ADA dietary fluoride supplement schedule: the daily dose by the child's age and the fluoride in the water, tested before you write it

What it says#

The schedule is one small table, and almost every cell in it is the word None. Dosing is based on the natural fluoride concentration of the child's drinking water and the age of the child. Under 0.3 ppm fluoride the doses run birth to 6 months none, 6 months to 3 years 0.25 mg a day, 3 to 6 years 0.50 mg a day, 6 to 16 years 1.0 mg a day. At 0.3 to 0.6 ppm the first two bands are none, then 0.25 mg from 3 to 6 years and 0.50 mg from 6 to 16 years. Above 0.6 ppm every band is none. The ADA prints two conversions with the table: 1.0 part per million equals 1 milligram per liter, and 2.2 mg of sodium fluoride contains 1 mg of fluoride ion.

The table is not the recommendation on its own. The ADA's chairside guide, drawn from the same 2010 report, opens by telling practitioners to evaluate all potential fluoride sources and conduct a caries risk assessment before prescribing, then states three recommendations: for children at low caries risk, dietary fluoride supplements are not recommended and other sources of fluoride should be considered as a caries preventive intervention; for children at high caries risk, supplements are recommended according to the schedule; and when supplements are prescribed they should be taken daily to maximize the caries prevention benefit. Each cell of the table carries an evidence grade, and the grades are worth noticing. The four dosing cells that produce an actual milligram figure are graded B, based on higher levels of evidence. Every None cell, and all three recommendations above, are graded D, based on lower levels of evidence or expert opinion.

The conditions the ADA attaches to the table are, in its own words, that if fluoride level is unknown the drinking water should be tested for fluoride content before supplements are prescribed and the local or state health department contacted for testing; that all sources of fluoride should be evaluated with a thorough fluoride history; that patient exposure to multiple water sources may complicate proper prescribing; that ingestion of higher than recommended levels of fluoride by children has been associated with an increased risk of mild dental fluorosis in developing, unerupted teeth; and that long-term daily compliance is required to obtain the benefit. The ADA spells out where the other water comes from: the workplace, school or day care, bottled water, filtered water, and processed beverages and foods prepared with fluoridated water. Supplements are not recommended for children living in a community with adequate levels of fluoride in the water supply.

Mechanically, tablets and lozenges are manufactured at 1.0, 0.5 and 0.25 mg fluoride, most contain sodium fluoride, and tablets and lozenges are meant to be chewed or sucked for one to two minutes before swallowing to maximize the topical effect. For infants, supplements come as a liquid used with a dropper. All dietary fluoride supplements must be prescribed by a dentist or physician. For children under 6, the ADA says health care providers should weigh the risk for tooth decay without supplements, the decay prevention supplements offer, and the potential for dental fluorosis, and that consideration of the child's other sources of fluoride, especially drinking water, is essential in determining that balance. Parents and caregivers are to be told about both the benefit and the fluorosis risk.

Two outside bodies line up behind the same idea from slightly different angles. The US Preventive Services Task Force, in its December 7, 2021 recommendation on preventing dental caries in children younger than 5, gives a B grade to prescribing oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride, with deficiency defined as less than 0.6 ppm F. The American Academy of Pediatric Dentistry reprints the identical table in its Fluoride Therapy best practice, describing supplements as effective and worth considering for children at high caries risk who drink water below 0.6 ppm F, and adds a caution the ADA page does not: the schedule was last revised in the early 1990s and has not been adjusted since municipal water was standardized or since fluoridated toothpaste from the first tooth was promulgated, so caution is indicated for children under age 6.

Who it applies to#

Children from 6 months through 16 years who are at high caries risk and whose primary drinking water is fluoride deficient. It reaches the dentist or physician who signs the prescription, the hygienist and assistant who take the water history, and the front desk staff who field the parent's question about whether the bottled water at home counts.

It does not apply to children at low caries risk, where the ADA panel recommends against supplements outright. It does not apply to any child whose water is above 0.6 ppm, or to any infant under 6 months, at any water level. And it does not cover toothpaste, varnish, gels, rinses or silver diamine fluoride; the amounts and ages for those sit in the AAPD fluoride therapy entry in this directory, aapd-fluoride-therapy-best-practice-2023, and this entry deliberately does not repeat them.

What changed#

The numbers have not changed since 2010, and the underlying schedule has not been substantially revised since the early 1990s. What changed around it is the water. In April 2015 the US Public Health Service standardized the recommended community level at 0.7 ppm, and the ADA states plainly that its dietary fluoride supplement recommendations remain unchanged in light of that, and that the 2015 recommendation does not change the Council on Scientific Affairs systematic review, clinical recommendation and chairside guide released in 2010. The ADA also notes the majority of bottled waters contain less than 0.3 ppm fluoride, and that reverse osmosis and distillation systems can reduce fluoride in a home supply while carbon and charcoal filtration do not.

Where the source is#

The link under the title is the ADA's Oral Health Topics page, Fluoride: Topical and Systemic Supplements, last updated June 14, 2023, which prints the table under the heading Fluoride Supplement (Tablets and Drops) Dosage Schedule 2010 (Approved by the American Dental Association Council on Scientific Affairs) along with the Important Considerations list. The two-page chairside guide linked in the downloads, adapted from the 2010 JADA report with the ADA's permission, carries the same table with its evidence grades and the three clinical recommendations, and states that it may be used, copied and distributed for non-commercial purposes without prior approval from the ADA. The AAPD's Fluoride Therapy PDF reprints the table with its own note on why it has not been revised. The underlying JADA article, cited above, is behind the journal's paywall; its abstract on PubMed was read for this entry and states the panel's conclusion that supplements should be prescribed only for children who are at high risk of developing caries and whose primary source of drinking water is deficient in fluoride.