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Total fluoride intake higher in subjects of low socioeconomic status
A RTICLE
THERAPY
Total fluoride intake higher in subjects of low socioeconomic status
A NALYSIS & E VALUATION
Franco AM, Martignon S, Saldarriaga A, Gonza´lez MC, Arbelaez´ MI, Ocampo A, et al. Total fluoride intake in children aged 22-35 months in four Colombian cities. Community Dent Oral Epidemiol 2005;33(1):1-8.
Original Article
3
Level of Evidence
What are the levels of combined fluoride intake in children aged 22 to 35 months in 4 Colombian cities, how do they compare to the so-called ‘‘optimal’’ level of intake, and do they differ by socioeconomic status (SES)?
Purpose/Question
Government
Source of Funding
Cross-sectional study
Type of Study/Design
Summary SUBJECTS The subjects were 118 children of both genders (no distribution given) aged 22 to 35 months from the 4 cities of Bogota´, Medellı´n, Manizales, and Cartagena, Colombia. Children had similar, low-fluoride drinking water supplies (0.05-0.08 ppm). They attended Colombian Family Well-being Day-care Centers if of low socioeconomic status (LSES) or private day-care centers if high SES (HSES). For LSES, it was a stratified, cluster sample of children, while for HSES, it was a convenience sample. The dates during which the study was conducted are not provided.
J Evid Base Dent Pract 2005;5:209-10 D 2005 Mosby, Inc. All rights reserved. doi:10.1016/j.jebdp.2005.09.014
EXPOSURE Estimated fluoride intake from foods and beverages was determined using a ‘‘duplicate plate’’ technique. A duplicate sample was obtained from all ingested foods and beverages at day-care centers, homes, restaurants, or relatives’ homes on 2 weekdays and 1 weekend day for each child. Collection was done by auxiliary personnel at day care and parents/person in charge otherwise, after appropriate training and supervision of first home duplication. Fluoride intake from toothpaste was estimated by (1) determining amounts placed by weighing the toothbrush before and after placement; (2) fluoride level of toothpaste was determined with microdiffusion analysis (with appropriate internal and external quality control); (3) amount of noningested toothpaste fluoride calculated from recovered rinsing solution (including
209
remnants on face/clothes recovered with facial tissue); (4) amount ingested calculated as amount used minus amount recovered; and (5) amount ingested multiplied by brushings per day to estimate daily fluoride intake from toothpaste.
MAIN OUTCOME MEASURE Combined fluoride intake expressed as mg F/kg body weight (BW)/day. MAIN RESULTS The estimated mean (F SD) total daily fluoride intake (TDFI) was 0.11 F 0.09 mg/kg BW. Mean levels by city were 0.11 (F 0.10), 0.14 (F 0.12), 0.10 (F 0.07), and 0.07 (F 0.16) mg F/kg BW/day in Bogota´, Medellı´n, Manizales, and Cartagena, respectively. Low SES mean intake by city was 0.07, 0.11, 0.16, and 0.21 mg F/kg BW versus 0.06, 0.07, 0.08, and 0.09 mg F/kg BW for high SES. Overall, LSES children had significantly higher mean daily intake than did HSES (0.14 F 0.10 vs 0.07 F 0.05 mg F/kg BW, respectively.) In Medellı´n and Bogota´, but not Cartagena and Manizales, LSES children’s intake was significantly greater than for HSES children. Approximately 72% (LSES) and 39% (HSES) had estimated intake exceeding the so-called optimal range of 0.05 to 0.07 mg F/kg BW/day. LSES children overall used toothpaste with significantly more fluoride than HSES children (1408 F 357 vs 1090 F 452 ppm, respectively). About 70% of toothpaste used was ingested. In 2 of the 4 cities, LSES children had significantly more toothpaste used then did HSES children. Overall, more than 80% reportedly brushed with fluoride toothpaste 2 or more times daily. Toothpaste accounted for about 70% of total fluoride intake (mean of 66% for HSES vs 76% for LSES), followed by foods (24%) and beverages (b6%). CONCLUSIONS Mean intake for children from 3 cities exceeded the ‘‘optimal range,’’ with those in the fourth averaging the upper bound of the optimal range; LSES children ingested significantly more fluoride than did HSES children; and about 70% of estimated intake was from toothpaste. Due to elevated risks of dental fluorosis from these elevated intakes at critical times of tooth development,
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Franco et al
health authorities should promote appropriate use of fluoridated toothpastes, including discouraging use of 1500 ppm fluoride toothpaste in children younger than age 6, emphasizing use of very small ‘‘pea-size’’ amounts of toothpaste and expectoration of excess, and marketing of low fluoride toothpastes (b 500 ppm) for young children. These may be especially important for children of LSES.
Commentary and Analysis This study provides valuable information about estimated fluoride intake among day-care attendees in Colombia. The study is well done overall and assesses well the major sources of intake. The very high estimated mean intake levels do suggest that levels are too high. However, some caution is needed because there was no validation evident for the toothbrushing frequency data. Should the true frequency of brushing be lower, then estimated intake would also be lower. Linkage to future examinations for dental fluorosis also will be valuable. Very little perspective about the use and importance of salt fluoridation is provided. The mean food fluoride intake is much lower than mean estimated toothpaste fluoride intake, but should be characterized further. For example, do those with higher food fluoride intake receive it primarily from the salt fluoridation program or ‘‘naturally’’ (eg, infant chicken foods mechanically deboned, in seafoods? Are the fluoridated salt distribution and use patterns similar across the 4 cities?). The results do strongly suggest that total and toothpaste fluoride ingestion are elevated in these 4 Colombian cities and that efforts should be taken to reduce such ingestion. These concerns should be reduced through a multifaceted approach, as outlined by the authors. However, such efforts probably should be reevaluated and focused further based on additional study of dental fluorosis patterns and salt fluoridation. Reviewer: Steven Levy, DDS, MPH University of Iowa College of Dentistry Department of Preventive and Community Dentistry Iowa City, Iowa
Journal of Evidence-Based Dental Practice December 2005
THERAPY
Total fluoride intake higher in subjects of low socioeconomic status
A NALYSIS & E VALUATION
Franco AM, Martignon S, Saldarriaga A, Gonza´lez MC, Arbelaez´ MI, Ocampo A, et al. Total fluoride intake in children aged 22-35 months in four Colombian cities. Community Dent Oral Epidemiol 2005;33(1):1-8.
Original Article
3
Level of Evidence
What are the levels of combined fluoride intake in children aged 22 to 35 months in 4 Colombian cities, how do they compare to the so-called ‘‘optimal’’ level of intake, and do they differ by socioeconomic status (SES)?
Purpose/Question
Government
Source of Funding
Cross-sectional study
Type of Study/Design
Summary SUBJECTS The subjects were 118 children of both genders (no distribution given) aged 22 to 35 months from the 4 cities of Bogota´, Medellı´n, Manizales, and Cartagena, Colombia. Children had similar, low-fluoride drinking water supplies (0.05-0.08 ppm). They attended Colombian Family Well-being Day-care Centers if of low socioeconomic status (LSES) or private day-care centers if high SES (HSES). For LSES, it was a stratified, cluster sample of children, while for HSES, it was a convenience sample. The dates during which the study was conducted are not provided.
J Evid Base Dent Pract 2005;5:209-10 D 2005 Mosby, Inc. All rights reserved. doi:10.1016/j.jebdp.2005.09.014
EXPOSURE Estimated fluoride intake from foods and beverages was determined using a ‘‘duplicate plate’’ technique. A duplicate sample was obtained from all ingested foods and beverages at day-care centers, homes, restaurants, or relatives’ homes on 2 weekdays and 1 weekend day for each child. Collection was done by auxiliary personnel at day care and parents/person in charge otherwise, after appropriate training and supervision of first home duplication. Fluoride intake from toothpaste was estimated by (1) determining amounts placed by weighing the toothbrush before and after placement; (2) fluoride level of toothpaste was determined with microdiffusion analysis (with appropriate internal and external quality control); (3) amount of noningested toothpaste fluoride calculated from recovered rinsing solution (including
209
remnants on face/clothes recovered with facial tissue); (4) amount ingested calculated as amount used minus amount recovered; and (5) amount ingested multiplied by brushings per day to estimate daily fluoride intake from toothpaste.
MAIN OUTCOME MEASURE Combined fluoride intake expressed as mg F/kg body weight (BW)/day. MAIN RESULTS The estimated mean (F SD) total daily fluoride intake (TDFI) was 0.11 F 0.09 mg/kg BW. Mean levels by city were 0.11 (F 0.10), 0.14 (F 0.12), 0.10 (F 0.07), and 0.07 (F 0.16) mg F/kg BW/day in Bogota´, Medellı´n, Manizales, and Cartagena, respectively. Low SES mean intake by city was 0.07, 0.11, 0.16, and 0.21 mg F/kg BW versus 0.06, 0.07, 0.08, and 0.09 mg F/kg BW for high SES. Overall, LSES children had significantly higher mean daily intake than did HSES (0.14 F 0.10 vs 0.07 F 0.05 mg F/kg BW, respectively.) In Medellı´n and Bogota´, but not Cartagena and Manizales, LSES children’s intake was significantly greater than for HSES children. Approximately 72% (LSES) and 39% (HSES) had estimated intake exceeding the so-called optimal range of 0.05 to 0.07 mg F/kg BW/day. LSES children overall used toothpaste with significantly more fluoride than HSES children (1408 F 357 vs 1090 F 452 ppm, respectively). About 70% of toothpaste used was ingested. In 2 of the 4 cities, LSES children had significantly more toothpaste used then did HSES children. Overall, more than 80% reportedly brushed with fluoride toothpaste 2 or more times daily. Toothpaste accounted for about 70% of total fluoride intake (mean of 66% for HSES vs 76% for LSES), followed by foods (24%) and beverages (b6%). CONCLUSIONS Mean intake for children from 3 cities exceeded the ‘‘optimal range,’’ with those in the fourth averaging the upper bound of the optimal range; LSES children ingested significantly more fluoride than did HSES children; and about 70% of estimated intake was from toothpaste. Due to elevated risks of dental fluorosis from these elevated intakes at critical times of tooth development,
210
Franco et al
health authorities should promote appropriate use of fluoridated toothpastes, including discouraging use of 1500 ppm fluoride toothpaste in children younger than age 6, emphasizing use of very small ‘‘pea-size’’ amounts of toothpaste and expectoration of excess, and marketing of low fluoride toothpastes (b 500 ppm) for young children. These may be especially important for children of LSES.
Commentary and Analysis This study provides valuable information about estimated fluoride intake among day-care attendees in Colombia. The study is well done overall and assesses well the major sources of intake. The very high estimated mean intake levels do suggest that levels are too high. However, some caution is needed because there was no validation evident for the toothbrushing frequency data. Should the true frequency of brushing be lower, then estimated intake would also be lower. Linkage to future examinations for dental fluorosis also will be valuable. Very little perspective about the use and importance of salt fluoridation is provided. The mean food fluoride intake is much lower than mean estimated toothpaste fluoride intake, but should be characterized further. For example, do those with higher food fluoride intake receive it primarily from the salt fluoridation program or ‘‘naturally’’ (eg, infant chicken foods mechanically deboned, in seafoods? Are the fluoridated salt distribution and use patterns similar across the 4 cities?). The results do strongly suggest that total and toothpaste fluoride ingestion are elevated in these 4 Colombian cities and that efforts should be taken to reduce such ingestion. These concerns should be reduced through a multifaceted approach, as outlined by the authors. However, such efforts probably should be reevaluated and focused further based on additional study of dental fluorosis patterns and salt fluoridation. Reviewer: Steven Levy, DDS, MPH University of Iowa College of Dentistry Department of Preventive and Community Dentistry Iowa City, Iowa
Journal of Evidence-Based Dental Practice December 2005