1995;126;1625-1632 J Am Dent Assoc

and JS Wefel SM Levy, FJ Kohout, MC Kiritsy, Heilman, JR

supplements and dentifriceInfants' fluoride ingestion from water,

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,> w STEVEN M. LEVY, D.D.S., M.P.H.;FRANK J. KOHOUT, PH.D., M.S.;

In fants MARY C. KIRITSY, M.SC., R.D.;11i11/ - ~~JUDY R. HEILMAN, B.S.;

JAMES S. WEFEL, PH.D.

Futeoride o

Ingestionfrom Water,Supplements|

and DentifriceS |111111| 111| 1 || |i __ _ _ B y the mid-1980s, the prevalence of

dental caries in children had de-clined dramatically in the UnitedStates and other developed coun-tries, mainly due to the widespreaduse of fluoride in many forms.12 More

recently, concerns have been raised about the in-creased prevalence and severity of dental fluorosisin the United StateS3-5 due to the widespread inges-

i 8tion of fluoride from a variety of sources. Local andregional studies in the United States and Canada

~~ ~have found the prevalence of mostly mild dentalX fluorosis to range from about 20 to 80 percent.5-7 In

an effort to help people achieve the "optimal" in-take of ingested fluoride to balance dental cariespevention and dental fluorosis, the recommended

dietary fluoride supplementation dosage recentlyhas been reduced in both the United States8'- andCanada.2In addition, prudent use of small quanti-ties of fluoride dentifrice by preschool-aged childrenhas been widely recommended.'' (Author's note:The optimal level of fluoride intake has never beendetermined scientifically and has been used only ingeneral terms. Levy and Guha-Chowdhury16 ad-dressed the limitations of current knowledge of "op-timal" fluoride intake levels.)

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TABLE I

I Imlafta-- I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

AGEE6 3 6 9

weeks months months months(n=122) (n=118) (n=98) (n=75)

(0.012) (0.08)

>0.6 0.46 0.57 0.64 0.46(0.33) (0.44) (0.36) (0.39)

Few studies have reportedcomprehensively on fluoride ex-posures or ingestion by children;most of these studies have usedretrospective designs, whichmay limit their validity and util-ity,17'18 especially in terms of thelevel of detailed response possi-ble many years after the expo-sure. Little is known about therelative importance of differentsources of ingested fluorideamong preschool children whosepermanent teeth are developingand who are at risk for dentalfluorosis. Levy, Kohout, Guha-Chowdhury and colleagues re-cently reported on the frequencydistribution of estimated intakeof fluoride from water by itself,mixed with infant formula andmixed with other beveragesamong a group of infants frombirth to 9 months of age.'8 The

purpose of this article is to re-port on the relative contributionof fluoride ingested from water,supplements and dentifrices tooverall fluoride intake among agroup of infants studied longitu-dinally from birth until 9months of age.

METHODS

One hundred ninety-two womenwith newborns were recruited in1990 from the postpartum wardsoftwo Iowa City hospitals, afterthey had delivered but beforethey had left the hospital.'8 Thisconstituted approximately 85percent of all those invited toparticipate. Appropriate in-formed consent procedures wereused. The mothers completed arecruitment questionnaire andsubsequently completed struc-tured mailed questionnaires con-

cerning their infants at 6 weeksand 3, 6 and 9 months of age.The questionnaires focused pri-marily on the children's feedinghabits, water sources and intake,as well as use of dietary fluoridesupplements and fluoride denti-frice during the time since theprevious questionnaire. Non-respondents received a secondmailing after three weeks andwere contacted by telephoneagain three weeks later.Participants received tooth-brushes as incentives. Fifty-sixmothers did not return any ques-tionnaire after recruitment, 21returned one of the four, 24 re-turned two, 26 returned threeand 65 returned all four.

Mothers reported whethertheir infants had ingested anyof these 13 categories of bever-ages and food during the previ-ous week, and if so, the averagedaily amount ingested:- water by itself;- powdered concentrate for-mula reconstituted with water;- liquid concentrate formulareconstituted with water;- ready-to-feed formula;- cow's milk;- breastmilk;- ready-to-drink juices;- beverages reconstituted withwater;- other ready-to-drink beverages;- ready-to-feed baby food;- powdered infant cereal recon-stituted with water;- other food made with water;- table food.

Total daily water intake wasestimated from the reported in-take of water by itself; pow-dered and liquid concentratedformulas reconstituted withwater; beverages reconstitutedwith water; powdered infant ce-reals reconstituted with water;and other food made with water(such as gelatin, pudding, soup).

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TABLE 2

VARIABLE

ig;g. t

Suppfleme.1n.-Sdt use IS I L.d ?fQ0;D'??t1 - 'S0Sxpplee2axt usema(anionig users ouly)

Numrnber of s-ubjects

Mean percentage(SD) of weeks inperiod

Mean percentage(SD) of days per week*

Mean daily intake(SD) frorn suipple-mentst

_I A l

s: I7W ' !W wvv

6 3 6 9weeks months months months

31

63(29)

83(28)

0.13(0.08)

In addition to completing aquestionnaire at each timepoint, mothers also completedthree-day intake diaries of allbeverages and foods that weused to confirm the mothers'answers concerning these cate-gories of ingestion. We contact-ed the mothers by telephone ormail to clarify important dis-crepancies between question-naire and diary responses. Noassessment of reliability of sub-ject responses was conducted.

Fluoride levels of well water,bottled water and filtered watersupplies in homes and childcare settings were assayed witha fluoride-specific electrode.Available information obtainedfrom the State of Iowa HealthDepartment reporting monthlyfluoride values was used to de-termine fluoride levels in thosehomes and child care settingsusing public water supplies. Weestimated the amounts of fluo-ride ingested from water ateach age by multiplying theamounts of water ingested

22

84(26)

86(22)

0.18(0.08)

22

82(30)

91(19)

0.19(0.08)

17

72(35)

86(26)

0.14(0.09)

times the fluoride levels of thewater used.

At each time point, mothersreported whether their infantsreceived dietary fluoride supple-ments. If so, then they reportedthe number of weeks that sup-plements were given, the aver-age number of days per weekgiven and the brand and dosageused. From these responses, wecalculated an average dailyfluoride supplement dosage. Ifdosage data were not available,we assumed that the then-recommended dosage of 0.25milligrams of fluoride was used.

Mothers also reportedwhether their infants had anyteeth yet, whether the teethwere brushed, the daily frequen-cy of brushing, whether fluoridedentifrice was used, the quanti-ty of dentifrice used (by choosingfrom among pictures of tooth-brushes with varying quantitiesof dentifrice)7",9 and an estimateof the proportion of dentifriceusually ingested. From these re-sponses, we estimated the in-

fants' average daily fluoridedentifrice use and ingestion.We analyzed the data using

SPSS-PC Plus (SPSS Incor-porated) with descriptive statis-tics generated at each time pointfor each variable for the wholesample. Here we present selectedresults according to compositewater fluoride levels (individuallyweighted averages ofhome, bot-tled water and child care settingsources) categorized as <0.3 partsper million, 0.3 to 0.6 ppm or >0.6ppm, according to the dietaryfluoride supplement categoriesfor water fluoride levels recentlyadopted by the American DentalAssociation, the AmericanAcademy of Pediatrics and theAmerican Academy ofPediatricDentistry.8-ll

The results presented hereare for the 122 respondents at 6weeks of age, 118 at 3 months,98 at 6 months and 75 at 9months. This is the same groupof children followed longitudi-nally, not different groups ateach time period.

RESULTS

We compared the baselineresponses at recruitment of re-spondents with those of non-respondents at the differenttime points to assess possiblenon-response bias.'8 No signifi-cant differences arose betweenrespondents and non-respond-ents in source of water, childcare plan, number of adults orchildren in the family or familyincome. Only on parent educa-tion did respondents differ sig-nificantly; the mothers and fa-thers of infants remaining inthe study at 6 months and 9months of age had significantlyhigher levels of education thandid the parents of non-respond-ents.'8 We also compared 3-month and 6-month fluoride in-

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TABLE 3

weeks months months months

take estimates between thoseresponding and those not re-sponding at later time points(six months and nine months).18Although we found no statisti-cally significant differences,those responding at more timepoints tended to have a higherestimated fluoride intake.'8

Table 1 summarizes the pre-viously reported18 frequency dis-tribution of estimated total fluo-ride intake from water for thetotal sample at each age check-point. There is substantial vari-ation in intake, with the stand-ard deviations larger than themeans. The distributions areskewed; the means are approxi-mately twice as large as the me-dians. The medians were 0.14mg of estimated ingested fluo-ride daily, except at age 6

months with median intake of0.24 mg, while the mean intakeswere from 0.29 to 0.38 mg. Themaximum individual intakesranged from 1.24 to 1.73 mg perday. Table 1 also presents themeans separately for water fluo-ride levels (weighted average ofhome, bottled and child-care-setting water sources) and cate-gorizes them as <0.3, 0.3 to 0.6,or >0.6 ppm fluoride.

Table 2 summarizes the use ofdietary fluoride supplements.Supplement use varied little atthe different time points, andthere was no apparent increaseor decrease over time. Amongthose who gave their childrensupplements, the mean percent-ages of weeks (in each time peri-od) that they used supplementswere 63 to 84 percent. In the

weeks that supplements wereused, they were used an averageof 83 to 91 percent of the days.Among the children using sup-plements, estimated mean dailyfluoride intake from supplementsvaried only from 0.13 mg at 6weeks to 0.19 mg at 6 months.No parents reported their in-

fants' using fluoride dentifricebefore their 9-month question-naires. At 9 months, 88 percentof the mothers reported thattheir infants had 1 or moreteeth and 56 percent of thesesaid their infants' teeth werebeing brushed. Among these 37children, 40 percent had teethbrushed less than once daily, 57percent brushed once daily and3 percent brushed twice daily(mean=0.80, SD=0.36). Thirtypercent of those whose teethwere brushed used fluoride den-tifrice (n=11). The estimatedquantity of fluoride dentifriceused per brushing varied fromless than 0.01 to 0.25 grams(mean=0.08, SD= 0.07). The es-timated quantity of fluoride in-gested daily ranged from lessthan 0.01 to 0.25 mg (mean=0.06, SD=0.08).

Table 3 summarizes the esti-mated total fluoride intake fromwater, supplements and denti-frice combined. The results arevery similar to, but slightly high-er than, those shown in Table 1for fluoride intake from water,since most infants received nei-ther fluoride supplements nordentifrice. There is substantialvariation in total estimated fluo-ride intake from these sources,and the distributions are posi-tively skewed (means weregreater than medians). Therewas a fairly consistent trend to-ward increased daily fluoride in-take with increasing age (exceptat 9 months). However, when ad-justed on the basis of fluoride in-

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TABLE 4

1__ I _VARIABLE AGE

a 3 6mweeks months months months

iA.an tmog t as, a t$users only)

From supple-merits

Range 0-99 0-100 3-100 0-98Mean (all) 14 12 18 12SD (all) 32 30 36 27Mean (among 65 80 77 52us3ers only)_ _

:$D ¢~0 0 0 0 2 0- f X 6Mean (arong 19users only)

take per unit body weight (mil-ligrams of fluoride per kilogramofbody weight), fluoride inges-tion remained relatively constantor declined slightly with increas-ing age.'14"8 Table 3 also presentsthe means reported separatelyfor the different water fluoridelevels (composite ofhome, bottledand child-care-setting water).Standard deviations also werehigher for those with higherwater fluoride levels.

Table 4 summarizes the sepa-rate distributions of total com-bined fluoride intake from water,supplements and dentifrice thatcome from each source separate-ly. The mean percentage of thisintake from water varied onlyslightly, from 82 percent for6-month-olds to 88 percent for3-month-olds. Overall, supple-ments and dentifrices contrib-uted little to the fluoride intake.However, among those using

supplements or dentifrice, thesesources contributed more sub-stantially to fluoride ingestion.For example, supplements con-tributed 12 percent (among 3-month- and 9-month-olds) to 18percent (among 6-month-olds) ofthe total fluoride intake fromthese three sources for the wholesample. However, when consid-ered for only those receiving sup-plements, the percentage contri-butions ranged up to maximumsof 98 to 100 percent, and themean percentage contributionsranged from 52 percent (at ninemonths) to 80 percent (at threemonths). Dentifrice ingestionwas not reported until the 9-month checkpoint. Among thetotal sample of 9-month-olds, themean percentage of fluoride in-take contributed by dentifrice in-gestion was only 2 percent.However, among only users offluoride dentifrice, dentifrice con-

tributed up to 46 percent, with amean of 19 percent.

DISCUSSION

Sample. There are several fac-tors to consider in interpretingthe results of this study.Although the infants in thisconvenience sample did show awide range of feeding patterns,water fluoride levels and pat-terns of use of supplements anddentifrice, the sample is notnecessarily representative ofthe broader population of in-fants.18 The values of fluorideintake calculated are estimatesonly, derived from parents' re-ports that were not validated.18And fluoride intake from ready-to-consume infant formulas,juices, baby foods and otherfoods and beverages was not in-cluded in this study."8 Also, theages of the participating infantsactually varied by anywherefrom a few days to severalweeks, which could affect foodand beverage intake patterns.'8

Furthermore, the numbers ofinfants for whom we have datavaried across the time periods.However, comparisons of base-line data from respondents andnon-respondents and of three-and six-month data according toresponse/non-response at latertime points showed few signifi-cant differences. In addition,other analyses (not described inthis article) showed similar di-etary patterns and estimateddietary intake for respondentswho provided data at all fourtime points as for the respon-dents overall.18 Individual bodyweights were not available;thus calculations of fluoride in-take per unit of body weightused only aggregate weightslinked to individual fluoride in-take data and, therefore, areonly estimates.18 For these and

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TABLE 5

IW W Ww

PERCENTILE ESTIMATED F BODY EXPECTEDINTAKE FROM WEIGHTt "OPTIMAL"THIS STUDY (KG) F INTAKE(MO/DAY) (MG/DAY)**

90

9 mo3ths

50 (median)7590

0.220.490.80

other reasons, caution is neces-sary in generalizing from theresults of this study, and specif-ic assessment of fluoride expo-sures and ingestion must bedone at the individual level.

Despite these limitations,this report has demonstratedsubstantial variation in esti-mated total ingestion of fluoridefrom water, dietary fluoridesupplements and dentifriceamong children ranging from 6weeks to 9 months of age.Virtually every child receivedsome fluoride from drinkingwater, whether only at home orboth at home and in the childcare setting. Supplements wereused by about 25 percent of thechildren, and only a small per-centage of 9-month-olds ingest-ed fluoride dentifrice.

8.79.39.8

0.44-0.610.47-0.650.49-0.69

Contributions of fluoridesources on ingestion and in-take levels. We evaluated thecontributions of the three fluo-ride sources-supplements,dentifrice and water (alone andin food and beverages)-to in-gestion and intake levels.

Supplements and dentifrice.When we averaged the contribu-tions of dietary fluoride supple-ments and fluoride dentifriceover the whole study group, wefound that they contributedsmall absolute quantities of fluo-ride ingestion and small percent-ages of total fluoride intake ateach age from 6 weeks to 9months. However, in the childrenwho ingested supplements or flu-oride dentifrice, absolute quanti-ties of intake from these sourcesand percentages of total intake

were substantially larger. Forsome infants, estimated inges-tion of fluoride from supplementsand/or dentifrice exceeded thatfrom water and all beveragesand foods prepared with water.Thus, all three general sources offluoride intake-water, supple-ments and dentifrice-should beconsidered when estimating totalfluoride intake.

Since children in this studywere studied only until 9months of age, fluoride denti-frice use was not yet nearly uni-versal, as it generally becomesby about age 18 months to 24months. Fluoride dentifrice wasused at 9 months by only about30 percent of those whose teethwere brushed, as many mothersinitially brush without denti-frice until more teeth haveerupted. Thus, dentifrice wouldbe a much more importantsource of fluoride intake at 12months of age and thereafter.

Water. Although infants whohad higher fluoride levels intheir drinking water generallyreceived more fluoride andclearly had higher mean fluo-ride ingestion than did thosewith lower water-fluoride lev-els, there was substantial vari-ability at the individual level.Some children ingesting largequantities of water with moder-ate fluoride levels may receivemore fluoride than do others in-gesting much smaller quantitiesof optimally fluoridated water.

Ready-to-feed food and bever-ages. It would be desirable alsoto include fluoride intake fromready-to-feed foods and bever-ages or those prepared withoutadding water. However, it gen-erally is difficult to estimatefluoride intake from thesesources since their levels canvary substantially, especiallydepending on the water sources

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Dr. Levy is a profes- Dr. Kohout is a pro-

sor and graduate fessor, Departmentprogram director, of Periodontics and

Department of Dows Institute for

Preventive and Dental Research,Community Dentistry, College of Dentistry,College of Dentistry, University of Iowa,The University of Iowa City.Iowa, Iowa City, Iowa52242. Address

reprint requests to used in theirDr. Levy. manufac-

ture. 14,16,20-22This does not negate the needfor the clinician to estimate achild's total fluoride intake toaccount for any substantialquantities of ready-to-feed high-fluoride foods or beverages-forinstance, ready-to-feed soy-based infant formulas, chickenbaby foods, infant grape juices,tea-that the child may be con-suming. Perhaps mean valuescould be used as estimates forthese products' fluoride levels.The optimal intake level.

We reported previously that esti-mated daily fluoride intake onlyfrom water itself, from wateradded to beverages and fromfoods made with water probablyexceeded the traditionally accept-ed optimal total daily fluoride in-take of 0.05 to 0.07 mg fluorideper kg ofbody weight for a sub-stantial percentage of the infantsin this study.'8 Similar and slight-ly stronger patterns of fluorideintake that exceed optimal fluo-ride intake are evident when in-take from supplements and den-tiftice (Table 3) are included. Forexample, a total optimal daily flu-oride intake of 0.05 to 0.07 mgfluoride/kg body weight wouldmean totals (Table 5) of about0.24-0.34 mg fluoride for a 6-week-old with mean body weightof 4.8 kg,22 0.30-0.42 mg fluoride

for a mean-weight (6.0 kg)3-month-old,0.38-0.53 mgfluoride for amean-weight

Ms. Kiritsy Is re- (7.6 kg) 6-search assistant, m andmonth-old andDepartment of

Preventive and 0.44-0.61 mgCommunity fluoride for aDentistry, College of

Dentistry, University mean-weightof Iowa, Iowa City. (8.7 kg) 9-

month-old.Mean (and median) fluoride

intake in this study from water,supplements and dentifrice (butexcluding other dietary fluorideintake) in infants up to 6 monthsold was within or less than theseoptimal total daily intakeranges. However, the 75th per-centiles from our data for6-week-olds, 3-month-olds and6-month-olds clearly exceededthe ranges for 75th percentiles ofexpected optimal intake byabout 0.10 to 0.27 mg. The 90thpercentile of estimated fluorideintake exceeded the expected op-timal daily fluoride intake for allage groups from 6 weeks to 9months, with the extra amountsbeing about 0.45 to 0.56 mg for6-week-olds, 0.58 to 0.72 mg for3-month-olds, 0.38 to 0.55 mg for6-month-olds and 0.11 to 0.31mg for 9-month-olds. These 90thpercentiles of intake for 6-week-olds and 3-month-olds are morethan twice the expected optimalintake, with the proportional dif-ferences somewhat less dramaticfor those 6 months or older.

Deciding when to use asupplement. With the majorityof children having much lessdecay than in the past, with di-verse sources and variablequantities of ingested fluorideand with the role of systemicfluoride understood to be lessimportant than previously be-lieved, decisions about use of di-

etary fluoride supplements aremore complex than they were inthe past. Their use has beenquestioned24 because it increas-es the risk of dental fluorosis,while average reductions indecay are more modest com-pared with those in the past.Therefore, our researchgroup '20,25 and others9" 3",5 haverecommended more conserva-tive use of dietary fluoride sup-plements, although continuedemphasis on dietary fluoridesupplements has also been rec-ommended.26 Specifically, ourresearch group recently recom-mended'4 that supplements be"considered a targeted preven-tive regimen instead of beingused routinely for the generalpopulation of all children livingin non-fluoridated areas."When considering use of di-

etary fluoride supplements, as-sessment of the patient's cariesrisk should be a primary consid-eration.'4 Although this deter-mination is especially difficultto make for young children,often the "previous caries histo-ry for the child, siblings, andparents; the family's dentalknowledge and preventive ori-entation; the child's physicaland cognitive status and use ofmedications; the child's oralpreventive behaviors; the child'sother fluoride exposures; andpossibly results of caries activi-ty tests"'4 are important aspectsto consider.

Monitoring fluoride in-take. The results of this studyare consistent with our recentrecommendations '4 concerningdietary fluoride. Since it is diffi-cult to avoid excessive intake offluoride by adjusting fluoride in-take via control of food and bev-erage consumption,'4 primaryemphasis should be on limitingfluoride ingestion from the more

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Ms. Holemn ls a rn- Dr Wefel Is profes-searoh assistant, aor, PediatricDow. Institute for Dentistry, and diroo-

Dental Researoh, tor, Dows instituteCollege of Dentistry, for Dental Researoh,University of Iowa, College of Dentistry,Iowa City. University of lows,

Iowa City.

defined sources of supplementsand dentifrices. However, manu-facturers ofbottled waters, juicesand soft drinks; infant formulas;and baby foods should be re-quired to monitor and list the flu-oride levels on their products.'4Also, "infants receiving substan-tial quantities of infant formulagenerally should not use powderor liquid concentrate if water flu-oride levels are near optimal orabove, since the water fluoridealone might then exceed total,recommended daily levels."'4

Monitoring dentifrice use.Concerning dentifrice use, theprevention of ingestion of largequantities of fluoride dentifriceby young children should be amajor emphasis of the wholedental team within the office, aswell as of professional organiza-tions and manufacturers. Use ofsmall, pea-sized quantities ofdentifrice by young children;parental responsibility for place-ment of dentifrice and actualbrushing, with special attentionto dentifrices flavored for chil-dren that may encourage inges-tion27 and those with highfluoride concentration; and elim-inating corporate promotion ofuse of a full strip of dentifriceare all important components ofsuch efforts.2-17,19-30 In addition,emphasis on future research andacceptance of dentifrices thathave a lower-than-conventional

concentration of fluoride is war-ranted.'2-'4,'6,20,3'

CONCLUSION

It is hoped that by consideringall sources of ingested fluoride;making more conservative, indi-vidualized use of dietary fluo-ride supplements; and prudent-ly using fluoride dentifrice,dentists and their patients canbest balance caries preventionand the risks of dental fluorosis.Also, because physicians pre-scribe most of the dietary fluo-ride supplements used by in-fants and young children, it isimportant for dentists and/orother members of the dentalteam to discuss these considera-tions with their medical col-leagues. m

Parts of this research were presented at the1994 annual meetings of the InternationalAssociation for Dental Research and theAmerican Association of Public HealthDentistry.

This project was supported in part byUSPHS NIDR grants R03-DE09200, R01-DE09551 and P30-DE10126.

The authors thank Ms. Mary Jo Mohr, Ms.Cindy O'Toole and Ms. Marilyn Pratt.

1. Brunelle JA, Carlos JP. Recent trends indental caries in U.S. children and the effect ofwater fluoridation. J Dent Res 1990;69(Special Issue):723-7.

2. Burt B. Trends in caries prevalence inNorth American children. Int Dent J 1994;44(Supplement 1):403-13.

3. Szpunar SM, Burt BA. Trends in theprevalence of dental fluorosis in the UnitedStates: a review. J Public Health Dent1987;47:71-9.[published erratum appears in JPublic Health Dent 1987;47(3):155]

4. Burt BA. Fluoride-how much of a goodthing? Introduction to the symposium. JPublic Health Dent 1995;55(1):37-8.

5. Rozier RG. Prevalence and severity ofenamel fluorosis in North American children.J Public Health Dent (In press).

6. Brunelle JA. The prevalence of dentalfluorosis in U.S. children, 1987 (Abstract). JDent Res 1989;68 (Special Issue):995.

7. Clark DC. Trends in prevalence of dentalfluorosis in North America. Community DentOral Epidemiol 1994;22:148-52.

8. American Dental Association. New fluo-ride guidelines proposed. JADA 1994;125:366.

9. American Dental Association. New fluo-ride schedule adopted. ADA News 1994; May16:12,14.

10. Committee on Nutrition, AmericanAcademy of Pediatrics. Fluoride supplementa-tion for children: interim policy recommenda-

tions. Pediatr 1995; 95:777.11. American Academy of Pediatric

Dentistry. Second step taken to ratify newfluoride dosage schedule. Pediatr Dent Today1994;July:2.

12. Report of the Canadian workshop on theevaluation of current recommendations con-cerning fluorides. Introduction to the work-shop. Community Dent Oral Epidemiol1994;22:140-3.

13. Bawden JW, ed. Changing patterns offluoride intake. Proceedings of the workshop.J Dent Res 1992;71:1212-27.

14. Levy SM, Kiritsy MC, Warren JW.Sources of fluoride intake in children. JPublic Health Dent 1995;55(1):39-52.

15. U.S. Public Health Service, Ad HocSubcommittee on Fluoride. Review of fluoridebenefits and risks. Washington, D.C.: U.S.Government Printing Office, February, 1991.

16. Levy SM, Guha-Chowdhury N. Totalfluoride intake and implications for dietaryfluoride supplements. J Public Health Dent(In press).

17. Levy SM, Maurice TS, Jakobsen JR.Feeding patterns, water sources and fluorideexposures of infants and 1-year-olds. JADA1993;124(4):64-9.

18. Levy SM, Kohout FJ, Guha-ChowdhuryN, Kiritay MC, Heilman JR, Wefel JS. Infants'fluoride intake from drinking water alone, andfrom water added to formula, beverages andfood. J Dent Res 1995;74(7):1399-1407.

19. Levy SM, Zarei-MZ. Evaluation of fluo-ride exposures in children. ASDC J DentChild 1991;58:467-73.20. Levy SM. Review of fluoride exposures

and ingestion. Community Dent Oral Epi-demiol 1994;22:173-80.21. Levy SM, Kiritsy MC, Heilman JR, Van

Winkle S, Vukovic S, Wefel JS. Fluoride lev-els of ready-to-feed juices and juice drinks(Abstract No. 1043). J Dent Res1993;72(Special Issue):234.22. Pang PTY, Phillips CL, Bawden JW.

Fluoride intake from beverage consumptionin a sample of North Carolina children. JDent Res 1992;1382-8.23. Fomon SJ, Nelson SE. Size and growth.

In: Fomon SJ, ed. Nutrition of normal in-fants. St. Louis: Mosby;1993:36-84.24. Szpunar SM, Burt BA. Fluoride supple-

ments: evaluation of appropriate use in theUnited States. Community Dent Oral Epi-demiol 1992;20:148-54.25. Levy SM, Muchow G. Provider compli-

ance with recommended dietary fluoride sup-plement protocol. Am J Public Health1992;82:281-3.26. Horowitz HS. Commentary on and rec-

ommendations for the proper uses of fluoride.J Public Health Dent 1995;55(1):57-62.

27. Levy SM, Maurice TJ, Jakobsen JR. Apilot study of pre-schoolers' use of regular fla-vored dentifrices and those flavored for chil-dren. Pediatr Dent 1992;14:388-91.28. Levy SM. A review of fluoride intake

from fluoride dentifrice. ASDC J Dent Child1993;60:115-24.29. Maurice TJ, Levy SM, Jakobsen JR.

Dentifrice use among preschool children.JADA 1993;124(9):57-60.

30. Beltran ED, Szpunar SM. Fluoride intoothpastes for children: suggestions forchange. Pediatr Dent 1988;10:185-8.31. Horowitz HS. The need for toothpastes

with lower than conventional concentrationfor preschool-aged children. J Public HealthDent 1992;52:216-21.

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