August 27, 2021
by Rachael Straus
The use of fluoride is normally an easy topic to agree upon for evidence-based dental professionals. However, in the past year, I’ve stumbled upon an aspect of fluoride usage that seems to be rather debated between dental professionals. The issue that leads to a difference of opinions is the age that a child should begin using fluoride toothpaste. At the time, I had a 6-month-old baby and didn’t know whether I should be brushing her teeth with a fluoride toothpaste or not. After asking fellow hygienists and receiving different answers, I began to explore the reasoning around this uncertainty.
This discrepancy led me to conduct my own micro experiment in Philadelphia. I approached 10 dental professionals and asked when they thought fluoride should be incorporated into a child’s oral hygiene regime. 8 of the 10 dental professionals answered that a child can start using fluoride when they are capable of spitting. Since this is usually around 24 months, they suggest parents start with a pea-sized amount of fluoride at the age of 2. For children under 2, they suggest the use of non-fluoridated toothpaste, or what might be advertised as a training toothpaste. Training toothpaste is a flavored toothpaste that is sold in every toothpaste aisle and does not contain fluoride. The remaining 2 dental professionals answered my question a little differently. They said fluoride toothpaste should be used after the eruption of the first tooth in the mouth. With these two different approaches, I decided to further my research and find the correct answer.
I conducted a brief Google search to see what the internet had to say about this topic and one of the top hits led me to the U.S. Department of Health & Human Services, where it stated the following: “As soon as the first tooth appears, begin cleaning by brushing without toothpaste with a small, soft-bristled toothbrush and plain water after each feeding. Begin using toothpaste with fluoride when the child is 2 years old.”1 This information was last reviewed in July of 2020, only 1 year ago. So it seems this information is in sync with the majority of my nonscientific survey of dental professionals. But where did the other 2 dental professionals base their opinion off of? After more research, I think I discovered the reason for this disparity. Just 7 years ago the fluoride rules changed.
Up until 2014, The Council of Scientific Affairs (CSA) used to recommend using water on a toothbrush for any child under 2.2 The reason was to prevent fluorosis from occurring. Fluorosis is caused by ingesting too much fluoride during tooth development and usually occurs in years 0-8.3 However, the most susceptible time period for children to get fluorosis is between 15 and 30 months of age.3 This is the origin for avoiding fluoride in children under 2. Fluorosis can appear in many different ways ranging from mild to severe and is typically a cosmetic problem.3 Mild usually appears as lacy white markings through the enamel whereas severe appears as a dark brown color with surface irregularities or even pits in the enamel.3 Because fluorosis is caused by ingesting too much fluoride, the common suggestion became to avoid fluoride toothpaste until the child could expectorate.
In February of 2014, the American Dental Association (ADA) saw an increase in dental caries in children under 2 years of age. To combat this increase, the ADA stated that the new guidelines would be to begin using a smear or rice-sized amount of fluoride toothpaste beginning after the eruption of the first tooth.4 Fluorosis can only occur when too much fluoride is swallowed. However, using only a smear or rice-sized amount twice daily, even if ingested, will not alone cause dental fluorosis.3 Using the fluoride dentifrice will simultaneously minimize the risk of dental fluorosis while also acting as a caries prevention for young children.
Despite this rule changing 7 years ago, some things are still unclear, and it has to do largely with the packaging of toothpaste. Since brands have to make disclaimers, a big one usually appears on every toothpaste tube that says, “Children under 2: Ask a dentist or physician.” Every toothpaste tube containing fluoride says these words which leads the parents to assume it’s not the preferable choice for children under 2.
Dr. Man Wai Ng, the Dentist in Chief at Boston Children’s Hospital, says that these words of caution found on the label are meant to direct parents to visit the dentist.4 The problem is that people aren’t actually doing that. A 2015 survey conducted in Western University of health sciences’ College of Dental Medicine said that on average the general population brings their children for their first dental appointment at age 2.5.5 This means that these parents are relying on marketing verbiage and will most likely avoid using fluoride toothpaste until their child is at least 2. In addition to these misleading labels, there are training toothpastes, which are non-fluoridated toothpastes that also include the tagline “safe to swallow” which gives parents the green light to use at an early age. These are also misleading because they are placed directly next to children’s toothbrushes encouraging more people to associate that toothpaste with the toothbrush. Both of these tactics make parents, who are not consulting a dentist, choose the non-fluoridated option.
All of these are reasons that people seem confused when to begin using a fluoride dentifrice. Since there is very little that we can do to control the packaging and labels of dental hygiene products, we must make sure that we are educating our patients with the correct and most current information. The official ruling as of now is that all children should brush twice a day with a fluoride dentifrice immediately following the eruption of the first tooth.6 This is the information we must all be aware of and ready to educate our patients about. The more widespread we make this knowledge the more we can prevent early childhood caries.
About the Author
Rachael Straus (AKA The Pink Hygienist) originally is from Atlanta, GA and graduated from New York University’s Dental Hygiene Program. Aside from finding out about the latest and greatest in dental hygiene, her interests include the color pink, makeup artistry, tennis and reading.