When Baby V started sprouting teeth, I hopped online to find out how to deal with the new sharp, white inhabitants of her mouth. I found my answer quickly. I’m supposed to use a pea-sized amount of non-fluoridated toothpaste until baby turns 2 and then switch to fluoridated toothpaste. No wait. I should gently wipe my teeth and gums with a damp cloth. Not really. I’m supposed to clean, but only with water. Thank you, Internet, for the clarification.
Since my failed fact-finding mission, I’ve decided to brush Baby V’s teeth mornings and evenings with a little fluoride-free toothpaste. But as I started hearing more and more horror stories from toddlers with teeth so decayed that they had to be anesthetized to fill their cavities, I began to worry. We may need to add a little more caries-removing fluoride to our toothbrushing program.
That sounded like a reasonable plan until I started writing research papers stating that ingesting fluoride during gum growth can lead to white, chalky streaks on teeth, a condition called fluorosis. In higher amounts, fluoride can cause bone problems. Caught between a mouth full of rotten teeth on one side and a disfiguring disorder on the other, what should parents do?
You could try to ignore the problem that worked for me until last week when the American Dental Association (ADA) helpfully released new guidelines (with paywall, but read a press release here) on how to care for young children’s teeth. Based on a research study conducted by J. Tim Wright, a pediatric dentist at the University of North Carolina School of Dentistry at Chapel Hill, the ADA now recommends that children’s teeth appear immediately with a fluoride-containing toothpaste. The new recommendations also change the advice for older children: Children should continue to use a smear until their third birthday – not the previously recommended pea-sized amount. Children between the ages of 3 and 6 should use a pea-sized amount of fluoride toothpaste.
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Fluoride works to prevent tooth decay by rebuilding the teeth. Highly reactive fluoride adheres to molecules in the tooth that are exposed when acid produced by bacteria attacks the teeth. Fluoride molecules attach to the tooth and attract other minerals like calcium and phosphate in a process called remineralization.
The main anti-cavity superpowers of fluoride come from topical application to the tooth surface – exactly the situation when fluoridated toothpaste is used. When ingesting fluoride, levels throughout the body are raised. The resulting fluoride-rich saliva washes around the teeth and enables remineralization.
Scientists know that this process works in adults. There aren’t any good studies on preventing fluoride cavities in young children, but fluoride is believed to have similar protective effects, Wright says. “Our knowledge always has gaps,” says Wright. But there’s enough evidence to convince him that the new guidelines will also help prevent tooth decay and fluorosis, he says.
The ideal fluoride level that prevents tooth decay but has no negative effects is around 0.05 milligrams per kilogram of body weight per day. (That limit is probably questionable, especially for young children, but that’s another post.) In the updated guidelines, the ADA calculates the likely exposure of children to fluoride from toothpaste: Assuming that an average-sized 2-year-old age her teeth brushing twice a day and swallowing the toothpaste, a toothpaste (about the size of a single grain of rice) would yield 0.013 milligrams of fluoride per kilogram of body weight per day. But a pea-sized blob would add up to 0.033 milligrams per kilogram. That’s nearing the level at which fluorosis could become a problem, Wright says.
Since studies have shown that the risk of fluorosis in some permanent teeth peaks around the age of 2, it makes sense for children between the ages of 2 and 3 to only use a swab with fluoridated toothpaste, especially since fluoride comes from sources other than toothpaste . The water in my city has fluoride added to it to reach 0.7 ppm. (In case you’re wondering, Brita filters won’t get rid of fluoride.) In such small amounts, “you have to drink a shipload of water” to get enough fluoride to cause fluorosis, Wright says. Likewise for food: fish, especially canned fish that contains bones, and tea can both be high in fluoride, but these are usually not a large part of a young child’s diet.
Perhaps a bigger problem: Parents should be careful about using too much fluoridated toothpaste – a fairly common habit, studies have shown. “People tend to think that a little is good, more is better,” says Wright.
Not so. For young children who cannot spit out toothpaste yet, parents can wipe the excess toothpaste off their teeth after brushing their teeth. (But not with water, Wright says. A water rinse washes away some of the benefits of fluoride.)
The new recommendations may not be ideal for people who drink well water with abnormally high levels of fluoride. But most young children in the United States should use some fluoride toothpaste, Wright says.
In a nutshell, while there isn’t any good data to show that small amounts of fluoride toothpaste prevent tooth decay in young children, it is likely to help more than it hurts. So I have my partial, best guessed answer. Tonight I’m going to buy fluoride toothpaste and smear Baby V. But only a little.
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