If you get a lot of cavities, what kind of fluoride toothpaste should you use?

Using fluoride toothpaste can substantially reduce your risk of decay.

If you have a history of getting cavities, you’ll want to make sure that the kind of toothpaste you use is the most effective possible in preventing tooth decay. And generally speaking, that means you’ll need to start using a fluoridated dentifrice (toothpaste).

Fluoride was the first type of therapeutic (active) ingredient to be included in the formulation of toothpaste. And over the last 60+ years of clinical research, studies have thoroughly documented its effectiveness in helping to prevent cavities and lowering decay rates.

▲ Section references – Marinho

Page table of contents.

• What fluoride compounds are used in toothpaste?
• Fluoridated toothpaste classifications: OTC dentifrices (less than 1500 ppm F-) vs. Prescription products (greater than 1500 ppm F-).
• The best fluoridated toothpaste brands: OTC and prescription.
• Fluorosis – Precautions needed with children’s use.
• How fluoride prevents cavities.

What fluoride compounds are used in toothpaste?

There are several different types of fluoride compounds that can be included in toothpaste formulations as effective agents in preventing tooth decay. In the EU, there are around 20 used. But in the USA, only three are allowed and they cannot be used in combination. They are:

• Stannous Fluoride (tin difluoride, SnF2) – This was the first fluoride compound added to the formulation of a commercial toothpaste as an anticavity agent (1956).
• Sodium Fluoride (NaF)
• Sodium Monofluorophosphate (SMFP, Na2PO3F)

▲ Section references – Lippert

b) Sodium Monofluorophosphate vs. Stannous Fluoride vs. Sodium Fluoride

No single type of fluoride compound is necessarily best.

In terms of providing cavity protection, each of the compounds listed above can be considered to be equally effective. Each one is simply a different means by which to create a product that’s capable of delivering an appropriate level of fluoride ions (F-) to the oral environment when used.

Why each type of fluoride is chosen.

Interestingly enough, the specific compound that’s chosen by a manufacturer often depends on what other ingredients are included in the product’s formulation. That’s because these additional agents can sometimes interfere with the fluoride compound’s ability to deliver an effective concentration of ions. Even the type of abrasive used in a product can trigger this problem.

An advantage of stannous fluoride.

We will mention that beyond just being a source of fluoride ions, the compound stannous fluoride also has antibacterial properties. This gives toothpaste formulated with it that added benefit without the need for the inclusion of additional ingredients.

c) What’s the right fluoride concentration for a toothpaste?

• By FDA regulation (USA), any dentifrice that contains more than 1500 ppm (parts per million) of fluoride is classified as prescription medicine. Some prescription items have a concentration as high as 5000 ppm F-.
• OTC (over-the-counter) toothpastes typically contain between 1000 – 1500 ppm F-. The vast majority of which are targeted toward the 1000 – 1100 ppm end of the range.

▲ Section references – Davies

Which is better, a 1000 or 5000 ppm fluoride toothpaste?

Dentifrices that make a higher concentration of fluoride ions available in the user’s mouth (like prescription ones do) produce an amplified anticavity effect. So, in the case of someone who has a high decay rate, a prescription item will be more effective in helping to lower it.

5000 ppm toothpastes (prescription products).

It must be kept in mind however that not everyone needs or should have the higher fluoride exposure that a prescription item provides. For example, this type of product wouldn’t be appropriate for young children with developing teeth (see precautions discussed below), or needed by adults who haven’t had a cavity in years and years.

But for people who are cavity-prone, or in a position where they are currently at increased risk for decay (like persons who have experienced gum recession), the extra level of protection that only a prescription product can provide may be indicated.

▲ Section references – Marinho

1000 ppm toothpastes (OTC products).

Regular OTC fluoride toothpastes are effective cavity preventers too. A review of dental literature performed by Walsh concluded that a dentifrice must deliver a fluoride concentration of at least 1000 ppm to produce significant anticavity effects.

As reported above, most OTC toothpastes meet this standard. Their F- concentration typically lies in the range of 1000 to 1500 ppm (the lower end of this range is the more common case).

▲ Section references – Walsh, Marinho

d) How to figure out the concentration of fluoride in toothpaste?

It’s easy enough to determine the concentration of fluoride ions produced by a dentifrice. Here’s how:

• Look at the product’s label and see what type of fluoride compound it contains and at what percentage.
• The following percentages all equate to 1000 ppm F-.

  stannous fluoride at 0.4% | sodium fluoride at 0.22% | sodium monofluorophosphate at 0.76%

• If your toothpaste contains a higher/lower percentage of the compound it will have a higher/lower concentration of fluoride ions. Here are some equivalents for 1100 ppm F-.

  stannous fluoride at 0.454% | sodium fluoride at 0.243% | sodium monofluorophosphate at 0.836%

• We’re only familiar with sodium fluoride being used in high-strength prescription toothpastes.

  5000 ppm products are formulated with 1.1% NaF

Note: Precautions with fluoride use.

Fluoridated toothpaste that’s swallowed by children during their tooth-forming years can lead to a type of permanent tooth staining termed “fluorosis.” (Explained in greater detail below.) For this reason, it’s important to both monitor the amount of toothpaste used, and the brush-and-spit-out habits of a child, when they clean their teeth.

Which are the best toothpaste brands for reducing cavity rates?

a) OTC fluoride dentifrices.

In regard to choosing an OTC (nonprescription) fluoride toothpaste, it turns out that it’s astoundingly easy to pick one out that’s been proven effective in reducing cavities.

As candidates, just look for those whose packaging displays the logo from the American Dental Association’s “Seal of Acceptance” program.

The ADA Seal of Acceptance.

Products that display this logo are effective anticavity dentifrices.

What you need to know:

• All ADA-Accepted dentifrices have been proven to deliver a therapeutic level of fluoride (by way of their manufacturer submitting research evidence). They must contain at least 90% of the fluoride amount stated on their labeling.

  Note: Some products that have the Seal are targeted for use by children, so by design they contain a lower concentration of fluoride than would be most effective for an adult.

• With the exception just noted, all OTC dentifrices that have earned the Seal can be considered to be equally effective in reducing decay.
• As stated above, any of the three fluoride compounds allowed for use in the formulation of toothpaste in the US (stannous fluoride, sodium fluoride, sodium monofluorophosphate) can be used to create an effective product. No one is best or most effective in terms of fluoride ion release.

Which OTC fluoride toothpaste brands are best?

In terms of cavity-fighting ability, as long as a dentifrice has the ADA Seal it should be considered to be equally effective in preventing decay.

At the time of the last update of this page, we counted roughly 50 individual dentifrice products that had earned the Seal. That suggests to us that it’s relatively inconceivable that you could go to your local store and not find one of them.

ADA accepted toothpaste brands with fluoride.

▲ Section references – ADA

Don’t overlook considering a multi-care product.

Just as the ADA’s Seal program evaluates cavity-fighting effectiveness, it recognizes categories for other toothpaste benefits too. So why not pick out a product that can provide multiple types of protection for your mouth and teeth?

These products are termed “multi-care” toothpastes and using one can make an excellent choice. We discuss the best ones here. (Below on this page we discuss the additional active ingredients these types of products often contain, and how they produce an extra benefit in helping to lower a person’s decay rate.)

b) Prescription fluoride toothpaste brands.

The ADA Seal program no longer evaluates “professional dental products.” We’re assuming that this includes prescription fluoride toothpastes because we found none when reviewing their list of accepted products.

Which high-fluoride toothpaste is best?

If your dentist has a strong opinion about which brand is the most effective, they will place its name on the prescription they write for you. Otherwise, you can assume that they feel a generic product is perfectly suitable.

The typical concentration of this type of product is 5000 ppm F-. And any that do can generally be considered to be equivalent in creating fluoride anticavity protection.

Prescription toothpaste brands with fluoride (5000 ppm).

Each of these products is a sodium fluoride (1.1%) dentifrice: PreviDent 5000, SF 5000 Plus, Clinpro 5000, Denta 5000 Plus

Concerns about fluoridated toothpaste use and fluorosis.

One possible concern with the use of any toothpaste that contains fluoride is the potential that if it is ingested by a child (swallowed when brushing, eaten, etc…) their teeth may develop the side effect fluorosis. All parents need to be aware of this issue and take the needed precautions discussed on this page with their children.

What is dental fluorosis?

• This condition takes the form of permanent tooth discoloration that forms as a result of a child experiencing periods of elevated systemic levels of fluoride during that time frame when their teeth are developing.
• The high level of fluoride in their blood serum disrupts the normal process of tooth enamel formation and can result in enamel hypomineralization (a reduced amount of mineral content) and increased enamel porosity.
• These changes may affect the appearance of the child’s teeth both in color and surface texture (see pictures below).

▲ Section references – Dean, Nowak

What does dental fluorosis look like?

Slight to mild dental fluorosis.

This type of fluorosis pattern is referred to as “snow capping.”

a) Mild cases.

• The staining pattern involved is usually one where chalky-white lines, or opaque white patches or flecks, can be seen dispersed across a limited region of the tooth’s enamel.
• The staining is typically bilateral, meaning the same tooth on each side of the mouth displays a very similar pattern of discoloration (see illustration below).
• Any portion of the tooth may be the region affected. – When the staining is found right at the tooth’s biting edge, it’s often referred to as “snow capping.” (See picture.)

Severe dental fluorosis.

Extensive fluorosis staining is referred to as tooth mottling.

b) Moderate to severe cases.

• A greater percentage, or even all, of the tooth’s surface will display staining. Tooth surface abnormalities such as pitting may be evident too.
• Besides just chalky-white, severe cases may exhibit yellow, brown, or even black discolorations.

Severe dental fluorosis.

The areas that are most affected have brown discoloration.

• Actually, and even in severe cases, when a tooth first erupts (comes through the gums) its areas of fluorosis will be white in color.

  Then, due to the low mineral content and porosity of the affected areas, darker color staining will accumulate over time (due to the incorporation of metal ions into the enamel such as copper and iron).

• In severe cases, the tooth’s under-mineralized enamel may be fragile and therefore damaged relatively easily.

  This might occur during events as simple as chewing hard or crunchy foods. People who clench or grind their teeth excessively may cause significant tooth wear.

▲ Section references – Abanto

Streaks of fluorosis frequently have formed during the same time period.

They lie at different levels because the teeth were at different stages of development at the time of the fluoride exposure.

c) Bilateral symmetry is the norm.

Here’s why.

The explanation lies in the fact that the affected areas on matching pairs of teeth (left/right central incisors, lateral incisors, eyeteeth, etc…) were all at the same point of enamel formation when the exposure to the fluoride took place (see illustration).

However, the region of stain on different types of teeth can be expected to lie at different levels. That’s because, at any point in time, some kinds of teeth are further along in their development (more fully formed) than others.

How severe can a child’s fluorosis be expected to be?

The extent to which fluorosis has affected any one child’s teeth will vary, according to a number of variables.

• The actual level of fluoride reached in the child’s blood serum will play a role. As will how long that status existed, and the number of repeat episodes that were experienced.
• Even after experiencing a similar fluoride exposure, each individual child will have their own personal level of risk for, and resistance to, fluorosis.

  Governing factors include: the child’s genetic makeup and health status (malnutrition and renal insufficiency are known risk factors). Additional variables such as the child’s weight, level of physical activity, and even their geographic altitude can also influence the level of staining that occurs.

• Since whatever effects that do take place do so during tooth formation (a point when the developing tooth is still encased in the jawbone), it’s impossible to know to what extent it has actually been affected until it has finally erupted.

▲ Section references – Nowak, Abanto

Who’s at risk for fluorosis? – Answer: Young children.

What are the years of greatest concern?

Dental fluorosis only occurs when elevated levels of fluoride are ingested (swallowed) during that time frame when a child’s teeth are developing.

So once the crown portion of a tooth (the enamel-covered part that shows above the gum line) has completed its formation (a process that finishes long before the tooth’s root has completed its development), it’s no longer at risk.

Guidelines.

Based on studies that have documented the usual time frames associated with tooth development, the most critical years for the risk of fluorosis lie between the child’s birth and age 6 to 7 years.

• In regard to permanent teeth that show, the greatest risk lies between the ages of 1 and 4 years, with special emphasis on the period 20 to 30 months.
• Generally speaking, at around age 8 years, a child would no longer be at risk.

▲ Section references – Abanto

The damage isn’t actually visible until later on.

As mentioned above, because fluorosis only forms during that period while the child’s teeth are in the process of forming (and therefore still lie embedded in the jaws), its effects aren’t visible until the affected teeth have finally erupted (broken through the gum line).

Permanent and/or baby teeth may be affected.

Fluorosis forms during tooth development, so any teeth that are forming at the time of the child’s elevated fluoride exposure may be affected. That includes both permanent (adult) and deciduous (baby) teeth.

Since deciduous teeth ultimately exfoliate (fall out), correcting their appearance usually isn’t an issue. But having baby teeth that show signs of staining is often an indication that the child’s permanent teeth will show similar defects too.

A primary cause of fluorosis is swallowing toothpaste.

a) The underlying problem.

Small children, especially those younger than age 6, characteristically are not able to reliably spit out when brushing.

As a result, they may end up swallowing a large portion of the toothpaste that’s been placed on their brush. And if it contains fluoride, over time enough may be ingested that fluorosis forms.

• 1 to 3-year-olds may get up to 80% of their daily intake of fluoride from toothpaste. (de Almeida)
• It’s estimated that 2 to 3-year-olds ingest 48% of the amount of toothpaste dispensed, 4-year-olds 42%, 5-year-olds 34%, and 25% by 6-year-olds. The estimate for children between 8 and 12-years is around 10%. For adults, it’s 10% or less. (SCHER).

▲ Section references – de Almeida, SCHER

b) Avoidance. / Prevention.

The following suggestions can help to minimize a child’s risk for fluorosis.

• Children should be given instructions about how to properly brush and rinse. They should be supervised when brushing so to help them form and practice proper brushing habits.
• In most cases, it’s the amount of product that’s used rather than the concentration of its fluoride that poses the greatest risk (Davies). Fluoridated toothpaste should always be dispensed by an adult, not the child.

  Read your toothpaste’s instructions. Generally, only a small amount of toothpaste is needed. A common measurement for children is a dab the size of a green pea. For those younger than 3 years, just a smear or rice-size amount. Dispensing toothpaste the full length of a child’s toothbrush can correlate with an amount that’s many multiples of the proper amount.

• As a general rule, unfluoridated tooth cleansers should be used with children 2 years and under. Ask your dentist for their specific recommendation.

• Store fluoridated toothpaste out of the reach of children (some kids like the way it tastes and eat it).
• When purchasing fluoride toothpaste, look for one that has the American Dental Association’s (ADA) “Seal of Approval.” These products have been shown to be both safe and effective.

▲ Section references – Davies, Nowak

Treatments for fluorosis tooth staining.

a) Slight / Mild cases.

In cases where only minimal evidence of fluorosis is evident, no treatment is required if the person considers the appearance of their teeth acceptable. The integrity of the affected areas of enamel is seldom a concern.

In cases where the appearance of the person’s teeth is not acceptable to them, performing teeth whitening (details), microabrasion (involved tooth polishing), or resin infiltration (details) treatments may provide minimally invasive yet esthetically acceptable solutions.

b) Moderate and Severe cases.

In situations where the fluorosis is readily apparent and objectionable to the patient, a repair might be made by placing a dental filling (tooth bonding), porcelain veneer, or crown. Determining what type of restoration makes the most appropriate choice will need to be determined by the treating dentist.

How does fluoride prevent tooth decay?

Fluoridated toothpaste helps to provide anticavity protection in two primary ways.

Protection #1 – Fluoride promotes tooth remineralization.

You may never have heard of it but there’s a process called “remineralization” that plays a giant role in helping to slow down the rate of cavity formation. It’s a bit like tooth decay in reverse.

What takes place is that instead of the situation where some of the mineral content is leached from a tooth (a process that’s called demineralization), minerals are deposited back onto tooth areas where it has been lost (the damaged area is “healed” by remineralization).

(Use the links above for more details about both processes.)

How fluoride assists tooth remineralization.

Research has shown that when fluoride is present in a person’s oral environment it acts to enhance the remineralization process, and therefore ultimately helps to limit the amount of mineral loss that occurs during demineralization.

• When fluoride is not present, low pH conditions (approximately pH 5.5 and below) trigger tooth demineralization. (The loss of the mineral hydroxyapatite from the tooth.)

  Then, when conditions return back above this point, the process of remineralization can occur. (The redeposit of mineral back onto the tooth.)

• When fluoride is present, the demineralization of hydroxyapatite still occurs as above. But during the remineralization process, fluorohydroxyapatite that has formed is one of the minerals that is deposited back onto the tooth.

  What’s different is that remineralization with this molecule can occur at a lower pH than hydroxyapatite. And that means that the remineralization process can begin to start even before the oral environment has fully returned to more neutral pH conditions (like those required for hydroxyapatite). As a result, less overall mineral content is lost from the tooth.

▲ Section references – Abou Neel, Fejerskov

Extensive tooth decay.

Protection #2 – Fluoride helps to make teeth more decay-resistant.

A new type of tooth mineral is created.

What we didn’t mention is that this replacement compound is actually “harder” (more resistant to demineralization) than the type of mineral that was present originally. And that’s an astoundingly important factor in the prevention of cavities.

• Most of a tooth’s mineral content takes the form of hydroxyapatite and carbonated hydroxyapatite.
• The type of tooth mineral that’s created during the remineralization process when fluoride is present is fluorohydroxyapatite.
• Fluorohydroxyapatite is “harder” than the other forms, in the sense that it is more resistant to damage caused by bacterial acids (the agents of tooth demineralization).

  Specifically, fluorohydroxyapatite is able to withstand a more acidic environment (pH 4.5 vs. 5.5 for hydroxyapatite [approximate values, depending on mouth conditions]) before it begins to dissolve away.