The ADA(American Dental Association) currently advises caregivers to brush the teeth of children younger than 2 years with water, and to consult with a dentist or physician before using fluoride toothpaste. Use of a “smear” of flouridated toothpaste (approximately 0.1 gram of toothpaste or 0.1 milligram of fluoride) for children less than 2 years of age and use of a pea-sized amount of fluoride toothpaste (approximately 0.25 g toothpaste or 0.25 mg fluoride) is recommended for children from 2 to 6 years of age.
The optimal dose of fluoride is 0.05 mg per kilogram per day. Using a pea-sized amount of toothpaste versus a smear more than doubles the amount of fluoride potentially consumed by a child. For example, an average 2-year-old child who weighs 15 kg, brushes his or her teeth twice a day with a smear of toothpaste and swallows all of the toothpaste would ingest 0.2 mg of fluoride, resulting in a dose of 0.013 mg/kg. If this same child were to brush twice per day with a pea-sized amount of toothpaste and swallow all of the toothpaste, he or she would ingest 0.5 mg fluoride, resulting in a dose of 0.033 mg/kg. Children are exposed to fluoride through consumption of food and beverages. Considering these additional potential sources of fluoride and the risk of developing fluorosis at the time of tooth formation, the Council recommends use of a smear of toothpaste from eruption of the first tooth to age 3 years followed by use of a pea-sized amount for children aged 3 to 6 years. This regimen is intended to maximize the caries-preventive benefits of fluoride while further reducing the risk of developing fluorosis when compared with previous recommendations for use of a pea-sized amount of fluoride toothpaste starting when a child is 2 years of age.
Recommending fluoride therapy in children—whether it be fluoride supplements, toothpaste or professional topical applications—typically is tied to caries risk assessment, with fluoride therapies recommended for children who are at high risk of developing caries. All children should undergo a caries risk assessment before their dentists make recommendations associated with preventing or controlling dental caries. This is a critical step in developing a personalized prevention plan.
Considering the best available evidence and the continued high caries rate in children, the Council recommends the following:
For children younger than 3 years, caregivers should begin brushing children’s teeth as soon as they begin to come into the mouth by using fluoride toothpaste in an amount no more than a smear or the size of a grain of rice (Figure). Brush teeth thoroughly twice per day (morning and night) or as directed by a dentist or physician. Supervise children’s brushing to ensure that they use the appropriate amount of toothpaste.
For children 3 to 6 years of age, caregivers should dispense no more than a pea-sized amount (Figure) of fluoride toothpaste. Brush teeth thoroughly twice per day (morning and night) or as directed by a dentist or physician. Supervise children’s brushing to minimize swallowing of toothpaste.