Useoffluoridefororalhealthinchildren–

knowledgeandattitudesamongparents

Authors: Kaysar Pairo & Shilan Rustem

Tutor: Pernilla Lif Holgerson

Number of words in the abstract: 248

Number of words in the text: 2972

Number of tables and figures: 3

Number of cited referenses: 24

Abstract

In a ongoing research project, OMIC (Oral Microbiota in children), a sub study was made to

evaluate the use of fluoride, knowledge and attitude among parents of the 200 participating

children.

The children have been followed since birth and their parents answered questionnaires at 3,

18 months and 3 years in the main study. At the 5-year inspection in the main study the

parents were asked to fill in another questionnaire for the fluoride sub study.

In this study the parents were asked to answer questions about their own and their children’s

use of fluoride products and their view of the risk with using these products. Questions about

toothpaste and tooth brushing were also included.

All parents used fluoridated toothpaste and a third also used complementary products. In this

group of children there was no difference in caries experience between the ones using non-

fluoride against fluoride toothpaste. Children who brushed their teeth themselves had more

caries than children who got help from a grown-up.

In conclusion the results from our material do not support our hypothesis which is that the

lack of information regarding efficacy and safety of fluoride toothpaste over the years and the

impact from social media has resulted in lower use of fluoride toothpaste to children because

of the impact from the parents.

The survey need to be done in a more heterogeneous population for clearer results. It is

important to remember that parental support is a huge factor to improve oral health in

children.

3

Introduction

Caries epidemiology

In the beginning of the 19th century, the consumption of sugar increased as the industrialism

took place. This combined with poor oral hygiene led to the development of caries at a high

rate and because of the lack of knowledge the disease became more common among the

people (SBU, 2003). During the 1930´s only 1 % of the children in some parts of Sweden

were caries free (Aronsson et al., 2009).

Caries is one of the most common diseases in the oral cavity; it can affect cementum, dentin

and enamel (Fejerskov et al., 2015). The disease has a biochemical effect locally on the tooth

by bacteria producing acids after the host has consumed carbohydrates. As soon as the

biofilm on the tooth surface is removed mechanically by brushing, a thin layer of pellicle

starts to form from the saliva. To this pellicle, bacteria can attach and a dental plaque is

formed. The bacteria start to produce acids as soon as there are carbohydrates available and

the acids decrease the pH in the oral environment. When the intraoral pH decreases below 5.5,

protons and hydrogen ions diffuse from the saliva into the porous surface of the highly

mineralized enamel which contains up to 99% Ca10(PO4)6(OH)2 (hydroxyapatite) and a

demineralization starts (Fejerskov et al., 2016).

When fluoride is present in the oral environment, the fluoride ion attaches to the surface of

the teeth and the remineralization process begins. Instead of the natural surface of the enamel

with hydroxyl apatite, a surface more resistant to pH reduction starts to form, which is known

as fluoride apatite.

Fluoride

Fluoride is the 13th most common ion of all the elements and is a negatively charged ion,

which is highly reactive. Naturally it appears as a gas and is found in rocks, water, minerals,

soil and also naturally in some foods and beverages, for example in tea and dairy products

like milk. The ion is one of the most reactive elements and because of its reactivity, the ion

never occurs free in nature and usually occurs as compound with for example sodium

(sodiumfluoride as in tooth paste) (Fejerskov et al., 1996).

4

Fluoride in toothpaste was introduced in the late 1960´s. Fluoride works in a complicated way

on the structure of enamel, preventing the minerals of the dental hard tissue to leave the

structure (Tandläkartidningen, 2015). Aside from brushing twice a day with toothpaste, it is

the most common daily used product for preventing caries (Sun et al., 2017). Intake of

fluoride can also be administrated in forms of gels, mouth rinses, tablets or varnishes.

Daily use of fluoride toothpaste is an effective way of preventing caries, but because of the

risk of fluorosis from the stage of primary to permanent dentition it is not recommended to

use the same amount of fluoride in children as for adults (Fejerskov et al., 2015). In Sweden a

smear layer of toothpaste with the concentration of 1000 ppm sodiumfluoride is

recommended for children between 6-24 months and a pea sized amount for children between

2-6 years due to the reduced ability of swallowing reflex. Many countries recommend even

lower doses, as a maximum of around 500 ppm for children (Ming Jiang et al, 2014). In

Sweden we follow the recommendations from EAPD, and if these recommendations are

followed, there is no risk calculated (EAPD, 2009). It is also important to make sure that

children are capable of spitting out the toothpaste after brushing (SBU, 2003).

Fluoride and dental caries

The population in Sweden is comparatively healthy regarding the caries disease, at 6 years of

age, about 20-25 percent of the population have caries needed to treat (Socialstyrelsen, 2017).

To help children who have caries, Public dental health care in Sweden has programs that

provide extra support in the form of professional cleaning, shorter revision intervals,

carbohydrate restriction and fluoride products as complement. The fluoride has a dose

response effect and based on the individual risk of developing caries lesions, risk patients can

be recommended to use a higher concentration of fluoride. A study in-situ shows that

working according to the previously mentioned high-risk program, the caries reducing effect

is up to 44% (Hausen et al., 2007). Another study indicates that professional care as fluoride

varnish application at least twice a year has a caries reductive effect on the primary dentition

as a complement to daily use of toothpaste (SBU, 2002). However, there is a study from

Stockholm that shows that application of fluoride varnish does not reduce caries among

toddlers (Anderson et al., 2017).

5

Study findings showed that brushing teeth with fluoride toothpaste two times or more reduces

the risk of caries by 20-30% (O'Mullane et al., 1997) and what is also interesting according to

another study is that brushing daily with a non-fluoride toothpaste gave no detectable effect in

controlling caries (Koch and Lindhe, 1970). However one systematic review shows that the

concentration of fluoride in toothpaste is important too. The study adressed toothpastes with

higher fluoride concentration (1450 ppm) and toothpastes with lower flouride concentration

(440 ppm). Toothpastes with higher concentration showed a statistically significantly lower

mean dmft in a population with normal caries risk compared with the results of the control

group, while no statistically significant difference could be proven with the toothpaste with

lower concentration compared to the control group in mean of dmft (Timmothy, 2014). The

overall conclusion is that fluoridated toothpaste is easy to implement, relatively cheap and

when administrated with mechanical help from the toothbrush, it is one of the most effective

methods to prevent the caries disease (SBU, 2002). The mechanical part of the toothbrush

removes the plaque on the tooth in order to make the fluoride from the toothpaste to bind

easier to the plaque-free dental surface.

Scepticism to fluoride use for dental health

Studies has shown that fluorosis, which is a degenerative disease don’t just affect the teeth,

but it can also affect the body systemically such as skeletal fluorosis (Seraj et al., 2009). It has

also been suggested in other studies that relationship exists between lower intelligence levels

in children’s and high levels of fluoride in water (Duan et al., 2018). Apart from lower

intelligence levels, it has also been noticed that physical and mental problems has been

associated with intake of fluoride (Seraj et al., 2009). However, to reach levels that are

potentially damaging one would need large doses of high fluoridated water. These doses are

not reachable with the fluoride levels in water naturally in Sweden (Gelinas et al., 2014).

Broadbent et al (2015) showed no correlation between fluoride levels in the water and

cognitive development.

6

Aim

The aim of the present study was to evaluate the perception of fluoride use among parents to a

group of children and their habits of fluoride distribution to their children.

This was evaluated with an additional questionnaire to the original study (OMIC - Oral

Microbiota In Children) where the parents answered questionnaires containing questions

about fluoride. A second aim of the study was to see the effect of not using fluoride among

children with caries.

Hypothesis

Our hypothesis is that the lack of information regarding efficacy and safety of fluoride

toothpaste over the years and the impact from social media has resulted in lower use of

fluoride toothpaste to children because of the impact from the parents.

7

Material and Methods

Participants

The children are participants in an ongoing research study, OMIC (Oral Microbiota in

children). At the 5 year inspection in the main study the parents were asked to fill in yet

another a questionnaire for the fluoride sub study. The parents were given verbal and written

information and gave their consent to participate.

200 children have been followed since birth (2 days of age) and at different ages samples have

been collected (saliva and plaque). At the age 3 and 5 years a dental examination took place

as part of the routine examination at the Public dental health service. In the main study, the

parents have answered questionnaires at 3 months, 18 months, 3 years and 5 years. At the age

of 5 years the questionnaire was expanded with the present questionnaire about fluoride,

which parents to 117 children agreed to attend.

The questionnaire

Questions about the parents own use of fluoride products and their view of risks with using

these products were asked. Then questions of tooth brushing, tooth paste and use of fluoride

products for the child was included. See questionnaire as appendix 1.

Ethical considerations and reflection The original project, OMIC (Oral Microbiota In Children), was approved by the Regional

Ethical Review board at Umeå University (Dnr:2011-90-31M). This side-study has been

approved from the Local ethical committee, Institution of Odontology, Umeå University. All

the questionnaires that has been collected were decoded and the background data cannot be

traced to a specific person. All the information that has been collected in the project will be

handled in such way that no unauthorized person can take part of and trace the information

back to the participants. We cannot see any risk with answering the questions, and answering

was completely voluntary.

8

Statistics

The data was collected through extradition of fluoride questionnaires to the parents of

the children who participated in OMIC. The data collection consists of questionnaires answers

and background data from the OMIC study. All data is collected in paper format and then

transferred to Excel, the data is then analyzed and transferred to the statistical program SPSS

(IBM statistics 23, Chicago, USA) and for statistical analyzes we used Fisher´s Exact test and

Pearson Chi-Square, this to identify statistically significant differences, and the statistical

level of significance was set to 0.05. All the collected data is decoded and all the participants

are anonymous.

Literature search

To find literature we searched with The PubMed database and a number of separate searches

were made. As the first search, that included “fluoride toothpaste”, resulted in 2716 articles

and the second search “early childhood caries”, “children”, “fluoride”, “tooth brushing”

resulted in 1436 articles. To find relevant articles selected abstracts were read and articles

were also collected from the reference lists of the articles. We also used relevant textbooks for

the topic in which other sources of information were found.

9

Results

Parents of 117 children answered the questionnaire. The gender distribution for the children

was 50.4% boys and 49.6% girls. The mean age of the children was 5 years.

All parents who answered the questionnaires used fluoride toothpaste when brushing their

own teeth and 31% used other products that contain fluoride, as fluoride rinses, fluoride

chewing gum etc.

In table 1, there is higher caries prevalence among children who brush their teeth themselves

compared to those who get help from their parents (data collected from OMIC), though the

difference was not statistically significant.

In table 2, where data was collected from the original study OMIC, children who have a high

frequency of sugar intake (multiple days a week) have a higher amount of caries compared to

the children who do not eat sweets at all (not statistically significant difference).

When it comes to the question about the risk with using fluoride, 42 of the parents had heard

or read about it. Most of them from internet, but also from friends (table 3).

When we asked the parents if they were using fluoride toothpaste, 100% answered that they

did use it. Furthermore, the questionnaires showed that approximately 10% of the parents had

hesitated to use fluoride toothpaste.

70% of the parents started using the fluoride toothpaste for their children when the first tooth

was erupted and about 18% of the parents started using fluoride toothpaste when the child

was able to spit out, at about 2 years of age.

In the questionnaires we also asked how much toothpaste that was applied on the toothbrush.

The answers showed that about 75% used a toothpaste amount equal to the child's little

fingernail. About 20% used an amount equivalent to about 1 cm (half the toothbrush). The

remaining 5% used a toothpaste amount corresponding to about 2 cm of the toothbrush.

10

Discussion

The present questionnaire-based study was undertaken to evaluate the habits and perception

of fluoride use among parents and how they distribute the fluoride to their children. In our

study the majority of the parents used fluoride toothpaste for their child, only five of 111 used

non-fluoride products.

The hypothesis was that the lack of information regarding efficacy and safety of fluoride

toothpaste over the years and the impact from social media has resulted in lower use of

fluoride toothpaste to children because of impact from the parents, though this could not be

shown in our study and our hypothesis was rejected.

A majority of the parents help their children to brush their teeth but many children also brush

themselves. A weakness of the questionnaire is that we do not know to what extent the

parents helped their children. The alternatives were always, once a day and once a week. The

recommended age for interrupting adult surveillance of tooth brushing is 10 years but few

parents follow that recommendation. The reason that the limit is set at this age is that the

child's ability to handle the toothbrush is usually developed and they understand why they

have to brush in relation to diet and caries. There are certainly several reasons why parents

stop helping their children so early. We do not think it is about ignorance, but rather that the

toothbrushing is a big challenge in everyday life for many families. Parents own oral habits

are also reflected in the children, which is of a great importance to take into consideration.

70% of the parents started using fluoride toothpaste for their children when the first tooth was

erupted. The relatively high percentage can be related to the information the guardian receives

at the Child care center, where dental personel give lessons about why oral health is

important.

In this study we did not notice any statistically significant differences in the occurence of

dental caries among those who did use fluoride toothpaste compared with those who did use

non-fluoride toothpaste. One reason could be the skewed numbers of using non-fluoride and

fluoride products, another reason may be the homogeneous population that this study group

consists of, and in order to get a result that is fair, a population with higher incidence of caries

would be needed.

There are also other possible explanations why we not noticed any statistically significant

differences in the occurence of dental caries, for example it may be due to additative sources,

from which the children are exposed to fluoride, through water, foods etc.

11

Other studies have proven that there is a correlation between parents level of education and

the child´s compliance to oral hygiene (Cianetti et al., 2017). Educated parents were giving

their children far more praise to encourage desirable behaviour and more effective commands

to obtain compliance . Lack of ability of parents to help their children with tooth brushing

could be related to the occurence of caries, which likely is the result as children under the age

of 10 years do not brush properly on their own (Isaksson et al.,, 2018).

Parents have, in the last decade, demonstrated an increasing scepticism towards the use of

fluoride toothpaste (Tandläkartidningen, 2015), this may be because of the big influence from

different media sources. How people use Facebook and other social media in reaching

information in the area of dentistry have been studied but need to be deeper understood (

Holden 2017). The access to social media has increased because most people carry their

phones almost everywhere, which makes it easier to communicate through social platforms

such as Facebook, Instagram, Twitter etc.

Not only communication takes place through social media, but also discussions and the

expression of personal opinions which can affect individuals strongly through different

platforms. This affect people’s minds, both positively and negatively. For example, parents’

worries about not using fluoride containing toothpastes are based on negative influence from

today’s Internet, TV and newspapers, where news that fluoride is harmful for children

circulates (Tideström K, 2015; Milne et al., 2017)..Therefore, it is very important to do this

kind of study because there are many flourishing rumors when it comes to the use of fluoride,

and by clarifying the situation with scientific knowledge and source references, it could be

possible to disprove the rumors in the social media. Furthermore, we investigated why the

parents did not use fluoridated toothpaste to their children and 3% responded that it was due

to general health risks, 97% did not answer the question. The high proportion that did not

respond to the question is due to the fact that they use fluoride toothpaste. The questionnaires

showed that the toothpaste used instead of fluoride toothpaste was Jack N Jills, which is a

fluoride free toothpaste for children that can be bought in food stores.

Another factor that needs to be considerated is the fact that the parents have participated in the

study for a long time and knows what to answer to make it sound good, which can give false

results. This is a conclusion that have been stated in many studies before (Martins et al.,

2011).

12

In conclusion this study shows that, though parental help with toothbrushing is recommended

until about 10 year of age, many of the 5 year old children brush their teeth themselves, with

or without adult surveillance. Interestingly, all parents use fluoride for their own dental

maintenance, but not for their children. In the present group of children, there was no

statistically significant differences in the development of dental caries among those who used

fluoride toothpaste compared to those who used non-fluoride toothpaste. In order to get better

knowledge of the reasons for parents not to use fluoride products for their children, more

extensive studies with heterogeneous populations are needed.

13

Acknowledgements

We are thankful to the participating children and their parents and Pernilla Lif Holgerson for

her help and support during this process.

14

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16

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17

Table 1. Caries prevalence (taken from OMIC) compared to brushing methods, motivation and fluoride product

Caries Yesa No p-Valueb

Total 13 104

Gender Boys 8 51 Girls 5 53

Parental

toothbrushing 5 35 0.767

Children who brush themselves (but with

adult surveillance)

8 67

Motivated children 12 84 0.431 Non motivated

children 1 16

F-(Toothpaste) 0 5 0.417 F+(Toothpaste) 13 98

Rinse with fluoride (parents)

4 18 0.274

Not rinsing (parents) 9 82

a Included non- cavitated and cavitated lesions b p-value <0.05 significant staitistically difference. Tested with Chi square and Fishers test

18

Table 2. Cariesprevalance related to consumption (reported intakes) of functional food and candy (This Data is collected from the study Oral Microbiota in children)

Diet Caries Yesa No Total Milk No use 0 7 7 Once a week 1 12 13 More than once a week 12 84 96 Cheese No use 2 16 18 Once a week 5 32 37 More than once a week 6 55 61 Candy No use 0 9 9 Once a week 11 77 88 More than once a week 2 18 20

a Included non- cavitated and cavitated lesions

19

Table 3. Sources from where information (heard/read) is taken about the risk of fluoride

Frequency Percent Have heard / read 42 35

Have not heard / read 72 62 Did not answer 3 4

Sources Frequency Percent Internet 25 21

Internet + friends 8 7 Newspaper 4 3

From friends 3 3 More than 3 sources* 2 2

*Internet, newspaper, TV/radio and from friends

20

Attachment 1

OMFLUOR

Viärtvåtandläkarstudentersomgörenenkätstudieomhurföräldrarserpåanvändningavfluortandkrämochfluorprodukter.Fluorharunderenlångtidanväntsitandkrämochandraprodukterförattförebyggahålitänderna.Detfinnsettstarktvetenskapligtunderlagförattdagliganvändningavtandkrämmedfluoräreffektivtförattförebyggahålitändernahosbarnochungdomar.Viärintresseradeavattvetahurnisomföräldrarserpåanvändningenavfluor

tillErabarn.

Viskulleuppskattaomniharmöjlighetattsvarapånedanståendefrågor.

Tackpåförhand!

KaysarPairo&ShilanRustem

Frågortilldigsomförälder

1.Använderdufluortandkräm? Ja! Nej!

2.Hardunågongångfunderatpåattinteanvändafluortandkräm?Ja! Nej!

3.Använderdunågotannatpreparatmedfluor? Ja! Nej!

Omja,vilketochhurofta?_____________________________________________________

Kod:_____

21

4.Harduläst/hörtomnågonavdeartiklarsomförekommitomriskenmedfluor?

Ja!Nej!

Omja,varharduläst/hörtdetta?

Internet!

Vetenskapligtidskrift!

Tidning!

Tv/radio!

Avvänner!

Frågorsomgällerditt/dinabarn:

5.Vemborstardittbarnständer?

Vuxen!

Bådebarnetsjälv&vuxen!

Barnetborstarsjälv!

6.Närbörjadeduanvändafluortandkrämtillditt/dinabarn?

Använderintefluortandkräm!

Närförstatandenkomfram!

Närhenkundespottaut,vidca2år!

7.Ungefärhurmyckettandkrämsätternipåtandborstenvidtandborstningförert5-årigabarn?

enklickstorsombarnetslillfingernagel!

ca1cm(halvatandborsten)!

ca2cm(helatandborsten)!

22

8.Användernientandkrämsomärspecielltanpassadförbarn? Ja!Nej!

Omja,varförharnivaltden?

Mittbarnföredrarsmaken!

Mittbarnfickväljavadviskulleköpa!

Rekommendationavtandvårdspersonal!

Annananledning:________________________________

9.Omduinteanvänderfluortandkräm,avvilkenanledningundvikerdudettatilldittbarn?

Allmänhälsorisk!

Fluorskadorpåtänderna!

Riskförframtidabeståendeskadorpåskelettet!

10.Omduinteanvänderfluortandkräm,vilkentandkrämanvänderdu?

_____________________________________________________________________