European Archives of Paediatric Dentistry (2019) 20:507–516
https://doi.org/10.1007/s40368-019-00464-2

INVITED REVIEW

Guidelines on the use of fluoride for caries prevention in children:an updated EAPD policy document
K. J. Toumba1· S. Twetman2 · C. Splieth3 · C. Parnell4 · C. van Loveren5 · N. Α. Lygidakis6

Received: 10 June 2019 / Accepted: 21 June 2019 / Published online: 8 November 2019
© The Author(s) 2019

Abstract
Aim To update the exisitng European Academy of Paediatric Dentistry (EAPD) 2009 fluoride guidelines.
Methods Experts met in Athens, Greece duirng November 2018 for the following groups: I Fluoride toothpastes, II Fluoride
gels, rinses and varnishes, III Fluoridated milk, fluoridated salt, tablets/lozenges and drops, IV Water fluoridation. Systematic
reviews and meta-analyses were reviewed and discussed for each of the groups. The GRADE system was used to assess thequality of evidence which was judged as HIGH, MODERATE, LOW or VERY LOW based on the assessment of eight criteria
which can influence the confidence of the results. Following the quality assessment, GRADE was then used to indicate thestrength of recommendation for each fluoride agent as STRONG or WEAK/CONDITIONAL.
Results Parents must be strongly advised to apply an age-related amount of toothpaste and assist/supervise tooth brushing
until at least 7 years of age. The EAPD strongly endorses the daily use of fluoride as a major part of any comprehensive
programme for the prevention and control of dental caries in children. Regardless of the type of programme, community
or individually based, the use of fluoride must be balanced between the estimation of caries-risk and the possible risks ofadverse effects of the fluorides. Fluoride use is considered safe when the manufacturer’s instructions are followed. Preventive
programmes should be re-evaluated at regular intervals and adapted to a patient’s or population’s needs and risks.
Conclusions For the majority of European Countries, the EAPD recommends the appropriate use of fluoride toothpaste inconjunction with good oral hygiene to be the basic fluoride regimen.
Keywords Fluoride · Caries · Child

Background considerations* K. J. Toumba
jack.toumba@hsc.edu.kw
1

Developmental and Preventive Sciences, Facultyof Dentistry, Kuwait University, Kuwait city, Kuwait

2

Department of Odontology, Faculty of Health and Medical
Sciences, University of Copenhagen, Copenhagen, Denmark3

Department of Preventive and Paediatric Dentistry,
University of Greifswald, Greifswald, Germany

4

Oral Health Services Research Centre and HSE, Louth,
Meath, Ireland

5

Department of Cariology, Academic Centre for Dentistry(ACTA), University of Amsterdam, Amsterdam,
The Netherlands

6

Private Paediatric Dental Clinic, 2 Papadiamantopoulou
Street, 11528 Athens, Greece

The European Academy of Paediatric Dentistry (EAPD), in
collaboration with the Hellenic Division of EAPD, organised a workshop in Athens, Greece (June 1997), aimed at
drawing up guidelines for future use of fluorides among
European children. The first draft of these guidelines was
published in the EAPD newsletter, and members wereinvited to make comments and suggestions. The revised firstdraft was then presented at the biannual EAPD Congress in
Sardinia (1998), where it was discussed in great detail, sothat the members’ viewpoints were taken into consideration. The major concepts of the proposed guidelines wereapproved, and a working group, consisting of the authors of
the original paper, were authorised to finalise and publish
the recommendations (Oulis et al. 2000). In November 2008,
the EAPD organised another workshop, again in Athens,
Greece, to update the original fluoride guidelines (Toumba
et al. 2009). These updated fluoride guidelines employed the13Vol.:(0123456789)

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evidence-based SIGN (Scottish Intercollegiate Guidelines
Network) methodology for ranking the levels of evidence
and the grades of recommendations (SIGN 83 2005; SIGN
50 2008). In November 2018, the EAPD organised anotherworkshop, once again in Athens, Greece, to update the fluoride guidelines. These updated fluoride guidelines employed
the GRADE system (Ryan and Hill 2016) to assess the quality of evidence for the caries-preventive effect of various
topical and systemic fluoride agents. The quality of evidence
was judged as HIGH, MODERATE, LOW or VERY LOW,
based on the assessment of eight criteria which can influence our confidence in the results (Marinho et al. 2011).
These criteria are: risk of bias, indirectness, inconsistency,
imprecision, publication bias, a large magnitude of effect,
dose response and the effect of all plausible confounding
factors for reducing the effect or suggesting a spurious effect.
Following the quality assessment, GRADE was then used
to indicate the strength of recommendation for each fluoride
agent as STRONG or WEAK/CONDITIONAL. The interpretation of the gradings for quality of evidence and strengthof recommendation are shown in Tables 1 and 2.

(Slayton et al. 2018; Urquhart et al. 2019), but the present
EAPD guidelines focus on their preventive effect only.
Evidence suggests that the cariostatic effect of fluoride
is mostly exerted by its topical rather than systemic effect(Featherstone 1999). This effect might be even greater whencombined with good oral hygiene, such as when practiced
as comprehensive tooth brushing with a fluoride toothpaste(Rolla et al. 1991).
Concern about the prevalence of dental fluorosis in somechildren has mostly been related to the use of fluoride supplements, especially during the first 6 years of life (Ismail
and Bandekar 1999). However, it has also been shown thatearly exposure to fluoride toothpaste might also be a risk
factor due to the unintended ingestion of toothpaste (Levyet al. 1995; Wong et al. 2010). Studies that have summarised
the risks for dental fluorosis have concluded that the risk ishighest when the exposure takes place in both the secretory
and the maturation phases of enamel formation (DenBesten
1999; Wong et al. 2010). Therefore, three age groups can beconsidered in terms of having a risk for enamel fluorosis,
namely:

0–4 years

Introduction
Fluorides are the key element to successful caries prevention (Marinho 2009; O’Mullane et al. 2016). They are also
effective as therapeutic agents in non-restorative caries treatment (NRCT) for the inactivation or arrest of caries lesions

Babies and children under the age of 4 years are considered to be at risk of dental fluorosis of permanent incisors
and first molars, because the calcification and maturation ofthese teeth occur during this period of life. The longitudinal
Iowa study found that exposure to fluoride during the first

Table 1  GRADE ratings and their interpretation
GRADESof evidence
quality

Interpretation

HIGH
MODERATE

We are very confident that the true effect lies close to that of the estimate of the effectWe are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is apossibility that it is substantially different
Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effectWe have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate ofeffectLOW
VERY LOW

Table from the GRADE Handbook, available at http://gdt.guide​lined​evelo​pment​.org/app/handb​ook/handb​ook.html#h.9rdbe​lsnu4​iy
Table 2  Strengths of recommendation for patients, clinicians and policy makers Adapted from Guyatt et al. (2008)

For patients
For clinicians

Strong recommendation

Conditional recommendation

Most people would want the recommended course of action
and only a small proportion would not
Most patients should receive the recommended course ofactionMost people would want the recommended course of action,
but many would not
Different choices will be appropriate for different patients andeach patient should be advised for a management decisionconsistent with her/his values and preferences
Policy making will require substantial debate and involvementof stakeholders

For policy makers The recommendation can be adopted as a policy in mostsituations

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3 years of life were most important for fluorosis developmenton the permanent maxillary incisors, but other individual
periods were also important (Hong et al. 2006). It is during
this period when the use of fluorides must be carefully monitored and balanced with the need to prevent the occurrenceof early childhood caries. Special attention should be given
to the use of topically applied fluorides during this periodof life, because of the inadequate control of the swallowing
reflex.

4–6 years
The posterior teeth (premolars and second molars) are calcifying and maturing during this period and at risk of dental
fluorosis. Nevertheless, when this occurs, it represents lessof an aesthetic problem, which needs to be weighed against
the marked benefit of caries prevention brought about by theuse of fluoride.

6 years and above
The risk for enamel fluorosis during this period is negligible,
except for third molars.

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Table 3  Caries-preventive effect of fluoride toothpaste
Intervention

Control

PF % (95% CI)

Fluoride toothpaste
Supervised brushing
Brushing twice per day
1450–1500 ppm F
Fluoride toothpaste + othersources*

PlaceboNon-supervised
Once per day
1000–1100 ppm F
Fluoride toothpaste

24 (21–28)
11 (4–18)
14 (6–22)
8 (1–16)
10 (2–17)

PF is prevented fraction, expressed as percentage, with confidence
intervals (Marinho 2009)*Water fluoridation, fluoride varnish, fluoride gel, or fluoride mouthrinsing

caries recorded over the past 40 years. Tooth brushingwith fluoride toothpaste is close to an ideal public healthmethod being convenient, inexpensive, culturally approved
and widespread (Burt 2008). The use of fluoride toothpaste in children and adolescents has been subjected toseveral systematic reviews (Marinho et al. 2003; Twetman
et al. 2003; Twetman 2009; Wong et al. 2011; Wright et al.
2014; Walsh et al. 2019) and all have confirmed its efficacy
in preventing caries. The magnitude, expressed as caries
prevented fraction (PF), is summarised in Table 3.

Use of silver diamine fluoride
Silver diamine fluoride (SDF) at a concentration of 38%(44,800 ppmF) has been rarely used in Europe to arrest or
prevent dental caries, whereas in the Americas, Australasia and Asia, it has been frequently used to arrest dental
caries in children (Gao et al. 2019; Tiripathi et al. 2019).
The American Academy of Pediatric Dentistry (AAPD)
produced guidelines (Crystal et al. 2017) on the use of SDF
for the management of dental caries in children based on asystematic review of Gao et al. (2016). Per GRADE, this is a
CONDITIONAL recommendation based on low-quality evidence. Interest in the use of SDF in Europe is now growing.

Guidelines
The following guidelines are recommended as an integral
part of preventive programmes for children. It must beemphasised, however, that any dentist supervising a child’s
oral care must address individual needs.

Potential harm
One problem with young children’s use of toothpaste isthat they swallow some paste with a subsequent risk offluorosis (Wong et al. 2011). Fluoride toothpaste may
be responsible for up to 80% of the “optimal” total daily
intake of fluoride (Mejare 2018) and the first 3 years of life
seems most critical. Therefore, parents must be strongly
advised to apply an age-related amount of toothpaste andassist/supervise tooth brushing until at least 7 years ofage. To support parents and caregivers to apply the rightamount of toothpaste (grain of rice or pea size), manufacturers, public health institutions and national societies areencouraged to provide clear visual instructions on toothpaste packaging and in brushing instructions. Toothpastewith a lower concentration than 1000 ppm can be considered for young children regularly exposed to other sourcesof fluoride. However, the evidence for these low fluoride
concentration toothpastes of less than 1000 ppm for theprevention of dental caries is limited (Walsh et al. 2019).

Fluoride toothpastes
Clinical effectiveness
The widespread use of fluoride toothpastes has most likely
been one of the major reasons for the reduction of dental

Evidence‑based statements
Based on systematic reviews with moderate or low risk ofbias, the following statements can be formulated (Table 4).

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Table 4  Statements with qualityof evidence and strength ofrecommendation according to
GRADE

Statement

GRADE of evidence quality

GRADE ofrecommendation
strength

Daily brushing with fluoride toothpaste prevents caries
Toothpastes containing higher concentrations of fluoride are more
effective than those with lower concentration in preventing caries
Supervised tooth brushing is more effective than non-supervised
There is inconclusive evidence that the use of fluoridated toothpaste in young children is associated with an increased risk offluorosis

High
High

StrongStrongHigh
Low

StrongConditional

Table 5  Recommended use of fluoride toothpastes in children
Age (years)(ppm F)

Frequency

Amount (g)SizeFirst tooth—up to
2 years
2–6 years
Over 6 years

1000

Twice daily

0.125

Grain of rice

1000*
1450

Twice daily
Twice daily

0.25
0.5–1.0

Pea
Up to fulllength ofbrush*For children 2–6 years, 1000 + fluoride concentrations may be considered based on the individual caries risk

Good practice points on brushing behaviour
There are common recommendations on brushing behaviour
that are based on expert opinions and consensus rather thanon firm evidence:• Tooth brushing should be conducted so each tooth sur-face is reached and brushing should exceed 1 min, alsoin preschool children.
• Children should avoid rinsing with a lot of water afterwards.
• Children’s teeth should be brushed using either a soft
manual or power toothbrush.
High fluoride toothpaste
Toothpastes with more than 1500 ppm F are available onprescription in many countries. Toothpastes containing up to
5000 ppm F are primarily intended for patients with special
care needs, adolescents with increased caries risk and thoseunder treatment with fixed orthodontic appliances. Conclusive evidence for their superior effectiveness is, however,lacking (Pretty 2016).
Clinical recommendations
The EAPD recommendations for the use of fluoride toothpastes in children are summarised in Table 5.

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Twice daily use of fluoride toothpaste, in combination
with oral hygiene instructions, is the cornerstone of any
preventive programme for children, irrespective of caries
risk. Although the caries-preventive effect is statisticallysignificant only for concentrations of 1000 ppm and above,
toothpastes with lower concentrations may have some beneficial effects and could be considered for children at low
caries risk where the risk of fluorosis is of concern (Wonget al. 2011). The evidence of efficacy for outreach supervised
fluoride tooth brushing programmes targeting low socioeconomic high-risk groups and ethnic minorities remains
low (da Silva et al. 2016; Dos Santos et al. 2018). Where
fluoride is used in conjunction with other fluoride vehicles,
the cumulative fluoride exposure must be taken into consideration for children less than 6 years of age. Care must be
taken to ensure that a balance between maximising the preventive effect against dental caries and minimising the riskof dental fluorosis is maintained. Furthermore, best available scientific evidence must be balanced with the expertiseof dental professionals and the families’ expectations andpreferences. The background fluoride exposure as well as thesocio-economic level of the community may also influence
the abovementioned recommendations.
Knowledge gaps
According to a map of systematic reviews in paediatric dentistry (Mejàre et al. 2015), further research is needed on• The appropriate amount and concentration of fluoride in

toothpastes for preschool children related to the risk offluorosis.
• The effect of toothpaste introduction age, optimal brushing time and post-brushing behaviour on caries development.

Fluoride gels, rinses and varnishes
Apart from the basic caries prevention by the use of fluoridated toothpaste, other topical fluorides can be used especially in children assessed as being at increased risk forEuropean Archives of Paediatric Dentistry (2019) 20:507–516

caries development, including children with special oral
health care needs or under orthodontic treatment and inrisk periods such as tooth eruption. The evidence for the
caries-preventive effect of gels, rinses and varnishes isgreater in quality and quantity for permanent than primary
teeth (Marinho et al. 2013, 2015, 2016; Twetman and Keller2016). Especially in preschool children, the risk of ingestionand subsequent dental fluorosis should be weighed against
the potential caries-preventive benefits. Additionally, thecost effectiveness has to be considered for groups with low
caries prevalence (Schwendicke et al. 2018). This is also true
for the mode of application, e.g., with gels, where in-officeapplication offers greater control, but also higher costs, compared with settings such as schools or home application withlower costs, but also possibly reduced compliance.
Clinical recommendations
Available evidence, recommendations and good practicepoints for fluoride gels, rinses and varnishes in children andadolescents are shown in Table 6.

Fluoridated milk, fluoridated salt, fluoride
tablets/lozenges and drops
Fluoridated milk
Milk fluoridation has been reported to be successful indental caries prevention, particularly among children, andschemes have been developed in countries around the globe
based on integration with school health and nutrition programmes (Jürgensen and Petersen 2013). Fluoridated milk is
only ingested by children on school days and therefore not atweekends and school holidays. As no effort is required fromthe individual for ingesting fluoridated water, salt or milk,these methods have been designated as automatic systems
for dental caries prevention. The use of milk as a vehicle forproviding additional fluoride in dental public health programmes was evaluated in two recent systematic reviews(Cagetti et al. 2013; Yeung et al. 2015). Cagetti et al. (2013)searched literature from 01.01.1966 to 03.31.2011 and foundnine papers of which only two papers fulfilled their inclusion criteria (Bian et al. 2003; Stecksén-Blicks et al. 2009).
Both these studies investigated the caries-prevention effectof milk fluoridation on primary teeth. In the first study, the
GRADE recommendation strength is CONDITIONAL(Bian et al. 2003), each participant consumed 200 ml offluoridated milk (concentration 2.5 mg F-per litre) a day for
21 months. At the end of the experimental period, the mean
net caries increment was 0.4 dmft for the test group and 1.3
dmft for the control group (t test, p < 0.001). The second
study (Stecksén-Blicks et al. 2009) evaluated the effect of

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fluoridated milk on caries development in preschool children. Children in the intervention group received 150 mlof milk supplemented with 2.5 mg of fluoride per litre forlunch, while the control group received standard milk for
21 months. The authors concluded that daily consumptionof milk containing fluoride reduced caries in preschool
children, with a prevented fraction of 75%. The GRADE
strength of recommendation for this study was also CONDITIONAL. Of the other five studies, only one study (Ketley
et al. 2003) failed to demonstrate the caries-preventive effectof milk fluoridation. Four studies suggested that fluoridated
milk had a beneficial effect, reducing caries incidence inboth the primary and permanent dentitions. Cagetti et al.
(2013) concluded that the consumption of fluoridated milk
was an effective measure to prevent caries in primary teeth
but that there was low evidence that the use of milk fluoridation was effective in reducing the caries increment.
Yeung et al. (2015) included in a Cochrane review only
one unpublished RCT and concluded that there was lowquality evidence to suggest that fluoridated milk may bebeneficial to schoolchildren, contributing to a substantial
reduction in dental caries in primary teeth. Due to the low
quality of the evidence, further research is likely to have an
important impact on our confidence in the estimate of effect.
Furthermore, there was no information about the potential
adverse effects of the intervention. Additional RCTs of highquality are needed before we can draw definitive conclusions
about the benefits of milk fluoridation (Yeung et al. 2015).

Fluoridated salt
Traditionally, the fluoridation of salt has been considered as
an effective method for reducing caries, especially in areas
where water fluoridation cannot be implemented. Two systematic reviews have been published on the clinical effectiveness of salt fluoridation (Yengopal et al. 2010; Cagetti
et al. 2013). In one of these (Cagetti et al. 2013), no paper
related to the use of salt fluoridation in caries prevention
fulfilled the inclusion criteria, and the other one (Yengopal
et al. 2010) concluded that the contribution of fluoridated
salt to the decrease in the prevalence of caries could not be
quantified, and further high-quality studies are needed. Wennhall et al. (2014) observed that domestic salt in low caries communities with vulnerable groups of schoolchildren
did not seem to reduce the number of new caries lesions or
slow down the progression rate. But, it should be taken into
account that several confounders and bias were identified
in this study.
Fabruccini et al. (2016) concluded that in a cross-sectional oral health survey, fluoridated water appeared to provide a better protective effect against caries than fluoridated
salt among schoolchildren from developing countries. However, Jordan et al. (2017) observed that the use of fluoridated13

13
Primary teeth
Evidence/recommendation: none
As it is not recommended for preschool children, there is no grading. (Effect uncertain. Poulsen 2009; Marinho et al. 2015)
Permanent teeth
Evidence: moderate recommendation: conditional.
(Efficacious in preventing caries (Marinho et al. 2015; Twetman
and Keller 2016)

Gels (professional use; 5000–12,300 ppm F)

Rinses (home or use at schools); (a) daily: 0.05%
NaF (225 ppm F), (b) weekly: 0.2% NaF (900 ppm
F)

Primary teeth
Evidence/recommendation: none
As it is not recommended for preschool children, there is no grading. (No data available. Marinho et al. 2016; Twetman and Keller
2016)
Permanent teeth
Evidence: moderate recommendation: conditional(Efficacious in preventing caries (Marinho et al. 2016; Twetman
and Keller 2016)
Varnishes (professional use; typically, 22,600 ppm F) Evidence: moderate recommendation: conditional(Efficacious in preventing caries in both primary and permanent
teeth Marinho et al. 2013)

Grade of evidence quality and recommendation strength

Modality

Supervised use (by parents or at school) more efficacious thanunsupervised
10 ml of the solution is swished around the mouth for 1 min
Instruct child not to eat or drink for 20–30 min after application
Should be used for prevention of caries in both primary and permanent teeth
Varnish is the only high fluoride topical agent that can be used inpreschool
Use 2–4 times per year
Obvious deposits of dental plaque should be removed prior toapplication
In order not to exceed the PTD, clinicians should use a thin filmusing a minimal amount on caries predilection sites, initial caries
lesions and defects according to manufacturer’s instructions.
Instruct child not to eat or drink for 20–30 min

Use 2–4 times per year
In dental practice, remove obvious deposits of dental plaque andchoose appropriate size trays. Patient should sit in upright positionand not swallow; use suction devices during treatment and after
tray removal to minimise swallowing
In schools, it can be brushed on according to needs and for home use
brushed on weekly
Instruct child not to eat or drink for 20–30 min after application
Do not use in children < 6 yrs of age, as risk/benefit ratio is in favourof risk, due to danger of swallowing the rinse

Do not use in children < 6 years of age, as risk/benefit ratio is infavour of risk due to danger of swallowing the gelGood practice points and clinical advice

Table 6  The evidence, recommendations and good practice points for the use of fluoride gels, rinses and varnishes in the primary dentition (preschool, 0–5 years of age) and permanent dentition(mixed and young permanent dentition, 6–18 years of age)

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salt in a community feeding programme in an environment
with negligible availability of fluoride from other sources
resulted in a considerable caries-preventive effect.
Salt fluoridation is suggested (Pollick 2013; O’Mullane
et al. 2016) when water fluoridation cannot be implemented,
but one concern is that promotion of salt consumption fororal health benefits would be contradictory to the desired
reduction of consumption of salt to decrease the risk ofhypertension, and the drawbacks related to variation iningestion resulted in difficulties in maintaining an ideal
concentration.

Fluoride tablets/lozenges and drops
Fluoride tablets/lozenges and drops were first introduced toprovide systemic fluoride in areas where water fluoridation
was not available. At the time of introduction, the effectiveness of fluoride toothpaste was not yet firmly established.
Since the mid 1970s, effective fluoride toothpastes became
widely available. In these years, it was also accepted that the
post-eruptive effects of fluorides were sufficiently strong tokeep one’s teeth healthy when properly used (Fejerskov et al.
1981; Fejerskov 2004). These findings rated fluoride tablets/lozenges and drops as less meaningful caries-preventive
measures. Additionally, when using them, care should betaken that the products have sufficient substantivity in theoral cavity to also exert a topical effect.
In 2009, the EAPD concluded that at that time there wasa lack of evidence to make good recommendations (Swedish
Council on Technology Assessment in Health Care 2002;
Espelid 2008). The EAPD also advised to monitor the total
daily amount of fluoride ingested which should not exceed
0.07 mg/kg bodyweight daily (Fejerskov et al. 1977).
Since the previous position paper of the EAPD et al.
(2009), no new RCTs examining the effect of fluoride tablets/lozenges or drops have been published. Two systematic
reviews concluded that there might be an effect for permanent dentition, but that there was no clarity on the effect on
primary dentition (Tubert-Jeanin et al. 2011; Tomasin et al.
2015). It has to be noted that both reviews examined older
studies, conducted at a time when topical fluorides were notwidely used and that were also available when the previous
position paper of the EAPD (2009) was compiled.
One Cochrane review examining whether it was beneficial for pregnant women to use fluoride supplements to prevent future dental caries in their offspring found no evidence
to support this (Takahashi et al. 2017).

Recommendation
Fluoridated milk and fluoridated salt could be part of community health programmes in target groups with high caries prevalence and low compliance for tooth brushing with

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fluoridated toothpaste in areas without water fluoridation(GRADE of recommendation: CONDITIONAL). Fluoride
tablets/lozenges and drops could be considered on an individual basis for children at high risk for caries (GRADEof recommendation: CONDITIONAL), but improving thequality of tooth brushing or using a higher concentration offluoridated toothpaste would be the first option.

Water fluoridation
Water fluoridation
In the 21st century, dental caries remains a global healthproblem. It is estimated that 573 million children worldwide
have untreated dental caries in their primary teeth, while
untreated caries in permanent teeth affects 2.5 billion people (Kassebaum et al. 2017). Community water fluoridation(CWF) is the process of adjusting the amount of fluoride
found in water to achieve optimal prevention of dental caries (Centers for Disease Control and Prevention 2016). The
fluoride concentration of water in CWF programmes typically ranges from 0.5 to 1.1 mg/L.
CWF was introduced over 70 years ago as a public healthmeasure to prevent and control caries at a population level,
and in many countries throughout the world, CWF remains
a core component of oral health policy. In 2012, the worldwide total of people supplied with artificially fluoridated
water was estimated at approximately 370 million (British
Fluoridation Society 2012).
The great advantage of CWF is that it benefits all residents in a community, regardless of age, socio-economic status, education, oral hygiene practices, employment or accessto routine dental care, making it a truly equitable publichealth practice (Buzalaf et al. 2011; Public Health Agency
of Canada 2016). CWF is also a cost-effective method ofdelivering caries prevention to a large population, and thelarger the community served is, the greater the cost saving
will be (Ran and Chattopadhyay 2016).
The effectiveness of CWF at preventing dental caries has
been extensively and regularly investigated since the middle of the 20th century. A recent Cochrane review estimatedthat the initiation of CWF reduced caries levels by 35% in
the primary dentition and 26% in the permanent dentitionof children. The review also found that CWF led to a 15%
increase in the percentage of children with caries-free primary teeth and a 14% increase in the percentage of children
with caries-free permanent dentitions, compared to children
without water fluoridation (Iheozor-Ejiofor et al. 2015). The
reviewers questioned the applicability of these results to current lifestyles, as most of the included studies were conducted before the widespread use of fluoride toothpaste. The
inclusion criteria of the Cochrane review, which focused on

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the initiation of CWF, meant that the large body of contemporary data on CWF was excluded. Contemporary studies ofthe effectiveness of water CWF are primarily cross-sectional
surveillance surveys in populations with established CWF
programmes, where the use of fluoride toothpaste is ubiquitous. Reviews of such contemporary studies have reported
substantial caries reductions in both children and adults
who reside in fluoridated areas, compared to those in nonfluoridated areas (Griffin et al. 2007; Rugg-Gunn and Do
2012). A Cochrane review of the effectiveness of fluoride
toothpaste also found an additional caries-preventive benefit
when F toothpaste was used in areas with fluoridated water(Marinho et al. 2003).
Since its introduction in the mid-20th century, concerns
have been expressed about the possible health effects of
CWF. Several recent comprehensive reviews on the impact
of fluoridated water on human health have been published(Scientific Committee on Health and Environmental Risks(SCHER) 2011; Royal Society of New Zealand & Office of
the Prime Minister’s Chief Scientific Advisor 2014; Sutton
et al. 2015; National Health and Medical Research Council (NHMRC 2016)). No reliable evidence for any adverse
health effects associated with the use of fluoridated waterat the low levels used in CWF were found by any of thesereviews. One review also considered the environmental
impact of artificially fluoridated water and concluded that
exposure of environmental organisms to the levels of fluoride used for fluoridation of drinking water was not expected
to lead to unacceptable risks to the environment (ScientificCommittee on Health and Environmental Risks (SCHER)
2011).
Dental fluorosis at the lower levels (Dean’s Index) is the
only unwanted effect that is definitively associated with
CWF. The Cochrane review of water fluoridation estimated aprevalence of 12% for fluorosis of aesthetic concern at water
fluoride levels of 0.7 mg/L (Iheozor-Ejiofor et al. 2015).
Bottled drinking water is extensively used in many countries, including those with CWF, where it may displace
the consumption of fluoridated tap water. Bottled water, if
optimally fluoridated, could offer an additional option for
population caries prevention. However, further research on
the role of fluoride-containing bottled waters, dental caries
and fluorosis is needed.

Recommendation
The EAPD reaffirms its support for the use of community
water fluoridation as a safe, effective, relevant and costsaving public health measure for the prevention and control of dental caries. The Academy recognises that CWF
alone is not a panacea but should be seen as an importantelement in a multi-faceted approach to caries prevention

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and control, which includes oral health promotion andaccess to affordable care.
The Academy recognises the need for ongoing population surveillance of the dental and health effects of fluoridated water to assure its continued safety, effectivenessand relevance.
Acknowledgements The European Academy of Paediatric Dentistry
wishes to thank Professor Jack Toumba and Dr Nick A. Lygidakis(Workshop and Report Coordinators), for organising the Fluoride
Workshop in Athens, Greece, November 16–17, 2018, that has enabled the updating of the EAPD Fluoride Guidelines. Special thanks
should be attributed to those who took part in the Workshop and to the
speakers in the scientific sessions, who all contributed their valuableknowledge leading to the development of these guidelines.
Workshop groups moderators and participants:
Fluoride Toothpaste: Moderator: Svante Twetman (Denmark). Participants: Dominique Declerck (Belgium), Norbert Kramer (Germany),
Nick Lygidakis (Greece), Ulrich Schiffner (Germany), Jack Toumba(UK).
Fluoride Gels, Rinses and Varnishes: Moderator: Christian Splieth(Germany). Participants: Sotiria Gizani (Greece), Rita Cauwels (Belgium), William Papaioannou (Greece).
Fluoridated milk and salt, Fluoride tablets/lozenges and drops:
Moderator: Cor van Loveren (The Netherlands). Participants: Elias
Berdouses (Greece), Olga Cortes (Spain), Betul Kargul (Turkey), Katerina Kavvadia (Greece).
Water Fluoridation: Moderator: Carmel Parnell (Ireland). Participants: Mairead Harding (Ireland), Vassiliki Topitsoglou (Greece).
Fluorides and erosion: Adrian Lussi (Switzerland).

Compliance with ethical standards
Conflict of interest All authors declare that they have no conflict ofinterest.
Research involving human participants and/or animals The manuscript
is a review/guideline article and hence does not involve human or animal participants.
Informed consent Informed consents are not required as the manuscript is a guideline/review paper not involving human or animal participants.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat​iveco​
mmons​.org/licen​ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to theCreative Commons license, and indicate if changes were made.

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