This concentration ranges from 0.7 ppm to 1.2 ppm depending on the average maximum daily air temperature of the area ( 66--68 ). In 1991, PHS also issued policy and research recommendations for fluoride use ( 8 ). The U.S. Environmental Protection Agency (EPA), which is responsible for the safety and quality of drinking water in the United States, sets a maximum allowable limit for fluoride in community drinking water at 4 ppm and a secondary limit (i.e., nonenforceable guideline) at 2 ppm ( 69,70 ). The U.S. Food and Drug Administration (FDA) is responsible for approving prescription and over-the-counter fluoride products marketed in the United States and for setting standards for labeling bottled water ( 71) and over-the-counter fluoride products (e.g., toothpaste and mouthrinse) ( 72 ).
Documented effectiveness is the most basic requirement for providing a health-care service and an important prerequisite for preventive services (e.g., caries-preventive modalities). However, effectiveness alone is not a sufficient reason to initiate a service. Other factors, including cost, must be considered ( 254 ). A modality is more cost-effective when deemed a less expensive way, from among competing alternatives, of meeting a stated objective ( 258 ). In public health planning, determination of the most cost-effective alternative for prevention is essential to using scarce resources efficiently. Dental-insurance carriers are also interested in cost-effectiveness so they can help purchasers use funds efficiently. Because half of dental expenditures are out of pocket ( 259 ), this topic interests patients and their dentists as well. Potential improvement to quality of life is also a consideration. The contribution of a healthy dentition to quality of life at any age has not been quantified, but is probably valued by most persons.
In the United States, the standard concentration of fluoride in fluoride toothpaste is 1,000--1,100 ppm. Toothpaste containing 1,500 ppm fluoride has been reported to be slightly more efficacious in reducing dental caries in U.S. and European studies ( 161--164 ).
Fluoride mouthrinse is a concentrated solution intended for daily or weekly use. The fluoride from mouthrinse, like that from toothpaste, is retained in dental plaque and saliva to help prevent dental caries ( 183 ). The most common fluoride compound used in mouthrinse is sodium fluoride.
Dental caries (i.e., tooth decay) is an infectious, multifactorial disease afflicting most persons in industrialized countries and some developing countries ( 1 ). Fluoride reduces the incidence of dental caries and slows or reverses the progression of existing lesions (i.e., prevents cavities). Although pit and fissure sealants, meticulous oral hygiene, and appropriate dietary practices contribute to caries prevention and control, the most effective and widely used approaches have included fluoride use. Today, all U.S. residents are exposed to fluoride to some degree, and widespread use of fluoride has been a major factor in the decline in the prevalence and severity of dental caries in the United States and other economically developed countries ( 1 ). Although this decline is a major public health achievement, the burden of disease is still considerable in all age groups. Because many fluoride modalities are effective, inexpensive, readily available, and can be used in both private and public health settings, their use is likely to continue.
When used appropriately, fluoride is a safe and effective agent that can be used to prevent and control dental caries. Fluoride has contributed profoundly to the improved dental health of persons in the United States and other countries. Fluoride is needed regularly throughout life to protect teeth against tooth decay. To ensure additional gains in oral health, water fluoridation should be extended to additional communities, and fluoride toothpaste should be used widely. Adoption of these and other recommendations in this report could lead to considerable savings in public and private resources without compromising fluoride's substantial benefit of improved dental health.
Widespread use of fluoride has been a major factor in the decline in the prevalence and severity of dental caries (i.e., tooth decay) in the United States and other economically developed countries. When used appropriately, fluoride is both safe and effective in preventing and controlling dental caries.
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