Fluoride: Water and Supplements

Posted on: February 16, 2010

Bright Smiles from Birth is an ICAAP educational program that provides guidelines and support to Pediatricians and Family Physicians, Dentists, and families to make oral health a component of well child visits.

Fluoride is a negatively charged ion that has a high affinity for calcium–containing structures. When absorbed into the enamel matrix, fluoride forms fluorapatite.  Fluorapatite is more resistant to demineralization than the crystalline calcium phosphate found in teeth known as hydroxyapatite.  It thus prevents caries in the following 3 ways:

1. It remineralizes tooth enamel.
2. It inhibits enamel demineralization.
3. It also inhibits cariogenic bacteria’s acid producing abilities.

AAP Policy recommends pediatricians should screen for and discuss the adequacy of patients’ fluoride intake as part of routine health maintenance exams and oral health risk assessment[1].  Assessment should encompass a patient’s cumulative fluoride intake from all available sources, and direct any necessary preventive education discussions.

Fluoride Sources:


Community water fluoridation comprises one of the most widely available fluoride sources. Water fluoridation alone reduces dental decay by 20-40%, and has been proclaimed as one of the ten great public health achievements of the 20th century.  The per-person lifetime cost of community water fluoridation is less than the cost of one dental filling.

The CDC recommends fluoridated water contain 0.7 parts per million (ppm) to 1.2 ppm (0.7-1.2mg/L) of fluoride.  Community water fluoridation levels vary, thus it is important to know the fluoride content of local water supplies compared to this guideline.  In Illinois almost 99% of the population has access to fluoridated drinking water.  Chicago and its surrounding communities supplement fluoride at 1.0ppm. Specific information regarding fluoridation levels of other community water supplies can be found at the CDC website. People living in rural areas with private water wells do not have the benefits of optimal water fluoride supplementation.  As wide variations in the natural fluoride concentration exist, well water should be tested by contacting the Illinois Department of Public Health’s Division of Oral Health for a free testing kit at 217-785-4903 or Stacey.ballweg@illinois.gov.

Pediatricians should know that other water sources (Table 1) commonly consumed by children contain more variable fluoride levels that may significantly affect caries risk.

Table 1: Common Water Sources and their Fluoridation Levels
Source Fluoridation Level
Commercially bottled waters (unless marked as fluoridated) No or suboptimal levels (<0.3ppm)
Packaged sterile & distilled water No or suboptimal levels (<0.3ppm)
“Nursery” water or others marked as fluoridated Supplemented at 0.7ppm (0.7mg/L);
Home Water Filtration Systems
Reverse osmosis & distillation Remove fluoride ions
Activated charcoal & cellulose filters (e.g. Brita®, Pur®) Insignificant affect to fluoride content

Fluoride Supplementation

The CDC, ADA, and AAP recommend fluoride supplementation for infants and children 6 months to 16 years, according to age, available fluoride sources, and caries risk (Table 2).

Table 2.  Recommended Fluoride Supplementation[1]
Age Fluoride Concentration in Drinking Water
<0.3ppm 0.3-0.6ppm >0.6ppm
0-6mo None None None
6mo-3yrs 0.25mg/day None None
3-6 yrs 0.5mg/day 0.25mg/day None
6-16 yrs 1.0mg/day 0.5mg/day None

Infants who exclusively breastfeed deserve special mention as breast-milk contains suboptimal fluoride concentrations. Fluoride supplementation should be prescribed to these infants (6 months and older) until other dietary fluoride sources become adequate.  Fluoride containing multivitamin preparations (Poly-vi-flor®, Tri-vi-flor®) are common supplemental options that provide both vitamin D and fluoride to nursing infants.


  1. Children 6 months to 16 years should be assessed for fluoride supplementation.
  1. Pediatricians should assess patients’ fluoride intake, and educate patients and families regarding appropriate fluoride sources.
    1. Various bottled water and filtration sources should especially be discussed.
    2. Formula should be reconstituted using distilled water

Download Bright Smiles from Birth Fluoride: Water and Supplements (pdf)


For more information about community water fluoridation and Bright Smiles From Birth please contact:

Jennie Pinkwater
Project Director
1400 W. Hubbard
Chicago, IL 60642
Phone: 312/733-1026, ext 213
Fax: 312/733-1791