By David A. Albert, D.D.S., M.P.H.
Columbia University College of Dental Medicine

The toothpaste tastes like bubble gum. The kids love it so much, they're happy to brush their teeth.

This can only be good, right?

So why does the toothpaste package say that an adult should supervise brushing? Why so much concern for a product that has universally been regarded as safe and effective?

It's all because of the fluoride in the toothpaste. Yes, fluoride is good for teeth. It can strengthen them and prevent dental cavities. That's why it's in the toothpaste.

But too much fluoride is not good for the teeth that are still developing under the gums. It can cause dental fluorosis — white or brown spots on the teeth. Preventing fluorosis is the main reason that you need to supervise brushing for young children.

Permanent teeth develop from birth through around 16 years of age. Dental fluorosis is labeled from very mild to severe. Many of us have mild fluorosis (a few white specks on our teeth). Moderate or severe fluorosis appears as brown deformities known as "mottling" on the permanent teeth.

We can obtain fluoride from fluoridated water supplies and many products we eat or drink. So why be concerned with the amount of toothpaste your child is using?

First of all, the amount of fluoride in toothpaste is many, many times more than that found in drinking water. Most parents are surprised to learn that children's toothpaste contains the same amount of fluoride as adult toothpaste (1,000 to 1,100 parts per million).

Children's toothpastes are frequently flavored like candy to broaden their appeal. Some of them are dispensed with sparkles. Others have cartoons on the bottle or tube. Because these toothpastes are fun to use, an unsupervised child or a misinformed parent may use too much. Only a pea-sized amount is recommended.

In addition, young children (especially before the age of 3) may not have complete control of their swallowing reflex. They may end up swallowing some toothpaste when brushing. In young children who cannot spit properly, almost all of the toothpaste is swallowed.

If this happens every day, your child is at an increased risk for mild dental fluorosis. Occasionally, moderate to severe fluorosis occurs.

What should a parent do?

• Always use fluoride toothpaste to brush children's teeth. The use of fluorides in toothpaste and mouth rinses has been absolutely proven to prevent dental cavities. Using these products, along with fluoridated water, reinforces children's teeth. This can help them to be caries (cavity) free.



• Instruct your children in the proper use of toothpaste. Monitor them carefully while they are brushing. Supervise; don't assume that your child can use the product without supervision.



• If your child is under age 3, brush the child's teeth yourself. For proper technique, see our video, Brushing Your Child's Teeth.



• If your children are 3 to 6 years old, you can allow them to brush their teeth, to get them used to the process. But then you should thoroughly brush their teeth afterward to make sure the job gets done right. Children in this age group usually do not have the coordination to brush their teeth on their own.



• Generally, a child who is able to brush responsibly can be allowed to brush without supervision. For some children, this could be as early as 7 years old. Others who have not shown that they can brush and use toothpaste properly should be supervised until they are older.

Since children must use toothpaste with caution, why don't we have lower levels of fluoride in toothpaste in the United States? In Europe, toothpastes containing lower levels of fluoride are available.

The main reason is that toothpaste manufacturers want to be able to label their products as anti-cavity. The U.S. Food and Drug Administration allows them to be labeled this way now. That's because it agrees with the manufacturers' research findings that toothpaste containing 1,000 to 1,100 parts per million of fluoride prevents cavities.

In order to make the same claim with low-fluoride toothpaste, manufacturers would need to conduct more research. They would have to study whether toothpastes with less fluoride also prevent dental cavities.

Even if lower-fluoride toothpastes were available, parental supervision and caution would still be needed. However, children would be at much lower risk of developing dental fluorosis on their developing and erupting permanent teeth.

In August 2001, the U.S. Centers for Disease Control and Prevention urged manufacturers to research the effectiveness of lower fluoride toothpaste for children. Six years later, no studies have been published in the United States.

Bubble gum flavored toothpaste may taste good, but that does not mean it's always safe for children to use. To avoid the increased risk of dental fluorosis, always follow the package directions, and supervise your child's brushing.

David A. Albert, D.D.S., M.P.H., is an associate professor and associate director of community health at the Columbia University College of Dental Medicine. He also holds an appointment in the Joseph Mailman School of Public Health at Columbia University. He maintains a practice within the ambulatory care network of the Columbia DentCare program in the community of Washington Heights/Inwood in Northern Manhattan.