Toothbrush Roundup – Part 1: Fluoride

Over the years – especially years where I’m sitting in the dental chair getting a crown – I’ve become particularly passionate about oral health — and my kid never having to go through this. This interest has been amplified by my son’s aspiration, since oral health is a big determinant for his risk for developing aspiration pneumonia. This will be a 3-part series on oral health: fluoride, toothbrushes and tooth brushing, and the pillars of aspiration pneumonia.


“Ooh, baby has teeth now?”

“She just cut her first tooth!”

“That’s so exciting! Now you get to brush them!”

“… seriously? … with a toothbrush?”

And just like that, I crush parents’ excitement in well-baby visits. Sorry!


Toothbrushing – every parent’s nightmare. Many parents don’t even know they’re supposed to brush baby teeth, whether they’re in a baby or a toddler. And their toddler definitely doesn’t like it – are they supposed to push it and make it a big power struggle?

Baby teeth matter!

Baby teeth can get cavities, and yes, it matters, even though they’re going to fall out. Cavities are painful and the decay can go deeper than the baby teeth, affecting adult teeth. Decayed teeth can become infected, infecting the teeth around them. Pain makes it difficult to sleep, eat, and focus in school. Early childhood cavities are the number one chronic disease in kids, five times more common than asthma. Almost 10 percent of one-year-olds have dental disease, 20% of 2-year-olds, and half of all kindergartens have one or more cavities. Early childhood cavities are linked to adult health problems like heart disease and diabetes.

Even in babyhood, baby teeth matter — they’re important for good nutrition, for pronunciation, and they help guide adult teeth into place.

Baby teeth matter!

How are cavities formed?

Hundreds of different kinds of bacteria live in our mouths. Only some of them are cariogenic (cavity-causing). These bacteria eat sugar and poop acid. The acid destabilizes teeth by drawing minerals out of the enamel, ultimately weakening the tooth’s structure and creating holes. Technically, that portion of the tooth collapses – cavitation.

Our saliva is full of minerals, so when there’s saliva around, there’s material available for fixing the microscopic damage. The roughly 20 minutes after eating carbohydrate-containing foods are considered the “danger zone” for the teeth, while they’re being repaired.

So, the first step in the list to keeping teeth healthy is to reduce the number of times (and the amount of time) that they’re in the danger zone and need to be repaired. That means that defined meals and snacks (typically three meals and two snacks) is better for the teeth than all-day grazing.

The next factor is what’s in the food – crackers and cookies are higher in carbohydrates than apples, and they stick to the teeth, making them harder to get off. Crunchy fruits and vegetables do their own tooth-scrubbing as you crunch them. Gummy vitamins stick like glue, so it’s hard to get the sugar off your teeth with your tongue alone, and the bacteria have a field day with what you’ve left behind.

The next factor is which bacteria set up shop in your child’s mouth. If you have cavity-causing bacteria in your mouth, wetting your child’s pacifier in your own mouth, sharing cups or straws or utensils, or tasting or chewing their food before giving it to them transfers your bacteria to them. You can reduce the risk of transmission by taking good care of your own mouth, getting your own needed dental care, and avoiding giving your saliva to your child.

bacteria + food + time on teeth = cavities

Overnight we have less saliva, which is why it’s so important to brush with fluoride toothpaste before bed. Fluoride helps to neutralize the acid that’s eating away at the teeth, and as a mineral, it gets incorporated into the structure of the tooth.

But that’s not all!

Fluoride inhibits the bacteria’s ability to produce acid! POW.

Fluoride reduces enamel demineralization, by neutralizing acid. You want to destabilize the tooth structure? NO WAY.

Fluoride promotes enamel remineralization! Hey teeth, use me, fluoride, in rebuilding yourself! YEAH!

Fluoride reduces the amount of acid in the mouth, neutralizes the acid that’s there, and reverses the damage done by the acid! Triple POW!

smear of toothpaste vs pea sized amount

How much fluoride toothpaste should I use for my baby or kid? (From AAPD: Guideline on Fluoride Therapy)

It wasn’t so long ago that we recommended using fluoride-free toothpaste until a kid could reliably spit, but the current recommendation from the American Academy of Pediatric Dentists and the American Academy of Pediatrics is to use a tiny amount of fluoride toothpaste from the time the very first tooth erupts, in a fountain of fussiness, from the baby’s tender gums.


Fluoride is available from multiple sources.

  • Tap water (and some well water), and food and beverages prepared with fluoridated water
  • Home administered toothpaste, mouthwash, etc
  • Professionally applied, like fluoride varnish at the doctor or dentist


Most municipalities add fluoride to the drinking water. This is a basic public health move. I was interested to learn that half of all Washington kids don’t have access to fluoridated water though (this map shows which water systems in Washington State have adequate fluoride, and where fluoride is naturally occurring in the water).

Some cities have taken fluoride out, and see significant increase in the number of cavities (for example, Calgary).

When you drink water with fluoride in it, there is transient contact with the tooth, and quick pH adjustments – rinse your mouth with water after eating if you can’t brush. It’s also absorbed and circulates in the blood. Teeth that develop in a fluoride-rich milieu are stronger, so it’s important to have fluoride in the water during the time of tooth development – when the fetus is developing in utero, and when kids are developing their adult teeth.

I was surprised to find that a lot of families in my practice are filtering out the fluoride with pretty substantial filtration systems. If your drinking water doesn’t have fluoride, whether it’s because your municipal water supply doesn’t add it, you’re on well water that’s been tested to have low levels of fluoride, or you’re working really hard to take it out, the AAPD recommends supplemental fluoride.


We recommend using fluoride-containing toothpaste from baby’s very first tooth eruption. You can use a baby washcloth or a toothbrush. This article was supposed to be about toothbrushes, but I guess that will be part 2!

Addendum: a whole post about fluoride toothpaste, and whether or not there is really debate about its use!

The other topical application of fluoride is fluoride varnish. Fluoride varnish is fluoride suspended in a sticky sap that gets painted on the teeth at either the dentist or primary care doctor, if they’ve been trained! We were lucky enough to be trained by Arcora – The Foundation of Delta Dental of Washington in preventing dental disease in pediatric primary care, and can bill Medicaid for basic dental exams and teaching, and both Medicaid and private insurance for applying fluoride varnish. Many kids don’t access dental care, or don’t have access, so primary care visits are a great place to receive some basic dental care.

Baby Dental Visit?

If you’re in Washington State and your kiddo has coverage through Medicaid (AppleHealth/DSHS), you should be able to find a dentist — check out ABCD, Access to Baby and Child Dentistry.

Babies should go to the dentist by their first birthday! I’ve found most general dentists say they don’t need to come until they’re 3, but we know that 8% of babies have decay by age 1, and 20% of babies have cavities by 2 years old, so it doesn’t make sense to wait. Go when they’re little, get established, develop a relationship, learn skills, get fluoride varnish, and take care of those baby teeth!


Brush your baby’s teeth with fluoride toothpaste before bed and after breakfast! If that seems too intimidating, start with brushing before bed, get it integrated into your routine, then add the after-breakfast brushing later.




American Academy of Pediatric Dentistry:

American Academy of Pediatrics recommends fluoride to prevent dental caries


Washington State 2016 report on kids’ oral health 

Fluoride Exposed



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