Toothpaste for Brushing Baby's Teeth - Yes or No ?

The question, “should I use toothpaste for brushing baby’s teeth?” doesn’t have a straight forward answer.  It seems, authorities around the world differ in their recommendations regarding toothpaste use, starting age, how much to use, etc.

Toothpaste – Yes or No ?

One of the reasons, is because of differing opinions over why toothpaste is necessary in the first place. According to the International Association of Paediatric Dentistry, if toothbrushing is primarily carried out to remove food from around teeth and gums, then toothpaste is not really needed. (1-3) The physical movement of the toothbrush over teeth and gums will achieve this mechanical function. However, if the process of toothbrushing is to optimize protection of teeth and gums against dental diseases such as tooth decay, then addition of toothpaste is needed. Toothpastes contain active ingredients that provide non-mechanical benefits. For example, fluoride helps with remineralization (the process of replacing minerals at tooth surfaces to compensate for demineralization damages). Toothpastes also neutralize acids, freshens breath and improves the pleasantness of toothbrushing. (3,4)

On the other hand, dental fluorosis risks increase with earlier use of the fluoridated toothpaste in young children. Dental fluorosis is a type of enamel defect that affects developing teeth as a result of excess ingestion of fluoride. (5) In its mild forms, dental fluorosis is primarily of aesthetic concerns but when dental fluorosis is severe, hypersensitivity and structural breakdown of the affected teeth can occur as well.

The general consensus from dental health and health authorities, such as the World Health Organization, World Dental Federation and the available scientific literature, is for the use of fluoridated toothpaste but there are conflicting suggestions about when to start using toothpaste and how much toothpaste to use. (6)

Toothpaste –  When to Start ?

When it comes to the age for commencing toothpaste, there appears to be 2 main schools of thoughts among dental and oral health authorities.

1. Use toothpaste as soon as teeth emerges (usually 6-7 months of age):

The American Dental Association(7), American Academy of Pediatric Dentistry(8,9), and National Health Services in England(10) are very clear in their guidance: “use toothpaste for toothbrushing baby’s teeth as soon as teeth emerge into the mouth.”

The New Zealand Dental Association(11) articulates that a smear of fluoride toothpaste should be used for toothbrushing infants. Infants generally refer to children under the age of 1yr.

2. Use toothpaste after baby is a bit older (past infant stage):

The Australian Dental Association(12) is very specific: “no toothpaste until 18 months of age”.  

Other authorities such as the International Paediatric Association of Dentistry, World Health Organization, Canadian Dental Association promote the benefits of using a fluoride toothpaste but do not appear to specify when to start using one.

The differences in recommendations may be related to some authorities being more concerned regarding increased risk of dental fluorosis with use of fluoride toothpaste in children <12mths of age. A 2010 Cochrane systematic review by Wong et al. (5), articulated that, “there is weak unreliable evidence that starting the use of fluoride toothpaste in children under 12 months of age may be associated with an increased risk of fluorosis. The evidence for its use between the age of 12 and 24 months is equivocal.”

Toothpaste – How Much to Use ?

Scientifically, researchers have recommended that the optimal dose of fluoride is approximately 0.05mg per kilogram body weight per day. (1) Since babies weigh only very light and cannot spit out the toothpaste, this generally means less fluoride is needed.

Two things need to be considered when it comes to how much toothpaste. One, the concentration of fluoride in the selected tube of toothpaste and two, the amount applied to the toothbrush each time.  Two 2010 systematic reviews published by the respected Cochrane Collaboration confirmed that 1000ppm fluoride toothpaste is beneficial for the prevention of dental decay in children but offer slightly different perspectives in their conclusions:

• Wong et al. (5) suggested, “If the risk of fluorosis is of concern, the fluoride level of toothpaste for young children (under 6 years of age) is recommended to be lower than 1000ppm”.
• Walsh et al. (13) concluded that dental decay prevention is “only significant for fluoride concentration of 1000ppm and above. The relative caries preventive effects of fluoride toothpastes of different concentrations increase with higher fluoride concentration. The decision of what fluoride levels to use for children under 6 years should be balanced with the risk of fluorosis.”

Adding to this was a 2015 study which highlighted that sodium lauryl sulphate in toothpastes may be more effective in inhibiting oral bacteria than children’s toothpastes with low fluoride 500ppm or less. (14)

Dental authorities again vary in their recommendations regarding how much fluoride to use for the very young children. For example,

• American Dental Association and American Academy of Pediatric Dentistry support using 1000ppm F toothpaste and advise “no more than a smear or rice-sized amount (0.1mg F) for children less than 3 years of age; and no more than a pea-sized amount for children aged 3-6yrs (0.25mg F).” (7-9)
• Canadian Dental Association also recommends a rice grain size of fluoridated toothpaste for children under 3yrs but noted that “the use of fluoridated toothpaste is determined by level of risk” in children under 3yrs. (15)
• National Health Services in England stated, “children up to the age of six who don’t have tooth decay can use a lower-strength toothpaste, but make sure it contains at least 1000ppm fluoride. Below the age of three years, children should use just a smear of toothpaste. Children aged three to six should use a pea-sized blob of toothpaste.” (10)
• Australian Dental Association’s policy statement suggests, “For children aged 18 months to five years (inclusive), the teeth should be cleaned twice a day with toothpaste containing 0.5-0.55mg/g (500-550ppm) of fluoride. A small pea-sized amount should be applied. Children should spit out, not swallow, and not rinse. For children who do not consume fluoridated water, or who are at elevated risk of developing dental decay, guidelines about toothpaste usage must be varied, as needed, based on dental professional advice. Variations could include more frequent use of fluoridated toothpaste, toothpaste containing 1mg/g (1000ppm) fluoride.” (12)
• Australian and New Zealand Society of Paediatric Dentistry and Australasian Academy of Paediatric Dentistry advise, “only a rice grain sized smear of toothpaste is needed before the age of two and a pea sized piece of toothpaste is needed after age two.” (16, 17)

It is worthwhile considering that guidelines and recommendations may be region specific. In addition to scientific findings, authorities generally issue advice after considering factors specific to their communities, e.g. population risks of dental decay, level of fluoride in water and other dietary sources, etc. (6)

For specific advice tailored to your baby and your family’s risks and needs, it is always best to see your dentist or paediatric dentist.

The basic consensus? It's a YES to fluoridated toothpaste – but remember, more is not better!

Toothpaste – Other Tips ?

To optimize the use of fluoride toothpastes, keep these general principles in mind:

• Parent/carer to brush children’s teeth twice a day (morning and night) and supervise the use of toothpaste at all times (6-9, 11,12)
• Do not rinse with water after toothbrushing but encourage spitting out the toothpaste if possible (6-9, 11, 14)
• Avoid toothpastes that closely resembles popular food flavours to avoid accidental excess ingestion, especially by very young children. (6, 12)
• Toothpastes with less than 1000ppm F is less beneficial for dental decay prevention than toothpastes with 1000ppm F or more. (13)
• Fluoride in toothpastes may be labelled in a variety of ways, read the labels carefully before buying. For example, 500ppm F = 0.11% sodium fluoride (NaF) = 0.38% sodium monofluorophosphate (NaMFP) vs. 1000ppm F = 0.22% sodium fluoride = 0.76% sodium monofluorophosphate.(18).

Hugs & Smiles

TaTa

REFERENCES

1. International Association of Paediatric Dentistry. Parents Information. Children 0-2 years of age www.iapdworld.org/parents/super_pages.php?ID=parents1#3
2. International Association of Paediatric Dentistry. Parents Information. Children 2-5 years of age www.iapdworld.org/parents/super_pages.php?ID=parents2#3
3. Ten Cate JM. Contemporary perspective on the use of fluoride products in caries prevention. Br Dent J 2013; 214(4): 161-167. doi: 10.1038/sj.bdj.2013.162.
4. Wilkins E. Clinical Practice of the Dental Hygienist. 9th edition. Philadelphia: Lippincott Williams & Wilkins, 2005.
5. Wong MC, Glenny AM, Tsang BW, Lo EC, Worthington HV, Marinho VC. Topical fluoride as a cause of dental fluorosis in children. Cochrane Database Syst Rev 2010; 20(1): CD007693. doi: 10.1002/14651858.CD007693.pub2.
6. O’Mullane DM, Baez RJ, Jones S, Lennon MA, Petersen PE, Rugg Gunn AJ, Whelton H, Whitford GM. Fluoride and Oral Health. Community Dent Health 2016; 33: 69-99.
7. American Dental Association Council on Scientific Affairs. Fluoride toothpaste use for young  children. J Am Dent Assoc 2014; 145(2): 190-191.
8. American Academy of Pediatric Dentistry Policy on Use of Fluoride. 2014. Accessed online: www.aapd.org/assets/1/7/P_FluorideUse1.PDF
9. American Academy of Pediatric Dentistry Guideline on Fluoride Therapy. 2014. Accessed online: www.aapd.org/assets/1/7/G_FluorideTherapy1.PDF
10. National Health Services in England. Children’s Teeth. 2015. Accessed online: http://www.nhs.uk/Livewell/dentalhealth/Pages/Careofkidsteeth.aspx
11. New Zealand Dental Association. Your Oral Health: Infants and Toddlers.  Accessed online: www.healthysmiles.org.nz/your-oral-health/infants-toddlers/
12. Australian Dental Association. Policy Statement 2.2.1 – Community Oral Health Promotion: Fluoride Use (Including ADA Guidelines for the Use of Fluoride) 2014. Accessed online: https://www.ada.org.au/Dental-Professionals/Policies/National-Oral-Health/2-2-1-Fluoride-Use/ADAPolicies_2-2-1_FluorideUse_V1
13. Walsh T, Worthington HV, Glenny AM, Appelbe P, Marinho VC, Shi X. Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents. Cochrane Database Syst Rev 2010; 20(1): CD007868. doi: 10.1002/14651858.CD007868.pub2.
14. Evans A, Leishman SJ, Walsh LJ, Seow WK. Inhibitory effects of children’s toothpastes on Streptococcus mutans, Streptococcus sanguinis and Lactobacillus acidophilus. Eur Arch Paediatr Dent 2015; 16(2): 219-226. doi: 10.1007/s40368-014-0159-3.
15. Canadian Dental Association. Your Oral Health. Cleaning Teeth. Accessed online: https://www.cda-adc.ca/en/oral_health/cfyt/dental_care_children/cleaning.asp
16. Australiasian Academy of Paediatric Dentistry. Tooth Toughening with Fluoride. 2014. Accessed online: www.aapd.org.au/articles/tooth-toughening-with-fluoride
17. Australia and New Zealand Society of Paediatric Dentistry. Tooth Toughening with Fluoride. 2014. Accessed online: www.anzspd.org.au/articles/tooth-toughening-with-fluoride
18. Fejerskov Ol, Kidd E, eds. Dental Caries. The Disease and its Clinical Management. 2nd Ed. Oxford: Blackwell Munksgaard, 2008.