Health officials are recommending that parents who feed formula to their babies consider using bottled water — rather than tap — when mixing it to prevent a dental condition that causes subtle white marks on developing teeth.

While emphasizing the significant benefits of fluoridated tap water in preventing cavities, new recommendations from the Centers for Disease Control and Prevention and the American Dental Association say parents need to be aware of how much fluoride babies and young children are exposed to.

“Since the beginning we knew there was a trade off between preventing tooth decay and enamel fluorosis,” said William Maas, director of CDC’s Division of Oral Health.

Enamel fluorosis is a condition involving changes to the enamel surface of teeth — ranging from barely noticeable chalk-like white flecks and lines to more severe pitting and staining. The condition occurs when children are exposed to too much fluoride while their teeth are forming — and mild forms have been on the rise since the late 1980s.

Currently about one-third of U.S. children will develop very mild or mild fluorosis — which causes subtle white specks or lines on their adult teeth that in most cases is not considered a cosmetic problem. About 4 percent will develop moderate and severe forms of the condition, usually from prolonged exposure to naturally high fluoride levels in some well water.

CDC has for years cautioned parents to limit the amount of fluoridated toothpaste children use to no more than a pea-sized dollop because ingesting the toothpaste during the first six years of their life — while adult teeth are forming — had been linked to an increased risk of fluorosis.

Then last year, for the first time, a study indicated an association between the use of infant formula and very mild and mild fluorosis, prompting the CDC and the American Dental Association to put out new guidance. Infant formula has not been associated with more severe forms of fluorosis.

“One of the more effective ways to reduce the already low fluoride levels the youngest children are getting is looking at the reconstitution of powdered or concentrated liquid formulas,” said John Stamm, a spokesman for the American Dental Association and professor of dental ecology at the University of North Carolina-Chapel Hill.

The issue isn’t the infant formula itself, but the water it’s reconstituted with, Stamm and Maas said. For their size, babies consume a large percentage of their body weight in fluoridated water when reconstituted formula is their primary source of nutrition.

Ready-to-use infant formula has low levels of fluoride because companies generally make it with demineralized water, and it is recommended by the ADA. But most consumers prefer the lower price and convenience of powdered formula or a concentrated liquid formula, which are mixed with tap water before use.

Most municipal water supplies in Georgia and across the country have added low levels of fluoride for decades as a means of preventing tooth decay. Fluoride, when it washes over teeth, stops the removal of minerals from teeth by oral bacteria. The CDC considers fluoridating community water supplies a highly safe and effective health measure.

Both the CDC and the ADA note that breastfeeding is best.

In a recommendation issued in November, the American Dental Association said that for infants who get most of their nutrition from formula, parents should use fluoride-free or low-fluoride bottled water to mix batches of formula.

The CDC, which published its background paper on the formula issue in December, said parents should check the fluoride level of their water supply, then weigh the risk of minor white flecking against the potential protective benefits of early fluoride exposure against tooth decay.

“They need to consider the trade off and decide accordingly,” Maas said.

Steven Adair, chairman of the department of pediatric dentistry at the Medical College of Georgia, said most wells in Georgia have low levels of fluoride, except some in coastal areas. Local water officials or dentists can assist in getting water tested.

“If your household has fluoridated water and your child is taking concentrated formula that’s reconstituted, if it’s economically feasible to use bottled water to reconstitute it, that would be a good idea,” Adair said.

Children are at greater risk, Maas noted, from improper use of toothpaste than from tap water. For years the CDC has urged parents to be careful with toothpaste to avoid children swallowing it and putting them at higher risk of fluorosis.

Since 1996 toothpaste tubes have carried a warning that parents should consult with a dentist or doctor before introducing a child younger than 2 to fluoridated toothpaste.

“People still don’t realize how important it is to control toothpaste use,” Maas said.

To read the American Dental Association’s and the CDC’s recommendations, go to: www.ada.org/prof/resources/positions/statements/fluoride_infants.asp and www.cdc.gov/fluoridation/safety/infant_formula.htm

For more information about children’s dental health, go to: www.cdc.gov/OralHealth/factsheets/brushup.htm

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