R E V I E W A RT I C L E

RM Davies
RP Ellwood
GM Davies

The rational use of fluoride

toothpaste

Authors affiliations:
RM Davies, RP Ellwood, Dental Health Unit,
Manchester, UK
GM Davies, Central Manchester Primary Care
Trust, Manchester, UK

Abstract: Well-formulated fluoride toothpastes are clinically

proven to prevent and control dental caries. They may also be a
risk factor in the aetiology of dental fluorosis. This review
considers the available evidence to support the appropriate use
of fluoride toothpaste to maximise the benefit and minimise the

Correspondence to:
RM Davies
Dental Health Unit,
Manchester Science Park,
Lloyd Street North,
Manchester M15 6SH, UK
Tel.: 44 161 232 4703
Fax: 44 161 232 4700
E-mail: robin.davies@man.ac.uk

risk. Three factors have an important influence on the anticaries

efficacy of fluoride toothpaste, namely concentration, frequency
of brushing and postbrushing rinsing behaviour. The evidence
suggests that low-fluoride (<600 ppm F) toothpastes provide
less caries protection than standard (1000 ppm F) or high
(1500 ppm F) concentration formulations. However, low-fluoride
toothpastes are appropriate for very young children (under
7 years) at low caries risk, particularly if living in fluoridated
areas. For other young children, higher concentrations of
fluoride should be used. Brushing should be recommended
twice daily, whilst rinsing with large volumes of water should be
discouraged. Small amounts of toothpaste are comparable in
efficacy to large amounts. The risk of fluorosis is associated with
the ingestion of high doses of fluoride during tooth development
and consequently only young children are at risk. The variability
in the dose of fluoride ingested is mainly a function of the amount
used, less so its concentration. To minimise fluorosis risk,
parents should be advised to use only a pea-sized amount of
toothpaste and encourage spitting out of excess. It is concluded
that by using fluoride toothpastes appropriately, the benefits
can be maximised and the risks of fluorosis minimised.
Key words: fluoride toothpaste

Dates:
Accepted 12 November 2001
To cite this article:
Int J Dent Hygiene 1, 2003; 38
Davies RM, Ellwood RP, Davies GM:
The rational use of fluoride toothpaste

Introduction
Fluoride toothpaste plays an essential role in any programme

Copyright # Blackwell Munksgaard 2003

designed to prevent dental caries in populations, communities

ISSN 1601-5029

and individuals. From a global perspective, fluoride toothpaste is

Davies et al. Rational use of flouride toothpaste

considered to have had the most significant impact of any inter-

fluoride concentration is an important factor affecting efficacy.

vention on the decline in dental caries (1), but there is evidence

Within the range 10002500 ppm F, an increase of around

that the swallowing of toothpaste by young children is associated

500 ppm F results in an additional 6% reduction in dental caries

with an increased risk of dental fluorosis in both fluoridated and

(13, 14). The clinical benefit of increased fluoride concentration is

non-fluoridated communities (210). Dental professionals are

accompanied by an increase in plaque fluoride levels (15).

frequently asked for advice regarding the choice and use of

Low-fluoride toothpastes, containing less than 600 ppm F, are

fluoride toothpaste, and it is important that this should be based

available for young children in many countries. In the UK, for

on the best available evidence. This review will consider the

example, where only 10% of the population receive fluoridated

factors that increase the benefits and minimise the risks asso-

water, 39% of 46-year-old children were reported to be using

ciated with fluoride toothpaste.

such toothpastes (16). Few clinical trials of low-fluoride toothpastes have been conducted in preschool children, the age group

Benefits

for which they are intended, but it seems likely that they would
be less effective than dentifrices containing 10001500 ppm F. In

Numerous clinical trials have demonstrated that the use of

a recent community-based programme, children initially aged

fluoride toothpaste reduced the caries increment by approximate-

12 months and living in deprived, non-fluoridated areas of the

ly 25% when compared with a non-fluoride toothpaste (11). How-

north-west of England, received free toothpaste until they were

ever, most clinical trials are conducted over 23-year time periods,

5 years of age. This study demonstrated that those children who

and while such intervals are sufficient to establish product effi-

had received toothpaste containing 1450 ppm F had significantly

cacy, they may underestimate the true magnitude of long-term

less caries experience at 5 years of age than either the group who

compound benefits. Recently, it was calculated that an improve-

had received toothpaste containing 440 ppm F or the control

ment of just 5% in caries prevention efficacy against a positive

group who had received no toothpaste other than that which they

control product would, in fact, have 10-year benefits of up to 15%

had purchased themselves (17). The mean dmft for the groups

and 20-year benefits of up to 28% (12). The efficacy of fluoride

were 2.18 (1450 ppm F), 2.55 (440 ppm F) and 2.60 (control).

toothpastes is potentially influenced by several factors, namely:

Toothpastes containing concentrations of fluoride higher than

 Fluoride concentration;

1500 ppm F have been shown to be significantly more effective in

 Frequency of use;

reversing root caries lesions in adults and have a place in the

 Amount used;

management of caries in the increasing, dentate elderly popula-

 Rinsing behaviour.

tion (18).

Fluoride concentration

Frequency of toothbrushing

In the European Union, the maximum permissible concentration

A number of clinical trials have reported an association between

of fluoride in a cosmetic dentifrice is 1500 ppm. Formulations

reported brushing frequency and caries incidence. In 3-year

with higher concentrations can only be purchased in pharmacies

clinical trials, the caries increments in subjects who brushed once

and in some countries, such as the UK, may only be available on

a day were 2030% more than those who brushed twice a day (14,

prescription. In the USA, most OTC dentifrices contain

19, 20). This association between brushing frequency and caries

1100 ppm F; formulations containing up to 1500 ppm F are

experience has also been reported in cross-sectional surveys of

available, but the labelling must indicate that they are for children

populations (21). While these data need to be interpreted with

over 6 years of age and adults living in non-fluoridated areas

some caution because of the association between reported brush-

considered to be at high caries risk. Dentifrices containing

ing frequency and other health indicators such as social class and

fluoride concentrations higher than 1500 ppm F are prescrip-

sugar consumption, it seems appropriate to recommend to brush

tion-only medicines.

twice daily. Such behaviour sustains elevated concentrations of

In most countries of the world, low-fluoride dentifrices, containing less than 600 ppm F, are available for young children. A

fluoride in plaque where it can inhibit dissolution of tooth mineral

by acid (22).

notable exception is the USA where, despite widespread water

Whether brushing should take place before or after eating is a

fluoridation, low-fluoride dentifrices are not marketed. The

debatable issue. Brushing before meals means that fluoride,

results of clinical trials of fluoride toothpastes have been reviewed

although present when eating takes place, is rapidly cleared by

extensively (11). Overall, the results support the conclusion that

saliva. If applied after eating, fluoride levels are sustained for

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Int J Dent Hygiene 1, 2003; 38

Davies et al. Rational use of flouride toothpaste

longer. There is no strong evidence to indicate which of these

a potential risk factor for fluorosis in a number of studies. The age

routines is more beneficial.

brushing commenced (2, 3, 7, 29), the frequency of brushing (57)

Evidence supports the recommendation that fluoride tooth-

and the amount of toothpaste placed on the brush (7, 10, 30) have

paste should be used prior to going to bed. Salivary flow rates

all been implicated as fluorosis risk factors. All of these factors are

decrease during sleep and the resultant reduction in buffering

associated with the inability of very young children to spit out and

capacity increases the risk of caries. Recently, it was demon-

the inevitable swallowing of toothpaste placed in the mouth.

strated that after using a toothpaste containing 1500 ppm F last

The ingestion of fluoride during the first 3 years of life appears

thing at night, the concentrations of fluoride in saliva 12 h later

to be the most critical for fluorosis of the aesthetically important

were comparable to those found 14 h after brushing during the

maxillary central incisor teeth (31, 32). In Britain, 49% of children

day (23).

aged 1.54.5 years were reported to have started toothbrushing

before the age of 1 year and another 40% had commenced the

Amount of toothpaste

Data concerning the effect that the amount of toothpaste has on

year after (21). The risk of fluorosis is related to the dose of

fluoride ingested which is a function of both the amount of
toothpaste ingested and its fluoride concentration.

efficacy is sparse. One study demonstrated that the mean salivary

The threshold level of fluoride ingested beyond which fluorosis

fluoride levels after brushing with 0.25 g of toothpaste was

may occur is not known accurately (33). The best data available

approximately one-third that obtained after brushing with 1.0 g

have been obtained from water fluoridation studies, which sug-

of toothpaste (24). However, a clinical trial of dentifrices contain-

gest that children should consume no more than 0.10 mg F/kg

ing 1000, 1500 and 2500 ppm F demonstrated a correlation

body weight (34), if an undesirable degree of fluorosis is to be

between plaque fluoride and increasing fluoride concentration

avoided. A lower threshold of 0.050.07 mg F/kg body weight has

of the dentifrices, but no correlation between plaque fluoride and

also been suggested (35). These thresholds are the best available

the amount of dentifrice used per application (25). These findings

but it should be noted that, whereas ingestion from fluoridated

were consistent with the caries increments observed and suggest

water produces a continuous low exposure to fluoride, ingestion

that the fluoride concentration of a dentifrice is more important

from toothpaste or tablets occurs less frequently and thus may

than the amount of fluoride applied in determining plaque

result in higher peak plasma levels. Such peak levels may result in

fluoride levels and efficacy.

a greater fluorosis risk for a given daily intake of fluoride.

In a recent cross-sectional study, an investigator asked 49

Rinsing behaviour

mothers of children aged 30 months to show how they normally

brushed their childs teeth. Twenty-four used a toothpaste con-

An important determinant of efficacy is the rinsing behaviour

taining 440 ppm F and the rest one containing 1450 ppm F (36).

after brushing with a fluoride toothpaste. In clinical trials, indi-

The amount of toothpaste and fluoride retained in the mouth

viduals who rinsed with large volumes of water had higher caries

were calculated. The mean weight of toothpaste placed on the

increments than those using smaller volumes (14, 19, 20). Whilst

brush was 0.3 g (range 0.091.0 g), the proportion ingested ranged

it is important to remove any excess toothpaste slurry from the

from 27 to 96% (mean 72%) and the mean weight ranged from

mouths of young children to minimise swallowing, vigorous

0.04 to 0.83 g. The mean weight of fluoride ingested per brushing

rinsing with water should be discouraged. Recently, it has been

using the 1450 ppm F toothpaste was 0.42 mg (range 0.05

demonstrated that using the toothpaste slurry as a rinse after

1.02 mg) compared with a mean of 0.10 mg (range 0.02

brushing can enhance the efficacy of fluoride toothpaste. A 26%

0.33 mg) for those using the 440 ppm F toothpaste. The potential

reduction in caries incidence of approximal surfaces was claimed

daily dose of fluoride ingested was calculated using the mean

for this method (26).

weight of the children and assuming that toothbrushing occurred

twice daily. For those using the 1450 ppm F toothpaste the mean

Risks

was 0.06 mg F/kg/day (range 0.0070.14) compared with

0.01 mg F/kg/day (range 0.0020.05) for those using the

The prevalence of fluorosis is reported to have increased in both

440 ppm F toothpaste. Using the 440 ppm F toothpaste twice

fluoridated and non-fluoridated communities in North America

daily, no child exceeded 0.05 mg F/kg body weight threshold.

(27), but a review of available data in the UK failed to substantiate

However, 14 out of 25 average-weight children would have

this claim on a population basis (28). Nevertheless, the use of

exceeded this value using the 1450 ppm F toothpaste; 7 would

fluoride toothpaste by very young children has been implicated as

have exceeded 0.07 mg F/kg body weight and 4 would have

Int J Dent Hygiene 1, 2003; 38

| 5

Davies et al. Rational use of flouride toothpaste

exceeded 0.10 mg F/kg body weight. The study reaffirms that the

completing a clinical trial, children, now aged 9 years but who had

amount of toothpaste applied is particularly important for young

used toothpaste containing either 550 ppm F or 1000 ppm F from

children, as they tend not to be able to spit out and hence swallow

2 to 5 years of age, were examined for fluorosis and compared with

a large percentage of the toothpaste applied. Whilst the risk of

a control group (43). Photographs of the maxillary incisor teeth

fluorosis is related to both the fluoride concentration and amount

were scored for fluorosis using the TF index. Two hundred and

of toothpaste swallowed and absorbed, this study indicated that

sixty-eight children (18%) and 825 (16%) of their teeth had a TF

the amount of toothpaste used has potentially a greater impact on

index score of 1 or higher. Significantly more children and teeth in

fluorosis risk than concentration.

both the 1000 ppm F toothpaste and control group had a TF score

Despite the fact that parents of young children are advised to

2 when compared with the group who had used the low-fluoride

supervise their children and apply a pea-sized amount of tooth-

toothpaste. However, there was no significant difference between

paste, many fail to do so. In the UK, manufacturers of toothpaste

the groups when the number of children or teeth with cosmeti-

have labelled their products with these instructions since 1990

cally unacceptable TF scores 3 were compared.

and yet 10% of children aged 1.54.5 were reported to have never
had their teeth brushed by an adult and 27% of 1.52.5-year-olds
brushed themselves (21). Furthermore, 58% of 1.52.5-year-olds

Summary

were reported to cover a small part of the brush with paste while

An important attribute of fluoride is that its benefits can be

37% covered half or more.

delivered in many ways. However, the versatility of fluoride is

Whilst the evidence indicates that early toothbrushing beha-

also its Achilles heel since young children may be exposed to too

viour may be associated with an increased risk of fluorosis, its

much fluoride which increases the risk of fluorosis. The available

impact on the prevalence of fluorosis in a population also depends

evidence supports the following advice regarding the use of

on how frequently this risk factor occurs in that population. The

fluoride toothpaste.

proportion of fluorosis observed in the population that can be

 Young children should be supervised when toothbrushing.

attributed to a particular risk factor is called the attributable risk.

 Parents should apply a smear or pea-sized amount (0.25 g) of

In a case/control study in a fluoridated community, it was esti-

toothpaste for young children.

mated that 71% of mild-to-moderate cases of fluorosis could be

 Teeth should be brushed twice a day, one occasion being last

attributed to having brushed more than once a day with more than

thing at night.

a pea-sized amount of toothpaste throughout the first 8 years of

 Excess paste should be spat out, not rinsed with a large volume

life (30). Brushing with no more than a pea-sized amount was not

of water.

associated with any increased risk. This emphasises the impor-

A professional decision concerning the appropriate concentra-

tance of parental supervision when dispensing toothpaste onto

tion of fluoride to advise should be made after considering the age

the toothbrush. In a further study, approximately one-third of

of the child or children, the degree of caries risk and possible

mild-to-moderate fluorosis cases in non-fluoridated areas and two-

exposure to other fluoride sources. From the preceeding discus-

thirds in fluoridated areas could be attributed to habits associated

sion of the appropriate use of fluoride toothpaste we would

with the early use of fluoride toothpaste (10).

recommend the amount of toothpaste to be used depending

Although there is some evidence that the prevalence of fluorosis has increased, it is important to know to what extent this is

on the age category, caries risk and fluoridated or non-fluoridated

water in Table 1.

perceived to be an aesthetic problem by those affected and their

parents. Several studies have addressed this issue (3740) and
there is general agreement that using the TF index (41), only

Table 1. Suggested use of fluoride toothpaste for different age

groups

Caries
risk

Water
fluoridated?

Toothpaste
advised
(ppm F)

Low
Medium
High
High

Yes or no
Yes or no
Yes
No

<600
10001100
1000 or 1100
1450

More than 6 years of age

All levels

Adults

High

cases with scores of 3 or more may be of aesthetic concern. In a

recent study in the UK, the prevalence of fluorosis in a fluoridated
community was 54% compared with 23% in a non-fluoridated
community (42). However, only 3% of subjects in the fluoridated

Age category
6 years of age or younger

area had a TF score 3 compared with 1% in the non-fluoridated

area. The prevalence of moderate-to-severe fluorosis in the USA
was reported to be extremely low at 1.3% (27).
Low-fluoride toothpastes have been specifically formulated for
young children to reduce the risk of fluorosis. After previously
6 |

Int J Dent Hygiene 1, 2003; 38

1100 or 1450
>1450

Davies et al. Rational use of flouride toothpaste

Acknowledgements
Robin Davies and Roger Ellwood are employees of the ColgatePalmolive Company.

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