The dental lobby is more or less in charge of prenatal fluoride. They do not accept any of the clinical trials as enough evidence to make it legal to add fluoride to prenatal vitamins, even at no cost and with no claims. I don't expect this position to change.

Dentists and doctors who do accept the studies generally prescribe generic sodium fluoride to go along with prenatal vitamins. The most common dosage used in the trials is 1 mg F per day (2.2 mg NaF). (That is the equivalent of 4 glasses of water in fluoridated areas, which is about half the country.)

If you would like a longer discussion of dosage, come along. This is not that well organized, but I'd like to present (1) arguments for lower doses, (2) arguments for higher doses, and (3) arguments for starting very gently, and gradually increasing doses.

1. Arguments for lower doses

I have seen very, very, very slight fluorosis in two cases that used 1 mg F in pregnancy. Both of these had several things in common. First, both started late in pregnancy, about the 6^th month. The fluorosis was barely visible, just a little whitishness on the permanent front incisors. These teeth start forming about the 7^th month. Both were good compliers (took the Rx every day), and started from almost zero fluoride intake (extremely low F in the water in Honolulu, HI, and no appreciable source in the diet). And, probably most importantly, both started their newborns on a dose that I now think is too high, the then-standard of .25 mg. (This infancy dosage is roughly 4 times greater than the pregnancy dosage. Math: .25 mg/3kg = .08 mgF/kg, which is pushing the threshold of fluorosis, .1 mg/kg. The dosage in pregnancy was roughly 1 mg/60kg = .02 mgF/kg. For more on infancy doses, see the OptiDose site.)

To me (I tend to be pretty conservative), it is credible to use a very low dose (such as .5 mg F per day) if the patient has most of these characteristics:

6^th month or later

body weight smaller than average

no appreciable fluoride intake

a few cavities would not be a financial hardship

aspirations for child to be a makeup model, in show business, etc.

(To argue against this position, though, .5 mg is the equivalent of 2 glasses of fluoridated water per day. Studies that compared fluoridated water in pregnancy as the only supply of F have shown very little cavity prevention, in the range of 20%. So this low dose is clearly at the borderline of nothing. However, it is still better than nothing.)

2. Arguments for higher doses (higher than the 1 mg used in most trials)

Dr. Glenn (one of the authors above, and in my opinion the best expert in this area) now uses 2 mg F per day, on top of fluoridated water. She has been right on just about everything through the years. For example, when everyone else was using the commercial doses that caused spotting of teeth, she was using half that much. (See the OptiDose link for more info, but quickly, the old doses were .5 mg for newborns, 1962 to 1979. In 1979 the doses were changed to what Dr. Glenn was using all along.) One of these days I will make a web page just on Dr. Glenn's accomplishments, but briefly they are:

She invented prenatal fluoride independently (others actually came first) and certainly did the most to publicize the concept.

She was the first to statistically prove that fluoride changes the shape of the molar teeth.

She was the first to find developmental advantages in the cells that grow teeth.

She was the first to find general growth and development advantages (less prematurity and low-birth weight).

Anyway, I think you could do worse than to just do what Dr. Glenn does.

Another high-dose recommendation (3 mg per day):

Institute of Medicine, Food and Nutrition Board, Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, Washington, D.C.: National Academy Press, 1997. AI (=daily adequate intake, which is the lower limit) for F is 3.1 mg for pregnancy. The UL (upper limit) is 10 mg for pregnancy. (Also called DRIs.) At least amongst these bone nutrients, and perhaps amongst all nutrients, the greatest disparity between recommended values and current dietary patterns is in fluoride. In the most well known nutrient deficiency, calcium, most pregnant women get about two thirds of the AI (AI is 1,000 mg, 50^th percentile intake is 656 mg). But in fluoride, most pregnant women probably get well under half of the AI, and many get about a tenth. The AI for fluoride in pregnancy is 3.1 mg, but he intake is 1.4 to 3.4 mg in fluoridated areas. It does not give the average intake, but it is probably about 2 mg (.5 mg in food, plus 6 glasses of water at .25 mg each). In non-fluoridated areas, which is half the women in this country, the intake is a piddling .3 to 1.0, or somewhere between a tenth and a third of the desired intake. (My emphasis is on pregnancy, but this goes for women in general also, which have the same AIs for F The criterion for all these AIs is caries prevention.)

3. Arguments for starting very gently, and gradually increasing doses (my recommendations)

Assumptions:  I place a higher priority on tooth appearance than I do on preventing cavities. I want to use the "gorgeous teeth" qualities in fluoride as the primary benefit, and assume most of the cavity prevention will follow. I would not worry about a few cavities.

Gentle start:  Since fluoride changes the appearance of the teeth (to whiter and glossier), the key is making the change either well before teeth start (before pregnancy would be best), or making it very slowly once teeth are forming. I would rather see a tooth yellowish and dull all over than see it change abruptly in the middle to white and glossy. (Quick note: In pregnancy we are generally starting before any of the permanent teeth begin, and the primary teeth do not show this cosmetic effect. So this "change in the middle of a tooth" is only given as an illustration.) Teeth form very slowly so the transition time should be at least a month or more. If you accept 1 mg as the ideal dose in pregnancy, and your patient is starting from the normal very low fluoride intake, that means you would increase her dosage by about .25 mg per week at most.

Consistency: The main issue here is how to deal with growth. Pregnancy is, of course, a time of major growth for both mother and fetus. My guess is that the ideal dose per pound in pregnancy is something between .005 and .015 mgF/pound (.011 to .033 mg/kg). This is the same as where I think it is for newborns. (The upper range of this works out to about Dr. Glenn's dose. A 140 lb woman would get 2.1 mg F per day. The lower range would be about .5 mg for a 100 pound woman.) So after making a gentle start, I would pick some target dose per pound, and stay with it during pregnancy. (Then, for the newborn, start again very low and keep the dosage constant for weight.)

Methods you could do without (or with) your doctor: I generally recommend a prescribed method of getting fluoride, just because people tend to follow it. Compliance is far more important than the details I'm about to give you. Plus I think it is generally nuts to take advice from some guy like me and not at least ask your doctor about it. Especially in pregnancy. However, here are a few alternatives. (Some of these are probably about as effective as a New Year's resolution to "eat more salad".)

The most gentle start would be just gradually increasing your natural sources of fluoride. Green leafy vegetables, the rougher-tougher the better, are the easiest and mildest.

My favorite food source of fluoride is canned salmon or sardines. Of these, fancy red sockeye salmon is one of my most favorite foods on earth. (My friend Vinny, who keeps up with methyl mercury, says to be sure it is wild pacific salmon, and to avoid great lakes salmon.) The fluoride is mostly in the bones, which are soft and very edible. A large serving (6 ounces) of canned fish provides the bioequivalent of a 1.1 mg NaF (.5 mg F) dose.

If you drink tea, each cup provides about .5 mg. Seaweeds are not consumed by many average Americans, but these are excellent sources.

A product called Bone Nourisher from L&H Vitamins, Inc. 1 800 221-1152 (or foodform.com/) has fluoride. Three of their tablets combined contain 1 mg F, so each one is about .3 mg F. (I didn't figure in the calcium effect on this one, but it would probably further reduce the dose to .1 mg.) A very gentle start program could be taking one tablet, one meal per day, for a week or so, then two meals a day, then three. After this start you could stay the same if you wanted to keep your daily amount very low, or ease up to the next product.

A way to get a pretty high dose is from a product called Monocal. It is available "behind the counter" (you ask your pharmacist for it). It has 3 mg F actual, but it has enough calcium to make only about 1 mg of that available. One of these once a day is about as high a dose as I would recommend in pregnancy. I like the calcium part and I like the way it lets you sort of sit on the fence. You're getting the high dose if you just figure the fluoride, or the low dose if you figure in the calcium effect.

Take into account other sources: If your water is fluoridated, estimate how many glasses you drink per day. An 8 oz glass has about .25 mg F. I would use whether or not you drink much fluoridated water help decide between the alternatives just above, or between other situations.

Wrap-up: It can be easily argued that I am way too picky on doses. While I don't think it is that much trouble to be careful, some people will be put off by it. I want to say emphatically that I think it is fine to just prescribe all pregnant women the same dose (of 1 or 2 mg F per day) just to keep it simple and encourage compliance. Dr. Glenn has reported on about 1500 children (now in their teens or older) who went through pregnancy on these doses, plus fluoridated water, with no problems of fluorosis, and still 93% cavity-free:

Glenn FB, Glenn WD. Prenatal and postnatal fluoride supplementation. Proceedings of the 3rd World Congress on Preventive Dentistry, June 14-17, 1991, Fukuoka, Japan. Morioko T ed. Fukuoka: The 3rd World Congress, pp. 178-179.

Age (yrs) # children % caries-free from PNF Comparable US national average if known 5 1428 97% 50% 9 871 95%   17 103 93% 16%