Fluoride-free toothpaste needs a warning label for parents: ‘doesn’t prevent cavities.’

The U.S. Food and Drug Administration requires a warning on all fluoride products that says: “Keep out of reach of children under 6 years of age. [highlighted in bold type] If more than used for brushing is accidentally swallowed, get medical help or contact a Poison Control Center right away.”

Seeing the word “poison” on any toothpaste would rightly scare any parent. And so, as a new mother six years ago, I wanted to protect my son and use only the safest toothpaste — hence it was logical for me to use fluoride-free “training” toothpaste because it is safe when swallowed. Having brushed his teeth regularly twice a day and minimized his intake of juices and candy, I was horrified to learn that, at 2 years old, he had cavities that got progressively worse to the point where he required four root canals and several fillings by the age of 4.

By the time my daughter came along, I used neither fluoride-free toothpaste nor bottled water. I used a tiny smear of the fluoride toothpaste and filtered, fluoridated tap water. To my surprise, despite her having consumed more candy than her brother, at 3 years old, she has no signs of cavities.

Data from the National Institute of Dental and Craniofacial Research show that dental caries (cavities) in baby teeth in children ages 2 to 11 years old declined from the early 1970s until the mid 1990s. From the mid 1990s until more recently this trend has reversed, however. Data from the National Health and Nutrition Examination Survey, conducted in 2011 and 2012, show that 23 percent of U.S. children aged 2 to 5 years had dental caries in their primary teeth. (Interestingly, World Health Organization maps for various age groups show that countries in Africa have among the lowest rates of dental cavities despite poor health and dental care. Suggested factors include fluoridated water consumption, fluoride toothpaste, and low accessibility and use of sugar-saturated foods.)

Based on these data, the ADA’s Council on Scientific Affairs issued Clinical Practice Guidelines in 2014 stating that caregivers should begin brushing children’s teeth with fluoride toothpaste as soon as the first teeth erupt, typically around 7 months old. They cautioned that children under three should use no more than a tiny smear of paste, or the size of a rice grain. The guidelines reversed a decades old recommendation that fluoride be avoided until 24 months.

That same year, an article in the February issue of the Journal of the American Dental Association concluded that fluoride toothpaste reduced dental caries in primary teeth and was safe in children under age 6 when the appropriate amount was used. Study findings indicate that caregivers often apply up to twice the recommended amount of toothpaste and that more emphasis should be placed on educating them about the appropriate quantity to use.

Ingesting pea-sized amounts or more of toothpaste can lead to mild fluorisis, a largely cosmetic mottling of the teeth. Other studies have suggested that high fluoride concentrations can have negative effects on the developing brain. But used correctly, the benefits seem to significantly outweigh the risks.

The FDA and other regulatory bodies should therefore shift their focus from cautioning against fluoride toothpaste to the hazards of fluoride-free toothpaste. While a warning on fluoride toothpaste is warranted, one on fluoride-free toothpaste should also be placed to indicate that its use does not necessarily prevent dental cavities.

Hospitals should also have qualified staff members to educate new mothers about using fluoride toothpaste versus fluoride-free ones after the onset of a baby’s first tooth, and pediatricians should make sure they are up to date on the latest thinking. At a time when the national dental care expenditure reached $111 billion in 2012, this would possibly save millions in the long run and allow health care resources to be diverted to other illnesses.

Lastly, there should always be “regulation” governing the candy jar at home.

B. Reena Rambharat is a master of public health student at the University of Maryland, Baltimore with a concentration in community and population health. Her email is bramb001@umaryland.edu.

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