Fluoride

Toothpastes containing fluoride significantly reduce the incidence of dental caries. Fluoride promotes enamel remineralisation through the formation of fluoride-containing apatites (eg fluorhydroxyapatite, fluorapatite), which are more resistant to future acid challenge than the carbonated hydroxyapatites of normal tooth enamel. Toothpastes that do not contain fluoride provide little protection against dental caries.

Note: Toothpastes that do not contain fluoride provide little protection against dental caries.

The recommended concentration of fluoride toothpaste varies according to age and risk of dental caries (see Recommended concentration of fluoride toothpaste according to age and risk of dental caries). Children up to 6 years of age are at increased risk of dental fluorosis—a mineralisation disorder of the teeth caused by excessive ingestion of fluoride during the tooth-forming years. In patients with dental fluorosis, the porosity of the subsurface enamel is increased and discolouration can occur (eg white spots, mottling).

To minimise ingestion of fluoride, after brushing the teeth, toothpaste should be spat out and not swallowed. The mouth should not be rinsed, to allow increased uptake of fluoride from the saliva.

Note: Do not rinse the mouth after brushing with fluoride toothpaste.

Table 1. Recommended concentration of fluoride toothpaste according to age and risk of dental caries
[NB1]
Printable table
Toothpaste for people not at elevated risk of dental caries Toothpaste for people at elevated risk of dental caries
Toothpaste for people not at elevated risk of dental caries
child younger than 18 months	twice-daily brushing without toothpaste
child 18 months to younger than 6 years	500 to 550 ppm (0.5 to 0.55 mg/g) fluoride twice daily, pea-sized amount [NB2]
child 6 years to adolescent	1000 to 1500 ppm (1 to 1.5 mg/g) fluoride twice daily
adolescent or adult	1000 to 1500 ppm (1 to 1.5 mg/g) fluoride twice daily
Toothpaste for people at elevated risk of dental caries [NB3]
child younger than 18 months	twice-daily brushing with toothpaste may be recommended [NB2]
child 18 months to younger than 6 years	1000 ppm (1 mg/g) fluoride twice daily [NB2] OR more frequent use of 500 to 550 ppm (0.5 to 0.55 mg/g) fluoride [NB2]
child 6 years to adolescent	more frequent use of 1000 to 1500 ppm (1 to 1.5 mg/g) fluoride [NB2]
adolescent or adult	5000 ppm (5 mg/g) fluoride twice daily OR more frequent use of 1000 to 1500 ppm (1 to 1.5 mg/g) fluoride
Note: ppm = parts per million NB1: Spit out fluoride products to minimise ingestion; do not rinse the mouth after use to allow increased uptake of fluoride from the saliva. NB2: Advise parents of the risk of fluorosis and the need to supervise toothbrushing. NB3: Toothpaste use may be varied as needed, based on the dentist's clinical judgment.

Use other topical fluoride products (eg mouthwash, gel, varnish) in patients at elevated risk of dental caries (see Examples of topical fluoride applications for patients at elevated risk of dental caries).

Water fluoridation is an effective, inexpensive and safe community health measure to prevent dental caries. Individuals without access to community water fluoridation are at elevated risk of dental caries—see Recommended concentration of fluoride toothpaste according to age and risk of dental caries for recommended fluoride toothpaste concentrations or Examples of topical fluoride applications for patients at elevated risk of dental caries for other topical fluoride products. Fluoride supplements in the form of drops or tablets are no longer recommended because of limited efficacy and the risk of dental fluorosis.

Note: Fluoride supplements in the form of drops or tablets are no longer recommended.

Table 2. Examples of topical fluoride applications for patients at elevated risk of dental caries
[NB1]
Formulation	Usual directions for use
neutral fluoride mouthwash 220 ppm (0.22 mg/mL)	Use in adults and children 6 years or older daily. Patients should rinse in the mouth for 1 minute at a time of day when toothpaste is not used [NB2].
neutral fluoride mouthwash 900 ppm (0.9 mg/mL)	Use in adults and children 6 years or older weekly or more frequently if indicated. Patients should rinse in the mouth for 1 minute at a time of day when toothpaste is not used [NB2].
neutral fluoride toothpaste 5000 ppm (5 mg/g)	Use in adults and adolescents twice daily for toothbrushing instead of 1000 to 1500 ppm (1 to 1.5 mg) fluoride toothpaste, continued indefinitely [NB2]. Although available over-the-counter, it must be recommended by a dental practitioner.
fluoride varnish 22 600 ppm (22.6 mg/mL)	Use in adults and children 1 year or older usually twice a year depending on dental caries risk. Applied by a dental practitioner to all at-risk dental surfaces.
acidulated phosphate fluoride gel or foam 12 300 ppm (12.3 mg/g)	Use in adults and children 10 years or older usually twice a year depending on dental caries risk. Applied by a dental practitioner for up to 4 minutes using trays—evacuate excess [NB2]. Acidulated phosphate fluoride is preferred to neutral fluoride products because it has better enamel uptake; however, avoid acidulated gels and foams in patients with ceramic crowns and bridgework, direct restorations containing glass particles, or poor salivary flow (eg patients undergoing head or neck irradiation).
neutral fluoride gel or foam 5000 to 9000 ppm (5 to 9 mg/g)	Use in adults and children (age restriction variable) usually twice a year depending on dental caries risk. Can be used for patients with ceramic crowns and bridgework, direct restorations containing glass particles, or poor salivary flow (eg patients undergoing head or neck irradiation). Applied by a dental practitioner for up to 4 minutes using trays—evacuate excess [NB2]. Adults can use neutral fluoride gel or foam at home, according to recommended instructions.
silver fluoride formulations	Use in adults and children (age restriction variable) usually twice a year or as recommended by a dentist. Applied by a dental practitioner to arrest carious lesions, but can stain teeth black.
fluoride+CPP-ACP 900 ppm+10% cream	Use in adults and children for noncavitated white spot lesions twice daily after brushing with usual fluoride toothpaste. Patients should apply the cream to the teeth, hold in the mouth for 3 to 5 minutes, spit out excess and avoid rinsing the mouth [NB2].
fluoride+CPP-ACP 22 600 ppm (22.6 mg/mL)+2% varnish	Use in adults and children for noncavitated white spot lesions usually twice a year depending on dental caries risk. Applied by a dental practitioner to all at-risk dental surfaces.
Note: CPP-ACP = casein phosphopeptide–amorphous calcium phosphate NB1: Treatment choice is based on clinical judgment and requires a complete assessment of the patient (eg age, other medications, disease risk). NB2: Spit out fluoride products to minimise ingestion; do not rinse the mouth after use to allow increased uptake of fluoride from the saliva.