Parent Refusal of Topical Fluoride for Their Children: Clinical Strategies and Future Research Priorities to Improve Evidence-Based Pediatric Dental Practice.

In the early 1900s, Frederick McKay discovered the oral health benefits of fluoride when he observed that individuals exposed to naturally fluoridated drinking water in Colorado Springs, Colorado were significantly less likely to develop tooth decay.1 Laboratory studies later confirmed his clinical observations. Since then, topical fluorides have become the cornerstone of prevention in dentistry. Fluoride is available in a variety of modalities each with varying concentrations: drinking water fluoridated at 0.7ppm; over-the-counter toothpastes and mouthwashes; foams, gels, and varnishes provided by health providers during dental and medical visits; and prescription-strength toothpastes, drops, or tablets. Fluorides prevent tooth decay by promoting remineralization and inhibiting demineralization of enamel.2–5 Fluoride is recommended as part of a comprehensive tooth decay prevention program.6–8 Regular exposure to fluoride is safe, even for young infants.9,10 Even though fluoride is effective and safe, recent data showed that 13% of parents refused fluoride treatments for their child during a preventive dental or medical visit.11 Even more parents are fluoride hesitant, meaning that they may accept fluoride for their children but have unresolved concerns. These findings, which are the only published data specifically on fluoride refusal behaviors, are of concern from an evidence-based perspective because fluoride is one of the only preventive treatments we have available for caries prevention. The growing phenomenon of fluoride refusal has implications for the way in which clinicians communicate with parents about fluoride so that parents can make optimal preventive health care decisions for their children. This article will include a discussion of conceptual issues related to fluoride refusal, including definitions and measurement-related gaps. Next, I will review the relevant scientific literature to identify potential factors related to fluoride refusal. This information will form the basis for recommendations on clinical strategies that can be incorporated into practice and future research priorities related to building on stronger scientific evidence base to manage and address fluoride refusal in clinical settings. Defining and Conceptualizing Fluoride Refusal I defined fluoride refusal as any instance in which a parent has refused, attempted to refuse, or considered refusing professional fluoride treatment for their child in a health care setting because of concerns about the necessity, safety, or consequences of fluoride. I emphasize the behavioral, cultural, or social origins of fluoride refusal behaviors rather than developmental or economic etiologies. Thus, fluoride refusal excludes reasons like a parent refusing because their young child does not like the taste (developmental) or the inability to pay for fluoride treatment when a parent would otherwise accept it (economic).12,13 Fluoride refusal is typically conceptualized as a binary behavior. A parent brings their child into clinic, is presented with the option of fluoride, and makes a decision to either accept or refuse fluoride. However, similar to the continuum-of-addiction model used to describe smoking14, fluoride refusal is positioned at one end of a continuum that ranges from complete acceptance of fluoride with no reservations to complete refusal with no desire to change one’s mind (Figure 1). Somewhere in the middle of this continuum are hesitant parents, regardless of whether they accept fluoride, with some degree of concern. Parents who refuse fluoride are considered hesitant, but not all hesitant parents refuse fluoride. Studies on parent preferences regarding preventive care have reported that most parents accept fluoride, but there are some parents with concerns.15,16 These findings support the continuum model. For simplicity, when I use the term “fluoride refusal” in this paper, it incorporates the concept of hesitancy Open in a separate window Figure 1 Continuum of fluoride hesitancy behaviors.