The trick-or-treating may be over but the enjoyment of your child’s “loot” may just be starting. Now would be a good time to discuss dental caries (cavities). In Dr. Charlotte W. Lewis’s fine review of the role of fluoride in preventing childhood cavities, we are reminded of some important principles regarding dental health:

• Children living in poverty are at highest risk of developing tooth decay. Although the reason for this is still not well-understood, Dr. Lewis explains that “in 2008, just 38% of Medicaid-enrolled children, ages 2 to 18 years, received dental care in the previous year.”

• Other risk factors of cavities in children include a history of previous cavities, visible plaque on teeth, consumption of sugar-sweetened beverages and candies, suboptimal fluoride exposure, and infrequent toothbrushing.

• Dental decay is caused by infectious, cariogenic  bacteria which produce acids in the mouth. Dr. Lewis says: “These acids dissolve the calcium-phosphate mineral of a tooth’s enamel during a process called demineralization. If not reversed through remineralization, the tooth structure erodes until the demineralized area collapses, resulting in a cavity.”

• “Fluoride is highly effective in preventing dental caries” by promoting remineralization of the tooth’s enamel.

• “CWF [community water fluoridation] is considered among the 10 greatest US public health achievements of the 20th century and one of the few public health interventions with clear-cut, significant cost-effectiveness.”


It was once thought that ingesting fluoride in water or in vitamin supplements resulted in cavity protection, even before the first tooth erupts during infancy. However, based on decades-old research, we now know that the main action of fluoride is topical rather than systemic. Throughout our lifespans, the health of our teeth is determined by-and-large by a careful balance of demineralization and remineralization occurring on teeth enamel:

When low levels of fluoride are sustained in saliva (after drinking fluoridated water or brushing with fluoride toothpaste [FTP]), the enamel demineralization and remineralization balance is pushed toward remineralization. Fluoride aids in incorporation of calcium and phosphate into enamel and is itself incorporated into enamel during mineralization.


Too much fluoride, especially when it is swallowed in large amounts, can be detrimental and cause fluorosis. Dr. Lewis describes fluorosis as “localized changes to tooth enamel, presenting in its mild forms as white markings on the teeth.” Severe fluorosis, which is rare in the U.S., can cause pitting of the enamel and increase the risk of cavities. Community water fluoridation has led to decades of anti-fluoridation controversies, misinformation, and conspiracy theories; Dr. Lewis effectively debunks all of it. Still, there is that “Goldilocks” range where children should receive not too much or too little fluoride to protect their teeth while avoiding fluorosis. Based on the evidence noted above, here are the current recommendations regarding the prevention of tooth decay in children:

• Children under the age of 2 years old should  brush with a rice-size smear of fluoride toothpaste (FTP — 1,000 ppm); children older than 2 should use a pea-size amount of FTP. Since children swallow most, if not all, of the toothpaste during brushing, it’s important to limit the amount used. Also, since fluoride works topically, do not rinse the teeth after brushing.

• Begin twice daily brushing in all children with fluoride toothpaste by one year of age and by 6 months old in all high risk (low-income) children.

• High risk, low-income children should receive topical fluoride varnishes at least twice a year beginning at one year of age. Fluoride mouthwash rinses should be considered for high-risk children older than 6 years old.

• Juices and sugar-sweetened beverages should be avoided, especially at bedtime, because they are known to cause cavities. Drinking fluoridated water regularly should be encouraged because it decreases the risk of cavities.


And don’t forget to floss!


Read more about pediatric dental health on The PediaBlog here.


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