Fluoride: What parents need to know - Part 1

Many parents are confused about fluoride.

Is it good or bad for children?

What are the risks and benefits of fluoride?

In this blog post we will answer these and other questions.

What is fluoride?

Fluoride is the 13th most abundant element on the earth's crust. It is found naturally in rocks, soil, water and some foods. The level of fluoride in water varies greatly between different geographical areas. Fluoride can also be emitted into air and water as a waste product of some industries.

Is fluoride good or bad?

In low levels, fluoride is beneficial in protecting teeth from decay. 

If the right level of fluoride is available while teeth are forming it is incorporated into the developing enamel, making it more resistant to acid attack, which is the cause of tooth decay. Teeth that have developed under the influence of fluoride also tend to have shallower grooves, making them less prone to decay. Tooth enamel formation starts from 3 months after conception (in the womb) and is completed by around 8 years old, with the exception of the wisdom teeth.

Studies in both the USA and the UK have demonstrated the ability of an optimum level of fluoride in drinking water (either naturally occurring or added) to significantly reduce dental decay in both children and adults.

Fluoride is also beneficial after teeth come through. The surface enamel of teeth is weakened and dissolved by acid attacks which occur after consuming sugary or acidic food and drinks. However, enamel can remineralise, or repair, itself by taking in minerals from sailva. Low levels of fluoride present in saliva and dental plaque encourage remineralisation and therefore make it less likely that a cavity will be formed. The fluoride also becomes incorporated into the enamel surface making it stronger and more resistant to acid attack.

Recent scientific studies have also shown that fluoride is able to reduce the ability of plaque bacteria to produce acid.

Scientists now believe that the effect of fluoride after teeth erupt into the mouth is more important than during tooth development. These effects explain why the incidence of decay has generally decreased with the introduction of fluoride toothpastes.

So what's the problem with fluoride?

Like many other minerals, fluoride is toxic at very high concentrations, but it is very rare to be exposed to these levels. The problem with fluoride is when you swallow more than the recommended level over a long period of time. The most common problem that is seen with consuming moderate levels of excess fluoride is dental fluorosis.

Dental Fluorosis 

Individuals who are exposed to too high a level of fluoride in early childhood (up to 7 years old) are prone to dental fluorosis, or mottling of the teeth.

In its mildest form, the only sign of fluorosis may be white specks on the enamel surface. Teeth more severely affected show discolouration, often in bands or lines, and pitting. Although they are more resistant to decay, teeth with severe fluorosis have structurally weaker enamel. 

The amount of fluoride in drinking water varies greatly. The level of fluoride in freshwater, for example rivers and lakes, is usually low. However as water seeps through soil and rocks it becomes contaminated with various naturally occurring substances or pollutants. These contaminants also become more concentrated where the groundwater level dips. 

India has become increasingly dependent on groundwater, from wells or bore-wells, to meet demands for drinking water and in some areas, this contains much higher than the recommended level of fluoride.

The optimum level of fluoride in drinking water - to provide dental health benefits and minimise side effects - is 1mg per litre. In India, the permissible level is up to 1.5 mg/l. 

The Indian Department of Drinking Water Supply reported that 203 out of 593 districts have higher than permissible levels of fluoride in water.

As this map shows,almost all states in India have districts where groundwater contains excessive levels of fluoride. Even in Bangalore, the level of fluoride varies between different areas and during different seasons. As water quality is not well regulated, it is not always easy to know the levels of fluoride in a particular area.

In some areas, the level of fluoride in water is excessively high. In these areas skeletal fluorosis may also occur. This causes pain and stiffness in the joints and, in more severe cases, bone deformities.

It is recommended to drink bottled or filtered water and, in high fluoride areas, to avoid food and products containing fluoride. Not all water filters remove fluoride, those which work by reverse osmosis and ion exchange resin are able to remove about 90% of the fluoride. Bone char filters have been found to be even more effective in removing fluoride. It is difficult and expensive to remove fluoride from the ground water supply and, in rural areas, other sources of drinking water are not always easily available. Recharging groundwater using harvested rainwater can be useful in reducing levels of contamination.  

Slides used from: http://www.schools.indiawaterportal.org/wq-test/fluoride-factsheet


In the second part we will look at how fluoride can be used safely to benefit dental health.

Is Dental Decay Contagious?

Tooth decay is the single most common chronic childhood disease, despite also being preventable.

Is dental decay a contagious disease? 

Is it possible to catch it from someone else?

In a previous post we discussed what causes dental cavities. 

To summarise, bacteria (germs) in our mouths convert sugar in food and drink that we consume into acid which damages teeth.

Bacteria live in dental plaque - a sticky film which builds up naturally on our teeth. Dental plaque contains many types of bacteria but only a small number of these cause dental decay. The main type of bacteria which causes dental caries is Mutans streptococci. Studies have shown that individuals with higher levels of Mutans streptococci are at a greater risk of cavities.

Recent research has shown that babies are not born with decay-causing bacteria. Any time after birth bacteria can be passed on from other people, especially mothers and other close caregivers. Once these bacteria are transmitted to a babies mouth, especially after the first teeth come through, they multiply and become established within dental plaque.

Bacteria can enter the baby's mouth by kissing, sharing food utensils, toothbrushes or other habits that transmit saliva.

If parents and other caregivers have cavities and poor oral hygiene they will have higher levels of decay-causing bacteria which can be passed onto their child.

The risk of a child developing cavities will be less if they are not infected with decay-causing bacteria at an early age.

Children can also "catch" bacteria from other children by sharing food and toys, but they are more likely to receive bacteria from their mother and other close relatives before this happens.

What can be done to reduce the risk?

Parents and caregivers can reduce the risk of passing on decay-causing bacteria from their own mouths by:

• cleaning their own teeth well, to reduce the amount of plaque (which contains bacteria)  in their mouths
• avoiding sugary snacks and drinks between meals which can lead to decay 
• visiting the dentist regularly for check-up and getting any cavities filled 
• avoiding sharing items such as food, spoons, cups and toothbrushes with their baby
• kissing the baby on their cheek, rather than the mouth

Protecting our children from abuse - Part 2

In the second post in our series on protecting children from abuse we will look at signs that may indicate a child is being abused and what to do if you know, or suspect that abuse has occurred.

What is Child Sexual Abuse?

Child sexual abuse involves persuading or forcing a child to take part in sexual activities, exposing a child to adult sexuality or encouraging a child to behave in sexually inappropriate ways.

If we don't make a fuss about the abuse, won't a child forget it?

Children do not forget abuse, it can cause devastating emotional, physical and social effects for the child, even into adulthood. Adult survivors of child sexual abuse may develop harmful sexual behaviours, experience inability to trust close family and friends and have marital problems. If abuse is not reported once discovered, not only will the abuse continue, but the abuser is also likely to harm other children.

Signs could indicate abuse

The majority of children do not report abuse. They may feel too scared, fear that they will not be believed, or have been threatened by their abuser not to tell anyone. Changes in a child's behaviour may be the first sign that something is wrong. 

One or two of the following changes may be a normal part of development but more should raise suspicion of possible abuse:

• Nightmares or sleeping problems
• Becoming withdrawn or unusually clingy
• Changes in personality, become more insecure
• Problems with studies or missing school
• Excessive anger
• Sexual language or behaviour (inappropriate for the child's age)
• Going back to younger behaviours eg. thumb sucking, bed-wetting
• Sudden changes in eating habits
• Become secretive, not talking
• Shows signs of fear of, or avoids being alone with, a particular adult. 

If you suspect or discover that a child is being sexually abused, get professional advice (see options below).  Seek medical advice immediately if you see physical signs of abuse, such as unexplained soreness/bruising of genitals or symptoms of sexually transmitted diseases eg. an unusual discharge.


What to do if a child discloses that they have been abused

A very small proportion (estimated to be 12%) of abused children report it. Even then, the reporting is often ambiguous as they may be too shy to narrate the incident clearly, or a younger child may not have the vocabulary to explain what has happened.

Your response is crucial. If the adult does not believe the child, or makes them feel ashamed, they may never risk telling anyone again and the abuse will continue. 

For example, a child may say, "I don't like that Uncle."

If the adult replies "How can you speak like that, don't be so rude!" the child will feel scared and not give any further information.

However, if the adult responds, "I see, what happened?" the child is able to reveal the reason, which may, or may not arouse suspicion.

An abused child wants two things:

• to be believed
• for the abuse to stop

If a child confides in you about abuse

• Acknowledge the child's feelings and praise them for having the courage to come and tell you.
• Tell the child it is not his or her fault. Do not blame or accuse the child, even if they did not report the abuse when it started - the abuser is the one at fault.
• Do not ask the child to "forgive" "forget" or "adjust"
• Do not confront the alleged abuser - it may give them an opportunity to silence, confuse or threaten the child about speaking out. It may also place the child in danger.
• Tell the child that you would like to take the help of other trusted adults (eg. close family members, child welfare services, medical professionals or police) to help, with the child's permission. 
• Do not tell other people who are not directly required to help and support the child.

Childline has a national toll-free number - 1098 - which an adult who is concerned about a child, or children in distress, can call for help and advice.

In Bangalore, 3 new Collaborative Child Response Units (CCRU) have recently been set up at M.S. Ramaiah Hospital, Bangalore Baptist Hospital and KIMS Hospital. They liaise between children, their families, doctors and other authorities to provide medical, psycho-social and legal assistance. More CCRU's are to be set up in other districts of Karnataka.

It is possible to contact the CCRU's directly, but they also receive referrals from the police, child welfare services and Childline.

Due to the recent "Protection of Children from Sexual Offences Act - 2012"  it has become mandatory for any person having knowledge of a child being sexually abused to report the same to the Special Juvenile Police Unit or local police. A child need never go to a police station, police will come in plain clothes to visit the child and record the statement in the child's own words.

Protecting children is every adult's responsibility.

In the next section, we will discuss guidelines for keeping children safe in various situations, both at home and outside. 

Protecting our children from abuse - Part 1

In this blog, we are going to cover a non-dental issue, because it is one that is important for us all to be aware of.


It is an issue which people do not like to discuss or even think about, but child abuse is alarmingly common in India and around the world.  As adults, we have a responsibility to protect not just our own, but all children from abuse. 



What is child abuse?
Child abuse is the term used when an adult, or another child, harms a young person under the age of 18. There are many types of abuse -  physical, emotional, sexual, neglect and specific offences such as child trafficking.

In this article we will concentrate on child sexual abuse (CSA), but many of the principles can also be used to protect children from other forms of abuse. 

How common is child sexual abuse in India?
Children from all social classes and backgrounds are susceptible to abuse. It is impossible to know the true incidence of CSA as the vast majority of those abused do not tell anyone. Social stigma in Indian society often prevents people from coming out in the open and talking about abuse. 

A goverment study published in 2007 (http://wcd.nic.in/childabuse.pdf), found that 53% of the children surveyed reported having faced sexual abuse, 21% serious sexual abuse. In the majority of cases the abuser was someone known to the child, or in a position of trust and responsibilty. Most of those abused had not reported it to anyone. With statistics like these, it is not an issue that we can afford to ignore.

How can I keep my child safe?
Parenting is challenging, and the issues are different for babies and small children than for older children who are starting to become independent. Childhood should be a carefree time and we don't want to worry our children, but we need to give them some guidelines on keeping safe. 

We tend to be concerned about our children when they are out and about but, as the majority of abusers are known to the child, we also need to consider keeping our children safe at home, school, when visiting relatives and friends or participating in other activities or using the internet. In a future article, we will look at safety issues for various situations. 

Good Communication

Good communication with your child is the key, both to listen to their concerns and so that they will listen to you when you give advice and rules on keeping safe. 

As the quote says, this needs to start when your child is young. Listening to your child, at a time when you are not rushed or distracted is important. Put down your phone, and make eye contact with your child. 

Find the best times to talk and listen, maybe at bath-time or bedtime, going to and from school, while in the car or walking together. If your child wants to talk when you are busy, assure them that you will make time as soon as possible. Ask your child about their feelings and emotional well-being. The art of listening builds trust. Your child may also have other adults, such as grandparents, who they trust and can talk to.



As difficult as it may seem, it is better to give your child some guidelines on keeping safe, rather than waiting until until you have a concern. This should be done in a way that is appropriate for your child's age and understanding. A good tip is not to treat it like a lecture, it's much better to find easy ways to have comfortable chats, little and often. Adding simple conversations into your day or routine about staying safe will help prevent your child from feeling like it's a big deal, unusual or weird.

The UK charity NSPCC has developed The Underwear, or P.A.N.T.S rule as a simple way of talking to your child without using scary words or mentioning sex. You can click on the above link for details, but in summary:-

Privates parts are private
Always remember your body belongs to you
No means no
Talk about secrets that upset you
Speak up, someone can help



In India, Enfold Proactive Health Trust, based in Bangalore, are involved in education and training to protect children from sexual abuse.

In the next blog, we will discuss signs that may raise concern and what to do if you suspect abuse or a child tells you they have been abused.