Fluoride Permission Slip


Leverett Elementary School participates in the Weekly Fluoride Mouth Rinse Program coordinated and funded by the Office of Oral Health at the Massachusetts Department of Public Health. Participation in the program is voluntary and free. Your child can participate in this program only if you give your permission by signing and returning the bottom half of this letter to your child’s teacher.

The Food and Drug Administration has approved the 0.2% weekly sodium fluoride mouth rinse as a safe and effective means of preventing tooth decay. This simple method of applying fluoride has been demonstrated to reduce tooth decay 20%-40%. Under supervision, participating students rinse their mouths in school with 2 teaspoons of fluoride solution for one minute each week. The solution is not swallowed. There are no known side effects associated with thisprocedure.

This program helps improve the dental health of your child, although it will not take the place of

regular dental checkups and proper tooth care at home. Fluoride is not a substitute for any other fluoride your child may be getting, either by fluoridated water, from your dentist, or by prescription.

In order for the fluoride to take effect the child doesn’t have any food or liquid for 30 minutes after the rinse. Snacks are timed appropriately by the classroom teacher. It is our intent to provide the fluoride mouth rinse weekly for most of the school year. However, because of unforeseen schedules (field trips, assemblies, absenteeism, etc.) your child may receive it less.



_____YES, I want my child to participate in the fluoride mouth rinse program.

_____NO, I do not want my child to participate in the fluoride mouth rinse program.

Child’s Name Grade Teacher

Date Parent/Guardian Signature ________________________