁷

While AADR always welcomes research on water fluoridation safety and effectiveness in the current context of fluoride availability, the balance of evidence currently shows that community water fluoridation is safe, effective and cost-saving and in some communities, reduces oral health disparities. Therefore, AADR supports community water fluoridation and recommends the fluoridation of community water sources to a level of 0.7 milligrams of fluoride per liter of water.

References
1. Centers for Disease Control and Prevention. Water Fluoridation Basics. Atlanta: Centers for Disease Control and Prevention, US Department of Health and Human Services; [accessed 8 September 2017]. https://www.cdc.gov/fluoridation/basics/index.htm.
2. Gutmann JL. The Evolution of America's Scientific Advancements in Dentistry in the Past 150 Years. The Journal of the American Dental Association. 140:11S-15S.
3. Low W, Tan S, Schwartz S. 1999. The effect of severe caries on the quality of life in young children. Pediatr Dent. 21(6):325-326.
4. Seirawan H, Faust S, Mulligan R. 2012. The Impact of Oral Health on the Academic Performance of Disadvantaged Children. American Journal of Public Health. 102(9):1729-1734.
5. Jackson SL, Vann WF, Kotch JB, Pahel BT, Lee JY. 2011. Impact of Poor Oral Health on Children's School Attendance and Performance. American Journal of Public Health. 101(10):1900-1906.
6. Griffin SO, Jones JA, Brunson D, Griffin PM, Bailey WD. 2012. Burden of Oral Disease Among Older Adults and Implications for Public Health Priorities. American Journal of Public Health. 102(3):411-418.
7. Griffin SO, Griffin PM, Swann JL, Zlobin N. 2004. Estimating Rates of New Root Caries in Older Adults. Journal of Dental Research. 83(8):634-638.
8. Griffin SO, Griffin PM, Swann JL, Zlobin N. 2005. New Coronal Caries in Older Adults: Implications for Prevention. Journal of Dental Research. 84(8):715-720.
9. Dye B, Thornton-Evans G, Li X, Iafolla T. 2015. Dental caries and sealant prevalence in children and adolescents in the United States, 2011-2012.  NCHS Data Brief, no. 191. Hyattsville, MD: National Center for Health Statistics.
10. Iheozor-Ejiofor Z, Worthington HV, Walsh T, O'Malley L, Clarkson JE, Macey R, Alam R, Tugwell P, Welch V, Glenny A-M. 2015. Water fluoridation for the prevention of dental caries. Cochrane Database of Systematic Reviews. (6).
11. Rugg-Gunn AJ, Spencer AJ, Whelton HP, Jones C, Beal JF, Castle P, Cooney PV, Johnson J, Kelly MP, Lennon MA et al. 2016. Critique of the review of 'Water fluoridation for the prevention of dental caries' published by the Cochrane Collaboration in 2015. Br Dent J. 220(7):335-340.
12. Truman BI, Gooch BF, Sulemana I, Gift HC, Horowitz AM, Evans CA, Jr., Griffin SO, Carande-Kulis VG. 2002. Reviews of evidence on interventions to prevent dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries. American Journal of Preventive Medicine. 23(1):21-54.
13. Griffin SO, Regnier E, Griffin PM, Huntley V. 2007. Effectiveness of Fluoride in Preventing Caries in Adults. Journal of Dental Research. 86(5):410-415.
14. Neidell M, Herzog K, Glied S. 2010. The Association Between Community Water Fluoridation and Adult Tooth Loss. American Journal of Public Health. 100(10):1980-1985.
15. Ran T, Chattopadhyay SK. Economic Evaluation of Community Water Fluoridation. American Journal of Preventive Medicine. 50(6):790-796.
16. O’Connell J, Rockell J, Ouellet J, Tomar SL, Maas W. 2016. Costs And Savings Associated With Community Water Fluoridation In The United States. Health Affairs. 35(12):2224-2232.
17. Beltrán-Aguilar ED, Barker LK, Canto MT, Dye BA, Gooch BF, Griffin SO, Hyman J, Jaramillo F, Kingman A, NowjackRaymer R et al. 2005. Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis United States, 1988-1994 and 1999-2002. Surveillance Summaries. 54(03):1-44.
18. Burt BA. 2002. Fluoridation and Social Equity. Journal of Public Health Dentistry. 62(4):195-200.
19. McDonagh MS, Whiting PF, Wilson PM, Sutton AJ, Chestnutt I, Cooper J, Misso K, Bradley M, Treasure E, Kleijnen J. 2000. Systematic review of water fluoridation. BMJ. 321:855-859.
20. Jones G, Riley M, Couper D, Dwyer T. 1999. Water fluoridation, bone mass and fracture: a quantitative overview of the literature. Australian and New Zealand Journal of Public Health. 23(1):34-40.
21. Demos LL, Kazda H, Cicuttini FM, Sinclair MI, Fairley CK. 2001. Water fluoridation, osteoporosis, fractures—recent developments. Australian Dental Journal. 46(2):80-87.
22. Whiting P, McDonagh M, Kleijnen J. 2001. Association of Down's syndrome and water fluoride level: a systematic review of the evidence. BMC Public Health. 1(1):6.
23. Agency for Toxic Substances and Disease Registry (ATSDR). 2001. Toxicological profile for Fluorides, Hydrogen Fluoride, and Fluorine. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service. 
24. U. S. Department of Health and Human Services Federal Panel on Community Water Fluoridation. 2015. U.S. Public Health Service Recommendation for Fluoride Concentration in Drinking Water for the Prevention of Dental Caries. Public Health Reports. 130(4):318-331.
25. Martinez-Mier EA, Soto-Rojas AE. 2010. Differences in exposure and biological markers of fluoride among White and African American children. Journal of Public Health Dentistry. 70(3):234-240.
26. Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. 1999. Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries. MMWR Weekly. 48(41):933-940.
27. Centers for Disease Control and Prevention. My Water's Fluoride. Atlanta: Centers for Disease Control and Prevention, US Department of Health and Human Services; [accessed 3 February 2017]. https://nccd.cdc.gov/DOH_MWF/Default/Default.aspx.

* The authors of the Cochrane systematic review determined that the evidence for community water fluoridation for the prevention of dental caries was low quality and that many studies were conducted before 1975. The Cochrane review method considers randomized clinical trials as the gold standard of evidence and automatically rates common methods for evaluating public health interventions as low. However, randomized trials are usually not feasible for interventions at the population level. The authors noted this gap in their evidence grading system and that the evidence pointed in the same direction of fluoridation reducing tooth decay. 

(adopted 2018)

IMPACT OF TOBACCO USE ON ORAL HEALTH

The AADR recognizes that use of tobacco in any form increases the risk for death and disease among people that use these products and those exposed to second-hand tobacco smoke.  Cigarette smoking is causally related to chronic periodontitis, responsible for an estimated one-half of cases in the United States.  Cigarette smoking is the major causal factor for cancers of the oral cavity and pharynx in the United States.  Use of other combusted tobacco products — including cigars, pipes, and hookah —also increases the risk for these malignancies.    Use of smokeless tobacco is causally related to oral cancer, increases the risk for localized gingival recession, and may increase the risk for root surface caries.  Mounting evidence implicates exposure to second-hand tobacco smoke as a risk factor for early childhood caries.  Smoking also reduces the success rates for surgical and non-surgical periodontal therapy, increases the risk of failure of dental implants, and increases the risk of complications following oral surgical procedures. 

1. Based on an extensive body of scientific literature on the negative impact of tobacco use on oral health, effective methods of reducing tobacco, and the inextricable link between oral health and overall health, it is recommended that:
2. Oral health care professionals incorporate evidence-based approaches to tobacco use intervention into clinical practice and establish linkages with tobacco cessation resources in their communities.
3. National, state, and local dental professional organizations advocate for adoption of health policies that incorporate best practices for comprehensive tobacco control.
4. Research be supported and conducted to assess the oral health effects of established and newly emerging tobacco products in the United States.
5. Dental educational institutions increase the competency of students and residents in providing behavioral interventions for tobacco use and appropriate use of pharmacotherapy.
6. Oral health care professionals become active members of tobacco control coalitions in their communities.
7. In choosing meeting sites, AADR give preference to cities that have enacted comprehensive clean indoor air policies that include restaurants, hotels, conference centers, and other public spaces

(adopted 2015)

ORAL DISEASE RELATED TO TOBACCO USE

Tobacco use is the principal risk factor for oral cancer. It also increases the risk for periodontal disease and decreases the ability of oral tissues to heal. Other oral effects include halitosis (bad breath), decreased ability to taste, and increased staining of the teeth. Smokeless tobacco (spit tobacco), snus and electronic nicotine delivery systems (ENDS) are, although considered harm reduction alternatives to smoked tobacco, are not without their risks. Tobacco use in any form is harmful to health and should be discouraged. The AADR urges oral health professionals to subscribe to practices that prevent initiation of tobacco use in any form among their patients and the public, and to facilitate and reinforce cessation among users and to carry out cessation programs in their offices using standard procedures and medications as appropriate.

(adopted 1996, revised 2015)

SEALANTS

Pit and fissure sealants are polymeric materials that are applied to the occlusal surfaces of teeth, which do not benefit from the caries-preventive effects of fluoride to the same extent as smooth surfaces. Dental caries, one of the most common diseases of childhood, occurs predominantly as carious lesions in pits and fissures of teeth. A large percentage of occlusal surfaces can remain caries-free for up to ten years or more after a single application of a sealant. There is strong evidence supporting the effectiveness of sealants for the prevention of dental caries. Furthermore, studies show that incipient carious lesions that remain sealed do not progress. Based on current evidence, the American Association for Dental Research (AADR) continues to strongly recommend greater use of sealants by practitioners in private and public health practice. The AADR also endorses the practice that sealants could be used in conjunction with other caries-preventive measures, such as fluoride application.

References:
JD Bader, DA Shugars, and AJ Bonito (2001). Systematic reviews of selected dental caries diagnostic and management methods.  J Dent Educ. 65(10): 960-968
Benedict I. Truman, Barbara F. Gooch, Iddrisu Sulemana, Helen C. Gift, Alice M. Horowitz, Caswell A. Evans Jr, Susan O. Griffin, Vilma G. Carande-Kulis. The Task Force on Community Preventive Services (2002). Reviews of Evidence on Interventions to Prevent Dental Caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries. Am J Prev Med;23(1S)
Ahovuo-Saloranta A, Hiiri A, Nordblad A, Worthington H, Mäkelä M (2004). Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD001830. DOI: 10.1002/14651858.CD001830.pub2.
Hiiri A, Ahovuo-Saloranta A, Nordblad A, Mäkelä M (2006). Pit and fissure sealants versus fluoride varnishes for preventing dental decay in children and adolescents.Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD003067. DOI: 10.1002/14651858.CD003067.pub2
Griffin SO, Oong E, Kohn W, Vidakovic B, Gooch BF, Bader J, et al (2008). The Effectiveness of Sealants in Managing Carious Lesions. Journal of Dental Research2008 (accepted).
ADA, and CDC Sealant Guidelines-To be published JADA 2008
Oong E, Griffin S, Kohn W, Gooch B, Caufield P. The effect of dental sealants on bacteria levels in caries lesions: a review of the evidence. JADA 2008 (accepted 12/31/2007)

(adopted 1991; revised 2009, revised 2015)

TEMPOROMANDIBULAR DISORDERS (TMD)

The AADR recognizes that temporomandibular disorders (TMDs) encompass a group of musculoskeletal and neuromuscular conditions that involve the temporomandibular joints (TMJs), the masticatory muscles, and all associated tissues. The signs and symptoms associated with these disorders are diverse, and may include difficulties with chewing, speaking, and other orofacial functions. They also are frequently associated with acute or persistent pain, and the patients often suffer from other painful disorders (comorbidities). The chronic forms of TMD pain may lead to absence from or impairment of work or social interactions, resulting in an overall reduction in the quality of life.

Based on the evidence from clinical trials as well as experimental and epidemiologic studies:

1. It is recommended that the differential diagnosis of TMDs or related orofacial pain conditions should be based primarily on information obtained from the patient's history, clinical examination, and when indicated TMJ radiology or other imaging procedures. The choice of adjunctive diagnostic procedures should be based upon published, peer-reviewed data showing diagnostic efficacy and safety. However, the consensus of recent scientific literature about currently available technological diagnostic devices for TMDs is that except for various imaging modalities, none of them shows the sensitivity and specificity required to separate normal subjects from TMD patients or to distinguish among TMD subgroups. Currently, standard medical diagnostic or laboratory tests that are used for evaluating similar orthopedic, rheumatological and neurological disorders may also be utilized when indicated with TMD patients. In addition, various standardized and validated psychometric tests may be used to assess the psychosocial dimensions of each patient’s TMD problem.
2.  It is strongly recommended that, unless there are specific and justifiable indications to the contrary, treatment of TMD patients initially should be based on the use of conservative, reversible and evidence-based therapeutic modalities. Studies of the natural history of many TMDs suggest that they tend to improve or resolve over time. While no specific therapies have been proven to be uniformly effective, many of the conservative modalities have proven to be at least as effective in providing symptomatic relief as most forms of invasive treatment. Because those modalities do not produce irreversible changes, they present much less risk of producing harm. Professional treatment should be augmented with a home care program, in which patients are taught about their disorder and how to manage their symptoms

References
1)   de Leeuw R, Klasser GD, Albuquerque RJ. Are female patients with orofacial pain medically compromised? J Am Dent Assoc 2005;136(4):459-68.
2)   Diatchenko L, Nackley AG, Tchivileva IE, Shabalina SA, Maixner W. Genetic architecture of human pain perception. Trends Genet 2007;23(12):605-13.
3)   Sessle BJ. Sensory and motor neurophysiology of the TMJ. In: Laskin DM, Greene CS, Hylander WL, eds. Temporomandibular Disorders: An Evidence-Based Approach to Diagnosis and Treatment. Chicago: Quintessence; 2006. p. 69-88.
4)   Reissmann DR, John MT, Schierz O, Wassell RW. Functional and psychosocial impact related to specific temporomandibular disorder diagnoses. J Dent 2007 Aug;35(8):643-50.
5)   Klasser GD, Okeson JP. The clinical usefulness of surface electromyography in the diagnosis and treatment of temporomandibular disorders. J Am Dent Assoc. 2006;137(6):763-71.
6)   Suvinen TI, Kemppainen P. Review of clinical EMG studies related to muscle and occlusal factors in healthy and TMD subjects. J Oral Rehabil 2007;34(9):631-44.
7)   Greene CS. The Role of Technology in TMD Diagnosis. In Laskin DM, Greene CS, Hylander WL (Eds).  TMDs – An Evidence-Based Approach to Diagnosis and Treatment.  Chicago, Quintessence Publishing Co, 2006, pp 193-202.
8)   Greene CS, Laskin DM. Temporomandibular disorders: moving from a dentally based to a medically based model. J Dent Res 2000;79(10):1736-9.
9)   Truelove E. Role of oral medicine in the teaching of temporomandibular disorders and orofacial pain. J Orofac Pain 2002;16(3):185-90.
10)  Dworkin SF, Massoth DL. Temporomandibular disorders and chronic pain: disease or illness? J Prosthet Dent 1994;72(1):29-38.
11)  Carlson CR. Psychological considerations for chronic orofacial pain. Oral Maxillofac Surg Clin North Am 2008;20(2):185-95.
12)  Lindroth JE, Schmidt JE, Carlson CR. A comparison between masticatory muscle pain patients and intracapsular pain patients on behavioral and psychosocial domains. J Orofac Pain 2002;16(4):277-83.
13)  AmericanAcademy of Orofacial Pain. Temporomandibular Disorders. In: de Leeuw R, ed. Orofacial Pain: Guidelines for Assessment, Diagnosis and Management. Chicago: Quintessence; 2008.
14)  Stohler CS, ZarbGA. On the management of temporomandibular disorders: a plea for a low-tech, high-prudence therapeutic approach. J Orofac Pain1999;13(4):255-61.
15)  Fricton J. Myogenous temporomandibular disorders: diagnostic and management considerations. Dent Clin North Am 2007;51(1):61-83.
16)  Okeson JP. Joint intracapsular disorders: diagnostic and nonsurgical management considerations. Dent Clin North Am 2007;51(1):85-103.
17)  Carlson CR, Bertrand PM, Ehrlich AD, Maxwell AW, Burton RG. Physical self-regulation training for the management of temporomandibular disorders. J Orofac Pain 2001;15(1):47-55.
18)  Dworkin SF, Huggins KH, Wilson L, Mancl L, Turner J, Massoth D, LeResche L, Truelove E. A randomized clinical trial using research diagnostic criteria for temporomandibular disorders-axis II to target clinic cases for a tailored self-care TMD treatment program. J Orofac Pain 2002;16(1):48-63.

(adopted 1996, revised 2010, reaffirmed 2015)

TOPICAL FLUORIDES

Fluoride’s predominant effect in caries prevention and management is post-eruptive and topical. However, as it relates to this statement, topical fluorides are those that are applied to erupted teeth, with the understanding that water fluoridation’s and dietary fluoride’s main effect is also topical. The American Association for Dental Research (AADR) strongly recommends twice daily use of fluoride-containing dentifrices as an effective means of reducing caries.

Furthermore, based on current evidence, the AADR also strongly recommends that fluoride-containing dentifrices should be used in small amounts in pre-school-aged children in order to reduce the risk of dental fluorosis through unintentional ingestion. It is important to note that professionally applied gels and varnishes also reduce caries incidence. Studies show that application at six-monthly intervals is appropriate for patients at increased caries risk, but application frequency may be decreased or increased according to risk status and degree of exposure to other sources of fluoride. Higher-risk patients should receive applications at three to six-month intervals. In addition, the AADR recommends the use of daily or weekly fluoride mouth rinses and gels for this group. The AADR makes the following caveat:  Because of their high fluoride concentration, mouthrinses and prescription gels are not recommended for pre-school-aged children. 

References:
Weyant RJ, et al., Topical fluoride for caries prevention, Executive summary of the updated clinical recommendations and supporting systematic review, J Am Dent Assoc 2013;144(11):1279-1291. (Recommended by Carey ,Gonzalez and Zhan)
Am Dent Assoc, Center for Evidence-Based Dentistry, Topical fluoride for caries prevention, Council on Scientific Affairs, November 2013. 
Fluoride varnishes for preventing dental caries in children and adolescents. Marinho VC, Worthington HV, Walsh T, Clarkson JE. Cochrane Database Syst Rev. 2013 Jul 11;7:CD002279. doi: 10.1002/14651858.CD002279.pub2. 
Cochrane reviews on the benefits/risks of fluoride toothpastes. Wong MC, Clarkson J, Glenny AM, Lo EC, Marinho VC, Tsang BW, Walsh T, Worthington HV. J Dent Res. 2011 May;90(5):573-9. doi: 10.1177/0022034510393346. Epub 2011 Jan 19.
Guideline on fluoride therapy. Pediatr Dent. 2013 Sep-Oct;35(5):E165-8.
Wright JT, Hanson N, Ristic H, Whall CW, Estrich CG, Zentz RR. Fluoride toothpaste efficacy and safety in children younger than 6 years. J Am Dent Assoc. 2014 Feb;145(2):182-9. doi: 10.14219/jada.2013.37.

(adopted 1996; revised 2009, revised 2015)