• Dental caries • Dental decay • Oral health • Fluorides • Primary prevention
• Secondary prevention • Children
• Fluoride is the key to prevention of tooth decay.
• There are multiple fluoride modalities.
• Effectiveness and safety of fluoride depend on dose and concentration.
• Individual level fluoride use occurs at home and with professional application.
• Community level prevention occurs through fluoridation of water or salt.
Dietary fluoride supplements
Where water supplies contain less than 0.3 mg/L fluoride, the following are recommended:
• No fluoride tablets should be prescribed before the age of 6 months;
• Between 6 months and 3 years, prescribe 0.25 mg fluoride per day;
• Between 3 and 6 years 0.50 mg fluoride per day; and
• Between 6 and 16 years 1 mg fluoride per day.
For water supplies with 0.3 to 0.6 mg/L fluoride, the following are recommended:
• Fluoride drops or tablets should not be prescribed before the age of 3 years;
• Between 3 and 6 years, prescribe 0.25 mg of fluoride per day; and
• Between 6 and 16 years 0.5 mg fluoride per day.
There is strong evidence that twice-daily use of fluoride toothpaste has a significant
caries-reducing effect in young permanent teeth compared with a placebo.18 Strong
evidence suggested a dose–response relationship with enhanced caries protection
from toothpastes with 1500 ppm of fluoride compared with formulations with
1000 ppm of fluoride in young permanent teeth following daily use.19 However, only
1000 to 1100 ppm fluoride toothpaste is currently available in the United States20
without a prescription. Nevertheless, daily tooth brushing with fluoride toothpaste,
even at less than optimal fluoride dosage, from the time of eruption of the first tooth
must be regarded as the best clinical practice today, based on moderate quality of evidence.
18 Toothpaste should be applied by the parent, with only a smear for children
younger than 3 years and a pea-size amount for those older than 3 years (Fig. 1A, B).
Toothpaste should be spit out after brushing, without water for rinsing. In addition,
there are toothpastes on the market that do not have fluoride; pediatric providers
should discourage patients from using these.
Prescription strength fluoride toothpaste
There is a strong evidence base for the use of high-fluoride toothpastes (5000 ppm
fluoride) in groups at a greater risk of caries.21 It is recommended to restrict its use
in those younger than 6 years to cases where the risk of severe morbidity caused
by caries is greater than that of aesthetically objectionable fluorosis. For children
younger than 9 years who are at risk for developing dental fluorosis, it is recommended
that the toothpaste be rinsed out with water after using high-fluoride toothpaste,
whereas when using regular fluoride toothpaste, it is recommended that the toothpaste
be spit out after use, rather than rinsed with water.
Recommendations to Reduce Dental Fluorosis
1. Defer the use of fluoride toothpaste until a child is aged between 18 and 36 months
unless the child has been assessed as being at increased risk of developing caries
(Forum on Fluoridation, 2002; Health Canada, 2010; Australian Research Centre for
Population Oral Health, 2012).4
2. Use a “smear” of fluoride toothpaste (0.1 mg) for all children younger than 3 years
and a pea-size amount (0.25 mg) for those older than 3 years (SIGN 2014; Public
Health England, 2014; ADA Council on Scientific Affairs, 2014).
3. Although not available in the United States, some countries recommend the use of
low-fluoride toothpaste for young children (EAPD, 2009; Australian Research
Centre for Population Oral Health, 2012). The 2012 Australian guidelines recommend
the use of low-fluoride toothpaste (500–550 ppm) for children aged
18 months to 5 years.66
Other than dental sealants that have been shown to effectively prevent pit and
fissure caries (see John Timothy Wright’s article, “The Burden and Management of
Dental Caries in Older Children,” in this issue) (Box 2), nonfluoride agents, such as
chlorhexidine and xylitol wipes rinse may serve as adjunctive therapeutics for preventing,
arresting, or even reversing dental caries, but they are not substitutes for proven
fluoride modalities for caries prevention.67,68
4. O’Mullane DM, Baez RJ, Jones S, et al. Fluoride and oral health. Community Dent
18. Twetman S, Axelsson S, Dahlgren H, et al. Caries-preventive effect of fluoride
toothpaste: a systematic review. Acta Odontol Scand 2003;61(6):347–55.
19. Walsh T, Worthington HV, Glenny AM, et al. Fluoride toothpastes of different concentrations
for preventing dental caries in children and adolescents. Cochrane
Database Syst Rev 2010;(1):CD007868.
21. Pretty IA. High fluoride concentration toothpastes for children and adolescents.
Caries Res 2016;50(suppl 1):9–14.
66. Australian Research Center for Population Oral Health. Fluoride consensus workshop
2012. Fluoride review guidelines. Available at: https://www.adelaide.edu.au/
arcpoh/dperu/fluoride/ARCPOH_FluorideOct2014.pdf. Accessed March 16, 2018.
67. American Dental Association Council on Scientific Affairs Expert Panel on Nonfluoride
Caries-Preventive Agents. Nonfluoride caries-preventive agents:
executive summary of evidence-based clinical recommendations. J Am Dent Assoc
68. Wang Y, Li J, Sun W, et al. Effect of non-fluoride agents on the prevention of
dental caries in primary dentition: a systematic review. PLoS One 2017;12(8):