56 l © 2025 American Dental Association
Section 2: Safety
29. What can be done to reduce the occurrence of dental fluorosis
in the United States?
Answer
The vast majority of dental fluorosis in the country can be prevented by limiting the ingestion of
topical fluoride products such as toothpaste and recommending the appropriate use of dietary
fluoride supplements—without denying young children the decay-prevention benefits of community
water fluoridation, the recommended optimal concentration of which has been reduced to better
balance caries and fluorosis prevention.
Fact
Tooth decay has decreased substantially in the country because more children today than decades ago
are benefitting from access to fluoride that is available from a wide variety of sources. Many of these
sources are intended for topical use only however, when they are used, some fluoride is inadvertently
swallowed by children.210,211,260 Inappropriate ingestion of topical fluoride can be minimized, thus
reducing the risk for dental fluorosis without reducing decay prevention benefits.
Fluoride Toothpaste
Fluoride toothpastes are effective in helping to prevent tooth decay, but the ingestion of fluoride from
toothpaste is a major risk factor for enamel fluorosis.210,211,260 Data from NHANES found that more than
38% of children aged 3 to 6 years used more than the recommended amount of toothpaste for their
age group.264
To decrease the risk of dental fluorosis, the ADA recommends:218
“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. (See Figure 4 in Question 23.) 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 3–6 years of age, caregivers should dispense no more than a pea-sized amount
(Figure 4) 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.”
The reason for including age information on directions for use of fluoride toothpaste is that it takes
into account the ages during which teeth are most susceptible to dental fluorosis (during the time
when the teeth are forming under the gums). Additionally, until approximately 6 years of age, children
have not developed the full ability to spit and not swallow toothpaste. Inadvertently swallowing
toothpaste during brushing can increase the risk of dental fluorosis. After age 8, the enamel formation
of permanent teeth (with the exception of the third molars) is basically complete 236 therefore, the
risk of developing dental fluorosis is minimal. Because dental fluorosis occurs while teeth are forming
under the gums, teeth that have erupted are not at risk for enamel fluorosis.
Additional information on this topic can be found in this Section, Question 27.
Several studies have established a direct association between young children brushing with more than a
pea-sized amount of fluoride toothpaste and the risk for very mild or mild dental fluorosis in fluoridated
or non-fluoridated communities.210,211,216,239,260 It was noted that 34% of the dental fluorosis cases in a
Section 2: Safety
29. What can be done to reduce the occurrence of dental fluorosis
in the United States?
Answer
The vast majority of dental fluorosis in the country can be prevented by limiting the ingestion of
topical fluoride products such as toothpaste and recommending the appropriate use of dietary
fluoride supplements—without denying young children the decay-prevention benefits of community
water fluoridation, the recommended optimal concentration of which has been reduced to better
balance caries and fluorosis prevention.
Fact
Tooth decay has decreased substantially in the country because more children today than decades ago
are benefitting from access to fluoride that is available from a wide variety of sources. Many of these
sources are intended for topical use only however, when they are used, some fluoride is inadvertently
swallowed by children.210,211,260 Inappropriate ingestion of topical fluoride can be minimized, thus
reducing the risk for dental fluorosis without reducing decay prevention benefits.
Fluoride Toothpaste
Fluoride toothpastes are effective in helping to prevent tooth decay, but the ingestion of fluoride from
toothpaste is a major risk factor for enamel fluorosis.210,211,260 Data from NHANES found that more than
38% of children aged 3 to 6 years used more than the recommended amount of toothpaste for their
age group.264
To decrease the risk of dental fluorosis, the ADA recommends:218
“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. (See Figure 4 in Question 23.) 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 3–6 years of age, caregivers should dispense no more than a pea-sized amount
(Figure 4) 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.”
The reason for including age information on directions for use of fluoride toothpaste is that it takes
into account the ages during which teeth are most susceptible to dental fluorosis (during the time
when the teeth are forming under the gums). Additionally, until approximately 6 years of age, children
have not developed the full ability to spit and not swallow toothpaste. Inadvertently swallowing
toothpaste during brushing can increase the risk of dental fluorosis. After age 8, the enamel formation
of permanent teeth (with the exception of the third molars) is basically complete 236 therefore, the
risk of developing dental fluorosis is minimal. Because dental fluorosis occurs while teeth are forming
under the gums, teeth that have erupted are not at risk for enamel fluorosis.
Additional information on this topic can be found in this Section, Question 27.
Several studies have established a direct association between young children brushing with more than a
pea-sized amount of fluoride toothpaste and the risk for very mild or mild dental fluorosis in fluoridated
or non-fluoridated communities.210,211,216,239,260 It was noted that 34% of the dental fluorosis cases in a
