The U.S. Food and Drug Administration (FDA) recently announced it will permit bottlers to make claims that fluoridated water may reduce the risk of tooth decay. The FDA's decision means bottlers may now claim what dentists have long known -- that optimally fluoridated water helps prevent tooth decay.

However, the Minnesota Dental Association wants to remind parents that this health claim is not intended for use on bottled water marketed for infants, for whom lesser amounts of fluoride are appropriate. "Parents who are using baby formula in the first year of their child's life want to closely evaluate the amount of fluoride in the water," said Dr. Dick Wiberg, President of the Minnesota Dental Association, whose practice is located in St. Paul.

A proper amount of fluoride is essential to help prevent tooth decay. But fluoride intake above optimal levels creates a risk for enamel (dental) fluorosis, which affects teeth during the development stage before emerging through the gums. Enamel fluorosis is not a disease but affects the way teeth look. Most cases of fluorosis result in faint white lines or streaks on tooth enamel that are not readily apparent to the affected individual or the casual observer.

Recent studies(1) have raised the possibility that infants could receive higher than optimal amounts of fluoride through liquid concentrate or powdered baby formula that has been mixed with tap water, and thus become more susceptible to enamel fluorosis. While more research is needed before definitive recommendations can be made on fluoride intake by bottle-fed infants, the American Dental Association (ADA) has issued this interim guidance for parents and other caregivers who are understandably cautious about what is best for their children.

Infant Formula

-- Breast milk is widely acknowledged as the most complete form of nutrition for infants. The American Academy of Pediatrics recommends human milk for all infants (except for the few for whom breastfeeding is determined to be harmful).

-- For infants who get most of their nutrition from formula during the first 12 months, ready-to-feed formula is preferred to help ensure that infants do not exceed the optimal amount of fluoride intake.

-- If liquid concentrate or powdered infant formula is the primary source of nutrition, it can be mixed with water that is fluoride free, or contains low levels of fluoride to reduce the risk of fluorosis. Examples are water that is labeled purified, demineralized, deionized, distilled or reverse osmosis filtered water. Many grocery stores sell these types of drinking water for less than $1 per gallon.

-- The occasional use of water containing optimal levels of fluoride should not appreciably increase a child's risk for fluorosis.

Parents and caregivers should consult with their pediatrician, family physician or dentist on the most appropriate water to use in their area to reconstitute infant formula. Ask your pediatrician or physician whether or not water used in infant formula should first be sterilized.

The Minnesota Dental Association is the voice of dentistry in Minnesota, representing 83% of practicing dentists. It is committed to the highest standards of oral health and access to care for all Minnesotans. You can learn more at


The Minnesota Dental Association (MDA) offers this additional guidance on other sources of fluoride for young children, each of which is beneficial under the circumstances described below:

Fluoride Toothpaste

Parents and caregivers should ensure that young children use an appropriate size toothbrush with a small brushing surface and only a pea-sized amount of fluoride toothpaste at each brushing. Young children should always be supervised while brushing and taught to spit out rather than swallow toothpaste. Many children under age six have not fully developed their swallowing reflex and may be more likely to inadvertently swallow fluoride toothpaste. Unless advised to do so by a dentist or other health professional, parents should not use fluoride toothpaste for children less than two years of age.

Fluoride Mouthrinse

Fluoride mouthrinses have been shown to help prevent tooth decay for both children and adults. However, the ADA does not recommend use of fluoride mouthrinses for children under six years of age, unless recommended by a dentist or other health professional. Children under age six may be more likely to inadvertently swallow fluoride mouthrinse.

Dietary Fluoride Supplements

Children should only receive dietary supplemental fluoride tablets or drops as prescribed by their physician or dentist based on the dietary fluoride supplement schedule approved by the ADA, the American Academy of Pediatrics and the American Academy of Pediatric Dentistry. Supplements are not recommended for children under six months of age.

Naturally Occurring Fluoride in Water

The optimal fluoride level in drinking water is 0.7 - 1.2 parts per million, an amount which has been proven beneficial in reducing tooth decay. Naturally occurring fluoride may be below or above these levels in some areas. Under the Safe Drinking Water Act, the U.S. Environmental Protection Agency requires notification by the water supplier if the fluoride level exceeds 2 parts per million. People living in areas where naturally occurring fluoride levels in drinking water exceed 2 parts per million should consider an alternative water source or home water treatments to reduce the risk of fluorosis for young children.

The MDA supports community water fluoridation as the single most effective public health measure to prevent tooth decay. It is a powerful strategy to reduce disparities in tooth decay among different populations and is more cost-effective than other forms of fluoride treatments or applications. Fluoridation is endorsed by the Centers for Disease Control and Prevention, which has listed community water fluoridation as one of 10 great public health achievements of the 20th century.

(1) Cited in the report of the National Research Council (NRC), "Fluoride in Drinking Water: A Scientific Review of EPA's Standards"

Minnesota Dental Association