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Publications

Published: 1 June 2017

Fluoride Content in Toothpaste for Children

Prescriber Update 38(2): 23-24
June 2017

Key Messages

  • Reduction of dental caries by fluoride toothpaste is balanced against the increased risk for dental fluorosis due to toothpaste ingestion by young children.
  • Toothpastes containing less than 1,000 ppm fluoride are not recommended for use at any age in New Zealand.
  • To minimise the risk of ingestion of toothpaste, children should be supervised when brushing their teeth, a smear of toothpaste (five years and under) or a pea-sized amount (six years and over) should be used and children should be taught to spit out any excess.
  • Toothpaste should be kept out of reach of children.


The use of fluoride toothpaste is an important public health measure to both prevent and reduce the severity of dental caries in all age groups. The protective effect of fluoride against caries is well recognised.

Fluoride works topically primarily by reducing demineralisation and enhancing remineralisation of enamel, reducing the susceptibility of the teeth to caries progression. A sustained level of fluoride in plaque and on the enamel surface is desirable and one important source is fluoride toothpaste. Fluoride in toothpaste is usually in the form of sodium fluoride (NaF) or sodium monofluorophosphate (MFP).

Commercially available fluoride toothpastes for general sale in New Zealand have differing levels of fluoride content ranging from approximately 500 parts per million (ppm) to 1,450 ppm fluoride. The 500 ppm formulations are labelled for children under six years by manufacturers, leading to confusion for consumers, as these low fluoride toothpastes are not recommended at any age in New Zealand1.

The New Zealand Guidelines for the Use of Fluoride recommend that 1,000 ppm fluoride toothpaste is used for children of all ages2. A recent Cochrane review found limited evidence of any caries preventive effect following use of toothpaste with less than 1,000 ppm fluoride3. Commencing tooth brushing with fluoride toothpaste before two years of age is associated with enhanced caries prevention.

The beneficial effects of fluoride toothpaste must be counterbalanced against the risk of dental fluorosis from its ingestion. The risk of dental fluorosis is of aesthetic concern and relates to ingestion of excess fluoride in children under age five years.

New Zealand studies show that the prevalence of diffuse enamel opacities that may be fluoride-related has not increased over time and that all cases recorded were either mild or very mild4-6. The evidence regarding the role of fluoride toothpaste in contributing to the risk of fluorosis is conflicting and may be related to the amount used, the concentration used and commencing use before age 12 - 14 months7.

New Zealand recommendations for toothpaste use in young children balance the issue of caries prevention and avoidance of moderate or severe dental fluorosis. The recommendation to use toothpaste of at least 1,000 ppm fluoride addresses the lack of evidence of a caries preventive effect for toothpaste below this concentration.

The recommendation to use a smear of toothpaste for children five years and under controls the amount of toothpaste that should be used. The recommendation to commence use of toothpaste as soon as teeth begin to emerge (approximately six months) recognises that teeth are at risk of dental caries from that time, the high levels of early childhood dental caries in New Zealand children and the lack of evidence of moderate or severe dental fluorosis in New Zealand children8.

Pharmacies and dental practices can also supply a 5,000 ppm fluoride toothpaste, which is not suitable for general use, but may be recommended in specific cases mainly in adults and in older children with high levels of dental caries. This toothpaste should be limited to use on the recommendation of an oral health professional.

References
  1. Li J, Dallas S, McBride-Henry K. 2016. Use of full strength fluoride toothpaste among preschoolers in New Zealand, and factors determining choice. New Zealand Medical Journal 129: 44-51.
  2. New Zealand Guidelines Group. 2009. Guidelines for the Use of Fluoride. Wellington: Ministry of Health.
  3. Walsh T, Worthington HV, Glenny AM, et al. 2010. Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents. The Cochrane Database of Systematic Reviews. CD007868. doi: 10.1002/14651858.CD007868.pub2 (accessed 26 April 2017).
  4. Kanagaratnam S, Schluter P, Durward C, et al. 2009. Enamel defects in 9-year-old children living in fluoridated and nonfluoridated areas of Auckland, New Zealand. Community Dentistry and Oral Epidemiology 37: 250-9.
  5. Schluter PJ, Kanagaratnam S, Durward C, et al. Prevalence of enamel defects and dental caries among 9-year-old Auckland children. New Zealand Dental Journal 2008; 104: 145-152.
  6. Mackay TD, Thomson WM. 2005. Enamel defects and dental caries among Southland children. New Zealand Dental Journal 101: 35-43.
  7. Wright JT, Hanson N, Ristic H, et al. 2014. Fluoride toothpaste efficacy and safety in children younger than 6 years. Journal of the American Dental Association 145:182-9.
  8. Ministry of Health. 2010. Our Oral Health: Key findings of the 2009 New Zealand Oral Health Survey. Wellington: Ministry of Health.
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