Drs Slayton and Dubik have disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Fluoride toothpaste has been recognized for many years as an effective therapeutic agent for the prevention of dental cavities, but there are conflicting recommendations for its use. To bring some order to the discourse the American Dental Association (ADA) Council on Scientific Affairs has published new recommendations.

Brushing teeth with fluoride toothpaste should begin as soon as teeth erupt. Brushing should be supervised and typically occur 2 times per day. For children <3 years old, the amount of toothpaste should be no more than the size of a grain of rice or “smear” on the brush. For children age 3 to 6 years, the amount should be no more than the size of a pea. This is a change from previous ADA recommendations that suggested waiting until a child is 2 or 3 years of age before introducing fluoride toothpaste.

Dental caries continues to be the most common chronic disease affecting children. It is caused by a combination of transmissible bacteria, dietary carbohydrates, and susceptible tooth surfaces. Susceptibility is increased among children with a family history of caries and in those who are frequent consumers of simple carbohydrate snacks and beverages. Caries risk is decreased by the regular removal of plaque from tooth surfaces and use of fluoride-containing toothpaste.

Oral bacteria colonize the mucosal tissues of the mouth shortly after birth. Cariogenic bacteria such as Streptococcus mutans and Lactobacillus metabolize dietary sugar and convert it to acid. Once teeth are present, this acid causes demineralization of the surface enamel and leads to cavities. The best predictor of caries is caries, so prevention of that first event is the most important step in optimizing life-long dental care.

Fluoride in topical agents decreases enamel demineralization and increases enamel remineralization. In young children who have limited ability to expectorate, there are concerns that ingestion of excess fluoride toothpaste could increase the risk for enamel fluorosis. The trick has always been to find a balance between the risk of fluorosis and the risk of dental caries. The optimal dose for fluoride is considered to be 0.05 mg/kg per day. The quantity of fluoride present in a pea-sized amount of standard fluoride toothpaste is about 0.25 mg and brushing twice per day would amount to 0.5 mg. This is the amount that is recommended for systemic supplementation in children between 3 and 6 years of age who do not have access to optimally fluoridated water. In a rice-sized smear of toothpaste, this quantity is approximately 0.1 mg. The risk of fluorosis occurs during enamel development and is primarily an esthetic concern for anterior teeth. Incisor tooth enamel is usually complete by 3 years of age. Employing fluoride toothpaste yet limiting the quantity used for infants and children is intended to decrease the risk of caries and minimize the risk of fluorosis. It...

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