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Table of Contents
Year : 2023  |  Volume : 10  |  Issue : 1  |  Page : 1-4

Parental awareness regarding the use of fluoride products in their children: A questionnaire study in Malappuram, Kerala, India

1 Professor and Head, Department of Pediatric and Preventive Dentistry, Malabar Dental College, Manoor, Kerala, India
2 Professor, Department of Pediatric and Preventive Dentistry, Annor Dental College and Hospital, Ernakulam, Kerala, India
3 Senior Lecturer, Department of Pediatric and Preventive Dentistry, Malabar Dental College, Manoor, Kerala, India
4 Post Graduate, Department of Pediatric and Preventive Dentistry, Malabar Dental College, Manoor, Kerala, India

Date of Submission06-Mar-2023
Date of Acceptance13-Mar-2023
Date of Web Publication31-Mar-2023

Correspondence Address:
R Krishna Kumar
Annor Dcental College and Hospital, Ernakulam, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpcdr.ijpcdr_2_23

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Introduction: Oral health is an integral part of general health and has an impact on the quality of life of children. Proper oral hygiene along with nutrition, regular dental visits, and fluoride (F) prophylaxis has got a significant impact on the oral health of children. Mostly, the family provides background for the development of knowledge regarding the use of F products among children. Hence, the aim of this study is to evaluate parental knowledge about the use of F products in children. The study included 356 correctly filled-in questionnaires from randomly chosen parents of children which were circulated through social platforms.
Materials and Methods: The questionnaire contained 21 questions relating to F products used by children, as well as their benefits and usage limitations. For statistical analysis, descriptive statistics were performed.
Results: More than 80% of parents have heard of F, and the main source of information was television/newspaper. Out of the parents, 59% of them believe that F can reverse early-stage tooth decay, whereas the other half do not agree with this. A very less number of parents are aware of the professional F treatments available in dental clinics. As per this study, 28.7% of school-going children had participated in school-based F preventive treatment. Among the mothers, 76% of them have not used any F-containing medications during pregnancy. Most of the respondents have not heard of the term fluorosis and are unaware of its symptoms.
Conclusion: There is an association between the female gender and knowledge about the benefits of F prevention. The parental knowledge about oral hygiene and anticaries prevention with the use of F in children is insufficient. Most parents are neither familiar with the type of toothpaste their children should use nor aware of the proper amount of dentifrice to apply on a toothbrush. Dentists would be able to guide them by providing proper knowledge regarding F use. Care must be taken to ensure that a balance is maintained between maximizing the protective F effect against dental caries and minimizing the risk of dental fluorosis.

Keywords: Fluoride, parental awareness, preventive treatment

How to cite this article:
Vijai S, Kumar R K, Peter J, Anaswara M S, Vrinda M P. Parental awareness regarding the use of fluoride products in their children: A questionnaire study in Malappuram, Kerala, India. Int J Prev Clin Dent Res 2023;10:1-4

How to cite this URL:
Vijai S, Kumar R K, Peter J, Anaswara M S, Vrinda M P. Parental awareness regarding the use of fluoride products in their children: A questionnaire study in Malappuram, Kerala, India. Int J Prev Clin Dent Res [serial online] 2023 [cited 2023 Jun 10];10:1-4. Available from: https://www.ijpcdr.org/text.asp?2023/10/1/1/373358

  Introduction Top

Fluoride (F) occurs naturally in our environment but we consume it in small amounts. F exposure can occur through dietary intake, respiration, and F supplements. Methods, which led to greater F exposure and lowered caries prevalence, are considered to be one of the greatest accomplishments in the 20th century's public dental health.

The primary and most important action of F is topical when the F ion is present in the saliva[1] in the appropriate concentration. Hydroxyapatite is the main mineral responsible for building permanent tooth enamel after the development of the teeth is finished.[1] During tooth growth, the enamel is constantly exposed to numerous demineralization processes, but also important remineralization processes, if the appropriate ions are present in the saliva. These processes can either weaken or strengthen the enamel.

The main action is the inhibition of the demineralization of enamel, which is carried out through different mechanisms. There are different cariogenic bacteria in the plaque fluid the most important being Streptococcus mutans. When bacteria metabolize sugars, they produce lactic acid[1] which decreases the pH in saliva. When the pH falls below the critical level of hydroxyapatite (pH: 5.5), the process of demineralization of enamel takes place and caries is formed. At the beginning, the process is reversible and it is possible to reduce the formation of new lesions with appropriate preventive measures.[2]

If F is present in plaque fluid, it will reduce demineralization, as it will adsorb into the crystal surface and protect crystals from dissolution.

After repeated cycles of demineralization and remineralization, the outer parts of enamel may change and become more resistant to the acidic environment due to a lowered critical pH level of newly formed crystals (pH: 4.5). The most important effect of F on caries progression is thus on demineralization and remineralization processes.[3]

Although it provides protection against dental caries, F consumed in large amounts during early childhood can have a negative impact on the teeth by causing dental fluorosis and can cause both skeletal fluorosis (more than 6 mg/l) and deformation of bones in children and adults.[4] Dental fluorosis is significantly associated with gender, family income, and parents' awareness (P ≤ 0.05).

Hence, the aim of this study is to determine the level of knowledge about F and its effect on children's oral health among parents of Malappuram.

  Materials and Methods Top

An online survey was carried out among the population of Malappuram and their participation was completely voluntary. A semi-structured questionnaire written in English and regional language was made by research expert. The questionnaire was pretested for validity and was revised according to the feedback. The questionnaire was made available using online mode as Google Forms and the link was circulated among the public using social media. All procedures performed in the study were conducted in accordance with the ethics standards given in 1964 Declaration of Helsinki, as revised in 2013. The study proposal was submitted for approval and clearance was obtained from the ethical committee of our institution. A written informed consent was obtained from each participant.

The participants of the questionnaire study included 356 randomly chosen parents. The survey contained questions regarding demographic data and questions regarding parental awareness on F products. The collected data were tabulated and statistically analyzed. The results of the survey were graphically represented.

  Results Top

Parents of 356 children answered the questionnaire. Questions included special reference to the age, gender, and education of the parent. Majority of the respondents were females (90.1%). Most of the parents were in the age group of 26–35 years.

Among the respondents, the majority of them were graduates (72%) and postgraduates (38.4%). Out of the respondents, the majority of them have heard of F mostly through television and newspapers.

From the above data, it is clear that only a few (18%) of the respondents could get to know Fs from dentists. A majority of the respondents are aware that F is naturally present in the body and has got health benefits.

Among the parents, many of them are unaware of the F-containing food products which are commonly used in our daily life.

Half of the respondents are aware of fluoridated toothpaste available in markets and that it is very important to brush using them but only very few are aware that it can reverse the early stage of tooth decay.

  1. Awareness regarding the availability of fluoridated toothpaste for children
  2. Fluoride can reverse early caries
  3. Importance of brushing using fluoridated toothpaste

Among the parents, only 28.3% of them are aware of professional F treatments available in dental clinics and they believe that it is very important for the child to participate in F treatments which are carried out in dental clinics.

A majority of the mothers (76%) responded that they have not used any F-containing medications while they were pregnant and are of unaware of such F-containing medicaments. Among the respondents, 52% of them have no idea about the ill effects of excessive F use.

Most of the respondents have not heard of the term fluorosis and are unaware of its symptoms. The result of this study shows that out of the parents who participated in this survey, only a few (31.6%) have participated in classes/camps on the importance of F supplementation. The result of this study also shows that the majority of the parents would like to extend their knowledge regarding F products [Figure 1], [Figure 2], [Figure 3].
Figure 1: The education qualification of the respondents and their source of information about fluoride

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Figure 2: Bar diagram showing the awareness of fluoride containing food products in daily life

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Figure 3: (I) Awareness regarding the availability of fluoridated tooth paste for children (II) Awareness about fluoride can reverse early caries (III) Awareness about the importance of brushing using fluoridated tooth paste

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  Discussion Top

The present questionnaire-based study was conducted to evaluate the perception of F use among parents and how they distribute the F to their children. Parents have a significant influence on their children in terms of confronting them with health-oriented attitudes and dental hygiene. Thus, they should be firstly informed about proper dental care. The questionnaire results suggest that parents do not possess sufficient knowledge in terms of F usage in their children.[5],[6]

A questionnaire study conducted by Bennadi et al. which included 248 mothers demonstrated that 72% of them allow their children to use toothpaste for adults (1450 ppm F), regardless of their age.[3] These results appear quite alarming because using toothpaste with an inappropriate F level in young children may lead to serious complications such as dental fluorosis, whereas in this study, only the participants who are graduates wish to use fluoridated toothpaste in their children.

From the study, it is also clear that the majority of the participants have not attended any classes/camps on the importance of F supplementation. The study by Al-Jundi et al. indicates that caries tend to be less intense in children participating in school-based caries prevention programs.[7],[8],[9],[10],[11]

According to the results of the present questionnaire, none of the women were advised to use F supplementation while pregnant. A study conducted by Stephen indicates that F supplements taken during pregnancy may possibly reduce dental caries in offspring.[12] On the basis of the literature review published so far, there is no clear scientific evidence on the real effectiveness of F supplementation during pregnancy to prevent caries in children.

The American Dental Association and the American Academy of Pediatric Dentistry recommend prescribing dietary F supplements (tablets, drops, or lozenges) for use by children aged 6 months to at least 16 years who are at high-caries risk, who live in nonfluoridated areas, or who drink F-deficient water (<0.6 ppm F).[5]

In our study, nearly 50% of the parents have not heard of the term dental fluorosis caused by intensive F exposition during tooth development. The risk of mild fluorosis may occur in individuals who consume over 0.1 mg F/kg bw/24 h and mottled enamel is the first symptom of chronic F poisoning.[4]

According to this study, 69.1% of parents are unaware of the symptoms of F poisoning. A study conducted by Creeth et al. showed that 60% of German and American parents and 30% in the UK are aware that excessive ingestion of F toothpaste may result in dental fluorosis.[6] In an evidence-based clinical study by Rozier et al. recommends that 5% of children under 2 years and 32% of children between 2.5 and 4 years rinse their mouth after brushing their teeth and 27% of children swallow most of the water together with toothpaste. It is claimed that a probable toxic dose that may trigger toxic symptoms and needs to be treated in a hospital is 5 mg F/kg.[11]

Depending on the consumed amount of F, the symptoms may include not only stomach ache and vomiting, but also salivation, tetany, arrhythmia, and the child's pulse becoming fast or imperceptible. Respiratory acidosis and cardiac arrest may also occur.[8]

  Conclusion Top

The questionnaire study puts an emphasis on the fact that parental knowledge about using F products in children is insufficient. Most of parents would like to extend their knowledge about F prevention in children. Therefore, dentists should focus on educating parents on the importance of daily and periodic F prophylaxis. Care must be taken to ensure that a balance is maintained between maximizing the protective F effect against dental caries and minimizing the risk of dental fluorosis. It appears necessary to raise parental awareness by implementing proper educational programs.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Pairo K, Rustem S. Use of fluoride for oral health in children – knowledge and attitudes among parents. DiVa portal 2018;83:56.  Back to cited text no. 1
Randhawa AK, Kaur P, Walia SS, Kaur N, Cheema N. A study on awareness regarding importance of fluoridated toothpaste and various oral hygiene practices among 15-16 year school children in and around Amritsar District. IJCDC 2014;4:11-4.  Back to cited text no. 2
Bennadi D, Kshetrimayum N, Sibyl S, Reddy CV. Toothpaste utilization profiles among preschool children. J Clin Diagn Res 2014;8:212-5.  Back to cited text no. 3
Poutanen R, Lahti S, Tolvanen M, Hausen H. Parental influence on children's oral health-related behavior. Acta Odontol Scand 2006;64:286-92.  Back to cited text no. 4
American Academy of Pediatric Dentistry. Guideline on Fluoride therapy [2014 revision limited to use of fluoridated toothpaste in young children]. Reference Manual 2014;39. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4697228/. [Last cited on 2021 Jun 24].  Back to cited text no. 5
Creeth J, Bosma ML, Govier K. How much is a 'pea-sized amount'? A study of dentifrice dosing by parents in three countries. Int Dent J 2013;63 Suppl 2:25-30.  Back to cited text no. 6
Al-Jundi SH, Hammad M, Alwaeli H. The efficacy of a school-based caries preventive program: A 4-year study. Int J Dent Hyg 2006;4:30-4.  Back to cited text no. 7
Sami E, Vichayanrat T, Satitvipawee P. Dental fluorosis and its relation to socioeconomic status, parents' knowledge and awareness among 12-year-old school children in Quetta, Pakistan. Southeast Asian J Trop Med Public Health 2015;46:360-8.  Back to cited text no. 8
European Academy of Paediatric Dentistry. Guidelines on the use of fluoride in children: An EAPD policy document. Eur Arch Paediatr Dent 2009;10:129-35.  Back to cited text no. 9
Howard CV, Micklem HS, Neurath C. association between maternal fluoride exposure and child IQ. JAMA Pediatr 2020;174:215.  Back to cited text no. 10
Rozier RG, Adair S, Graham F, Iafolla T, Kingman A, Kohn W, et al. Evidence-based clinical recommendations on the prescription of dietary fluoride supplements for caries prevention: A report of the American dental association council on scientific affairs. J Am Dent Assoc 2010;141:1480-9.  Back to cited text no. 11
Stephen KW. Systemic fluorides: Drops and tablets. Caries Res 1993;27 Suppl 1:9-15.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3]


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