Study says parents may overshoot fluoride toothpaste dose for toddlers, risking dental fluorosis

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In a recent study published in the journal Dr BDJ Open, researchers in Canada and Germany tested the dosage of fluoride toothpaste that parents gave children up to two years of age. Their findings suggest that many parents may be giving their children significantly more toothpaste than is optimal and should choose fluoride-free alternatives to avoid fluoride use.

Image credit: Inna Reznik/Shutterstock

Background

Although good oral hygiene during childhood is important for preventing tooth decay and other oral diseases, fluoride in toothpaste has raised toxic concerns about its safety for infants and young children.

The study also found that despite the frequent use of fluoride around the world, dental caries continue to be prevalent, with global estimates affecting nearly half of all children.

Fluoride can cause chronic toxicity and other adverse long-term effects. For this reason, guidelines in many regions of the world recommend limiting fluoride doses for young children to the size of a small grain or single grain of rice (up to 24 months of age) or a pea (for children under six). .

However, young children may swallow 64-100% of their toothpaste, putting them at risk of dental fluorosis because they are being systemically exposed to fluoride. Therefore, it is crucial to gather more information about how much toothpaste their parents are giving them.

About the study

In this study, the researchers hypothesized that it would be challenging for parents to follow guidelines that recommend giving two-year-old children a grain of rice worth of toothpaste. They tested this hypothesis by examining real-life doses of toothpaste given by parents to their children.

The study was conducted across five daycare centers in Germany, where parents were given two commercially available brands of toothpaste containing 1,000 ppm fluoride and suitable for children and asked to dose them as they normally would at home.

Photographs of children's toothbrushes with toothpaste A (left) and toothpaste B (right) at the reference dose (ie, a rice-sized grain of toothpaste recommended for toothpaste for 24-month-old children with 1000 ppm fluoride).  A natural grain of rice was used as a model.  Both amounts were dosed by an experienced dentist.

Photographs of children’s toothbrushes with toothpaste A (left) and toothpaste B (right) at the reference dose (ie, a rice-sized grain of toothpaste recommended for toothpaste for 24-month-old children with 1000 ppm fluoride). A natural grain of rice was used as a model. Both amounts were dosed by an experienced dentist.

To be included in the study, children had to use fluoride toothpaste regularly at home. Parents of children over the age of two were asked to provide a dose based on what they had done before the child’s second birthday. This was considered representative of how much they would give their children at home.

Each dose was weighed and compared to the ‘optimal’ recommendation of a grain. Parents were asked how often their child’s teeth were brushed each day to calculate fluoride exposure as well as their knowledge of the optimal dose.

Findings

Children were on average 24 months old at the time of the study and 61 parents met the inclusion criteria. More than 60% of parents said their children brush twice a day, while about 23% said they brush three times a day.

A reference dose of fluoride had a mean value of 0.039-0.045g; However, parents dose their children with an average of 0.263-0.281 grams of fluoride. The overdose factor was between 5.6 and 8.2.

More than 60% of parents are not aware of fluoride health warnings or conditions of its use. About 15% use fluoride tablets in addition to fluoride toothpaste for their children.

Conclusion

These results show that children may receive an excess dose of fluoride from their parents. The authors note that they may underestimate children’s exposure to the substance, because foods such as rice, cow’s milk and bananas, as well as drinking water and sometimes salt, also contain fluoride.

However, fluoride intake even through toothpaste is considered an upper limit to avoid dental fluorosis. Further studies should include a comprehensive risk assessment with other sources of fluoride and also consider the potential for neurotoxicity as a consequence. It should also take into account socio-economic factors.

One reason for the large dose size may be that television commercials often show excessive amounts of toothpaste on brushes. For example, previous research has shown that most advertisements depict a large swirl of paste that covers the entire brush head, exceeding the recommended dosage. The smell of toothpaste can be palatable to children, leading them to digest more.

Because providing the right amount of fluoride in rice cereal can be challenging for parents, researchers recommend using fluoride-free toothpaste varieties, some of which contain other anti-caries ingredients.

These may include calcium sodium phosphosilicate or hydroxyapatite, the latter of which has been shown to be protective against caries. It is safe for babies and toddlers if swallowed and can reduce bacterial colonization on tooth surfaces. Encouraging parents to replace fluoride toothpaste with effective and safe alternatives can promote oral care in young children – and keep them safe from fluorosis.

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