PFPC Fluoride Education Project

For more than 25 years, Dr. Hardy Limeback - "Canada's leading authority on fluoride"- has opposed fluoridated water while making contradictory statements on fluoride toothpaste and “topical benefits.”

He alternately criticizes and endorses fluoride toothpaste, depending on what best supports his case against water fluoridation. For years he has endorsed Scotland’s Childsmile program, which uses high-concentration fluoride toothpaste in toddlers and young children. In Scotland, babies are given a toothbrush and 1450 ppm fluoride toothpaste for home use when they are four months old. Parents are told to brush as soon as the first tooth erupts and not to rinse afterward - guaranteeing greater ingestion. The Childsmile program in nurseries starts in children 2 years old, accompanied by fluoride varnish treatments.

When asked why he promoted Childsmile’s fluoride-related posts while also calling fluoride a “neurotoxin,” he replied that a repost is not an endorsement or promotion.

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Has Limeback endorsed the Childsmile program and its fluoride component?

In fact, in his posts on social media, he has not only promoted the Childsmile program, he has called for its universal implementation, including in Canada. Apparently, fluoride is only a "neurotoxin" in fluoridated areas.

Receipts are below.


March 16, 2018

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April 18, 2018

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September 19, 2019

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  NOTE: Childsmile also employs a fluoride varnish children, starting at age 2.
  https://www.childsmile.nhs.scot/profess ... e-varnish/

September 30, 2022

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January 30, 2023

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April 3, 2024

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December 1, 2024

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December 9, 2024

• NOTE: While earlier stating that fluoride varnish is not "cost-effective" (see above), here is reposting Childsmile's fluoride varnish program - which starts at age 2!

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December 10, 2024 (Thanks to Brian Brown for the screenshots below)

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December 12, 2024

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Note Limeback's “opposition" (not!) to the “spit, don’t rinse” instruction. His claim that this results in “swallowing the least amount of toothpaste” is not true; the opposite is the case. Children ingest much higher amounts of fluoride when advised to “spit, not rinse.”


Even worse, there are countless photographs online showing Childsmile children brushing their teeth, with no cup or tissue in sight for spitting. A few examples below:

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Here are a few more photos and facts about the Childsmile program:

Toothpaste the children receive for in-home use, containing 1450 ppm fluoride:

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Childsmile Products - 6-months baby cups and 1450 ppm fluoride toothpaste

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Here is a picture of the amount of toothpaste on a toothbrush, accompanying the Childsmile guidelines for toothbrushing in toddlers:

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NHS - Childsmile information

Here is what a correct "smear" looks like on the Childsmile website:

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Here is what parents see on social media...a thick smear covering a third of the toothbrush: (note: writing on images done by the NHS)

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Here is yet another picture of an (incorrect) Childsmile "smear" and a "pea-size" amount on a toothrush:

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Here is a picture of a Childsmile child in the classroom

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Just for comparison, here is what the Baby Oral Health Program (bOHP) at the University of North Carolina at Chapel Hill (USA) shows parents:

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And lastly, a photo of a smear/rice size and pea size from the US ADA:

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Photo showing Childsmile children brushing their teeth. Remember, children are advised to NOT rinse - which would reduce the amount of fluoride ingested - but to spit after 2 minutes of brushing.
(All photos from publicly available Childsmile X account)

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Advice...

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More mislading public messaging:

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Here is one of Limeback's many false statements and charts on X:

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In the post above, Limeback claims that a rice-sized amount of toothpaste contains 0.02 mg fluoride, while also claiming that 0.02 mg is ingested daily from brushing twice a day. His chart further states that a pea-sized amount of toothpaste leads to 0.25 mg fluoride ingestion. Everything he claims here is wrong.

At 1450 ppm fluoride (as in Childsmile toothpaste), a rice-sized smear (≈ 0.125 g) actually contains 0.18 mg F.

Even if only half were swallowed (unlikely in toddlers), the ingested fluoride from a rice-sized amount would be 0.09 mg per brushing, not 0.01 mg. Brushing twice daily would result in roughly 0.18 mg/day from a single smear.

A pea-sized amount would, of course, lead to a considerably higher intake (recommended for about 3-year-olds). At 1450 ppm, a 0.25 g portion contains 0.36 mg F; if only 50% were ingested, that equals 0.18 mg per brushing, or 0.36 mg/day with two brushings. (Please keep in mind this is only one source of fluoride.)

As for his question, “Any evidence that it’s harmful to thyroids?”, Limeback again demonstrates not only a lack of understanding of how fluoride affects thyroid hormone metabolism, but also an apparent ignorance of what his own 2006 NRC report stated on the issue. Fluoride’s effects are not determined by body weight or mg/kg/day dose, but by thyroid and iodine status. Even very small amounts can further disrupt function in susceptible individuals, such as those with hypothyroidism or iodine deficiency.

This has been repeatedly shown in animals, children, and adults.

• (All studies are available on our website: viewtopic.php?f=7&t=1345)

Setting aside that mg/kg/day is not an appropriate exposure measure for thyroid endpoints, the 2006 NRC report, of which Limeback was a co-author, stated that in iodine-deficient humans, a dose of 0.01–0.03 mg/kg/day has been shown to affect thyroid function.

Applied to a 10 kg child, that corresponds to 0.1–0.3 mg/day. A child in the Childsmile program could ingest about 0.18 mg/day from a rice-sized smear of 1450 ppm toothpaste alone, which falls within that range.

For a 3-year-old using a pea-size of the same toothpaste, ingestion would be about 0.36 mg/day - exceeding the lower end of the range associated with thyroid effects in iodine-deficient individuals.

Most concerning is that Limeback knows parents do not follow the “rice-size” guideline. His own 2024 study reports parents apply five to seven times that amount, and young children swallow 80–100%, not 50%.
[See post below: viewtopic.php?p=7970#p7970]

Using Limeback’s own data, this translates to:

5.9 × 0.18 = 1.06 mg fluoride (at 1450 ppm)
7.2 × 0.18 = 1.30 mg fluoride (at 1450 ppm)

In real-world conditions - based on his own data - many Childsmile toddlers are ingesting approximately 1.1–1.3 mg fluoride per brushing, 4 to 13 times the level reported by the 2006 NRC to affect thyroid-hormone metabolism in iodine-deficient children. This is, of course, also far higher than what these children would ever ingest from “optimally” fluoridated water.


The X threads containing this discussion can be found here:
https://x.com/PFPC10/status/1868590182792061274
https://x.com/PFPC10/status/1868969293452656760

SUBSTACK:
https://substack.com/profile/46616808-p ... -169108173
https://blanphear.substack.com/p/the-fl ... /169274516

The following excerpts are from a study published by Limeback himself in 2024.

In this study involving 61 parents, Limeback and colleagues found that all parents used too much fluoride toothpaste in children up to 2 years old.

61 parents dosed a mean of 0.263 ± 0.172 g toothpaste A and 0.281 ± 0.145 g toothpaste B. The parents’ mean doses were 5.9 times higher for toothpaste A and 7.2 times higher for toothpaste B than an ‘optimal’ grain of rice-size amount (the reference dose as recommended). The difference between parents’ and reference dose was statistically significant (p < 0.001). Moreover, 39.3% of parents were not aware of the conditions of use and warnings that have to be printed on the package of fluoride toothpastes.

For children aged 18–30 months it was reported that 64.3–83.9% (mean) of the toothpaste is swallowed, and “(...) a high percentage of children in the two youngest age groups [18–30 months] appeared to ingest between 80 and 100% of the fluoride dispensed. (...)"

The dose of an even smaller toothpaste amount, i.e., a grain-of-rice-sized amount of toothpaste for children aged up to 24 months, seems to be even more challenging than the dose of a pea-sized amount of toothpaste.

A key finding of this study is that analyzing the fluoride intake from the fluoride toothpaste only (calculated from the mean toothpaste doses), the limit of the fluoride intake to prevent dental fluorosis is exceeded. Fluoride from other sources (fluoridated water, fluoride tablets, fluoridated salt etc.) will further increase this fluorosis risk.

• Sudradjat H, Meyer F, Fandrich P, Schulze Zur Wiesche E, Limeback H, Enax J - “Doses of fluoride toothpaste for children up to 24 months.” BDJ Open 10(1):7 (2024). doi: 10.1038/s41405-024-00187-7
  https://pmc.ncbi.nlm.nih.gov/articles/PMC10831090/

Yet, despite his own findings on the use and overuse of the recommended “rice-size” toothpaste amount - and his repeated assertion that fluoride is a "neurotoxin" and that the level in water should be zero - Limeback deems it appropriate to promote Childsmile's fluoride program.

Few double standards are starker than warning parents about fluoride’s neurotoxicity in one country while promoting it for infants, toddlers, and young children in another.

Here is the excerpt on what 2-year-old children can ingest from a 1000 or 1100 ppm fluoride toothpaste, from the 2006 NRC Report, of which Limeback was a co-author.

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And another excerpt:

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This is where it started...1998

Canadian Consensus Conference On the Appropriate Use Of Fluoride Supplements For the Prevention Of Dental Caries In Children

• Limeback H, Ismail A, Banting D, DenBesten P, Featherstone J, Riordan PJ - "Canadian Consensus Conference on the appropriate use of fluoride supplements for the prevention of dental caries in children" J Can Dent Assoc 64(9):636-9 (1998)
  https://www.cda-adc.ca/jcda/vol-64/issue-9/636.html

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In 2000, the US Fluoride Action Network distributed Limeback's letter "Why I am now officially opposed to adding fluoride to drinking water".

Again, Limeback stated that "the major reasons for the general decline of tooth decay worldwide, both in non-fluoridated and fluoridated areas, is the widespread use of fluoridated toothpaste, improved diets, and overall improved general and dental health (antibiotics, preservatives, hygiene etc).

• Limeback H - "Why I am now officially opposed to adding fluoride to drinking water" (2000)
  https://fluoridealert.org/content/limeback/

Other organizations echoed Limeback's statements.

In 2002, the Canadian Dental Hygienists Association published its position statement, and wrote:

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  Canadian Dental Hygienists Association - "THE FLUORIDE DIALOGUE: CDHA Position Statements" (2002)
  https://www.cdha.ca/pdfs/profession/res ... uoride.pdf

Limeback frequently invokes the widespread use of fluoride toothpaste to argue against water fluoridation. In a 2012 letter to the City of Windsor, ON, he cites the “widespread use of fluoridated toothpaste” to claim that any additional benefit from fluoridated water is minimal, and he describes fluoride’s effect as primarily topical (i.e., via toothpaste). He does not advise avoiding toothpaste or criticize its use; rather, he uses toothpaste to undermine the case for fluoridating water.

In this letter, he again misstates infants’ and toddlers’ intake while citing the 2006 NRC report and his role in it. He claims that babies and toddlers receive too much fluoride when tap water is used to make formula and that the majority of daily fluoride comes from drinking water in fluoridated areas. This is contradicted by the 2006 report he cites (see above) and the earlier 1991 U.S. Department of Health and Human Services report.

1991 HHS Report

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2006 NRC report:

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• Limeback H - "Letter and statement from Dr. Limeback" (2012)
  https://www.citywindsor.ca/Documents/ci ... 111613.pdf

Review of Fluoride Benefits and Risks: Report of the Ad Hoc Subcommittee on Fluoride of the Committee to Coordinate Environmental Health and Related Programs (1991)

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Here, Limeback states that, in his view, the "Spit, Don't Rinse" policy does not increase fluoride ingestion in "non-fluoridated" Scotland. Apparently, it only applies to fluoridated areas...

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In this thread on Substack, where he was asked to justify why he promoted the Childsmile program, he again relates any danger of ingesting fluoride as being an additional burden when fluoride is already present - while admitting that the "rice-size" amount recommendation is not followed!

"Our research (and that of the CDC) shows that the rice-size amount of toothpaste (as recommended in Canada, the US and in the EU, is NOT practical and not followed. No toothpaste packaging depicts a rice-size amount of paste on a toothbrush- not in Canada, the US or the EU. It is recommended but the makers of toothpaste won't do it. The packaging has warnings not to swallow more than what is used for brushing but it is up to the dentists and their associations to educate consumers on what that amount should be. A rice size of 1000 ppm toothpaste contains less than 0.10 mg fluoride, about same amount of fluoride in a 1/2 cup of fluoridated tap water. Scotland (which wanted a dental public public health program to substitute for fluoridation) no longer produces beverages and foods with fluoridated water, so the overall intake of fluoride from those sources is reduced. Compared to fluoridated Ontario and Alberta (Quebec and BC are fluoride free) and 75% of the US which is fluoridated, where 1600 ppm toothpaste is allowed for toddlers and promoted with candy flavours and cartoons, Childsmile kids in school are exposed to far less fluoride, even in dry classrooms where they are told to spit into tissues while brushing. Some of the kids' toothpastes in the US and Canada still show the full swirl of toothpaste on the package itself. Scottish kids are therefore 'being helped' in that their exposure to fluoride is far less than in other countries (like the Republic of Ireland where fluoridation is mandatory country wide and the kids are using fluoridated toothpaste as well)."

SEE: https://blanphear.substack.com/p/the-fl ... /169001101

Childsmile’s core message is framed as prevention, yet it knowingly increases ingestion by design. Calling that “less exposure” because Scottish beverages are not fluoridated is rhetorical smoke, not risk assessment. As stated in the Substack thread - and the posts above - Limeback's own publications have reported that young children receive 5 to 7 times the amount of of a "rice-size" amount and swallow 80-100 percent of it. This makes intake from toothpaste far higher than would ever be possible from fluoridated water, especially at a high-concentration fluoride toothpaste of 1450 ppm. It makes toothpaste the dominant source for many young children.

What is concerning, once again, is the constant contradiction in his statements.

Here is a rare example of Limeback expressing clear opposition to the "Spit, Don't Rinse" policy recommended by several websites - which is, by the way, a policy promoted by DENTAL organizations, not makers of toothpastes. (The only toothpaste we know of - so far - that has the advice of "Spit, Don't Rinse" on the actual toothpaste tube is the one manufactured for Childsmile in Scotland. It also does not have the "don't swallow" warning that US toothpastes are required to have.)

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This is clearly the right advice. Unfortunately - as seen above, Limeback now thinks it's only a problem in "fluoridated" areas. It's apparently not a "neurotoxin" in non-fluoridated areas.

Would the real Hardy Limeback please stand up?

Here are a few more details on the Childsmile fluoride varnish program.

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At a concentration of 22,600 ppm, a 0.25 mL application exposes the child to 5.65 mg F⁻.

A 0.40 mL application exposes the child to 9.04 mg F⁻.

Past studies have shown that serum and urinary fluoride levels rise greatly after Duraphat fluoride varnish application.

• Lockner F, Twetman S, Stecksén-Blicks C - "Urinary fluoride excretion after application of fluoride varnish and use of fluoride toothpaste in young children" Int J Paediatr Dent 27(6):463-468 (2017) doi: 10.1111/ipd.12284
  https://onlinelibrary.wiley.com/doi/10.1111/ipd.12284
  

• Ekstrand J, Koch G, Petersson LG - "Plasma fluoride concentration and urinary fluoride excretion in children following application of the fluoride-containing varnish Duraphat" Caries Res 14(4):185-189 (1980) doi: 10.1159/000260452
  https://karger.com/cre/article-abstract ... y-Fluoride?
  
  

No dental study has ever investigated what effect such fluoride peak levels have on thyroid hormone metabolism. That high fluoride peak doses can cause dental fluorosis - which, of course, is linked to thyroid dysfunction - has been established (Angmar-Månsson et al.,1976; Lyaruu et al., 2006)

Other studies have reported increased salivary fluoride concentrations in young children for several days to one week, and in some cases, even one month, after fluoride varnish applications (Nakornchai et al., 2017; Aasenden et al., 1968).

It should be stated here, that a RCT conducted by Milsom et al. in 2011 found that there was NO benefit after 9 varnish applications over 3 years in school children (Milsom et al., 2011). A large study from this year (Celis et al., 2025) also found that "fluoride varnish application was not significantly associated with caries experience."

• Angmar-Månsson B, Ericsson Y, Ekberg O - "Plasma fluoride and enamel fluorosis" Calcif Tissue Res 22(1):77-84 (1976) doi: 10.1007/BF02010348
  https://pubmed.ncbi.nlm.nih.gov/1000344

• Aasenden R, Brudevold F, Richardson B - "Clearance of fluoride from the mouth after topical treatment or the use of a fluoride mouthrinse" Arch Oral Biol 13(6):625-36 (1968) doi: 10.1016/0003-9969(68)90141-6

• Celis A, Conway DI, Macpherson LMD, Celis-Dooner J, McMahon AD -"Outcome of a national education program on supervised daily tooth brushing and biannual fluoride varnish application on dental caries in Chilean preschool children: an ecological cohort study" Caries Res (2025) doi: 10.1159/000546679
  https://pubmed.ncbi.nlm.nih.gov/40472824/

• Lyaruu DM, Bervoets TJ, Bronckers AL - "Short exposure to high levels of fluoride induces stage-dependent structural changes in ameloblasts and enamel mineralization" Eur J Oral Sci 114 Suppl 1:111-115, discussion 127-129, 380 (2006) doi: 10.1111/j.1600-0722.2006.00346.x
  https://pubmed.ncbi.nlm.nih.gov/16674671/

• Milsom KM, Blinkhorn AS, Walsh T, Worthington HV, Kearney-Mitchell P, Whitehead H, Tickle M - "A cluster-randomized controlled trial: fluoride varnish in school children" J Dent Res 90(11):1306-11 (2011) doi: 10.1177/0022034511422063
  https://pubmed.ncbi.nlm.nih.gov/21921250/

• Nakornchai S, Phranet W, Surarit R, Vichayanrat T - "Salivary and Plaque Fluoride Level after MU Caries Preventive Program in Daycare Centers" Journal of the Dental Association of Thailand 67(4):360-369 (2017) PFPC Library

More Toothpaste Studies of Interest

Adé DC, Filippi C, Filippi A - "A survey on toothbrushing practices and dosing of fluoridated toothpaste among preschool children in the cantons of Basel-Stadt and Berne, Switzerland" Swiss Dent J 133(2):18-34 (2024) doi: 10.61872/sdj-2024-07-08-01
https://www.swissdentaljournal.org/article/view/5657
"Approximately 50% of the parents of 0- to 2-year-old children applied more than the recommended 0.25 g of fluoridated toothpaste (both brushes, mean ± SD: 0.25 g ± 0.14 g), while two-thirds of the parents of 2- to 3-year-olds (both brushes, mean ± SD: 0.36 g ± 0.23 g) and nearly 90% of the parents of 3- to 6-year-olds applied more than 0.25 g (both brushes, mean ± SD: 0.43 g ± 0.20 g)."

Bennadi D, Kshetrimayum N, Sibyl S, Reddy CV - "Toothpaste Utilization Profiles among Preschool Children" J Clin Diagn Res 8(3):212-215 (2014)
https://doi.org/10.7860/JCDR/2014/7309.4165
"A majority of the mothers used adult toothpaste to brush their children's teeth and supervised their children while brushing. Fiftytwo percent mothers were aware about presence of fluoride in tooth paste but its clinical significance. Half the mothers applied full length of tooth paste to their children's brushes and most mothers made their children brush their teeth twice daily."

Bentley EM, Ellwood RP, Davies RM - "Fluoride ingestion from toothpaste by young children" Br Dent J 186(9):460-462 (1999)
https://doi.org/10.1038/sj.bdj.4800140
"The mean amount of toothpaste applied on the brush was 0.36 g of which 0.27 g (72%) was retained in the mouth. The mean amount of fluoride ingested per brushing was 0.42 mg when using the 1,450 ppm F toothpaste and 0.10 mg when using the 400 ppm F toothpaste."

Cochran JA, Ketley CE, Duckworth RM, van Loveren C, Holbrook WP, Seppä L, Sanches L, Polychronopoulou A, O'Mullane DM - "Development of a standardized method for comparing fluoride ingested from toothpaste by 1.5-3.5-year-old children in seven European countries. Part 2: Ingestion results" Community Dent Oral Epidemiol 32(Suppl 1):47-53 (2004) doi: 10.1111/j.1600-0528.2004.00139.x
https://onlinelibrary.wiley.com/doi/10. ... 04.00139.x
"The overall average percentage of dispensed fluoride ingested was 64%. A high percentage of children in the two youngest age groups appeared to ingest between 80% and 100% of the fluoride dispensed (Table 3). This percentage reduced markedly after the age of 3.5 years. The exception to this was Haarlem [Netherlands] where the percentages of children ingesting 80–100% of the fluoride dispensed were 48%, 42% and 38% for the three age groups, respectively."

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Creeth J, Bosma ML, Govier K - "How much is a 'pea-sized amount'? A study of dentifrice dosing by parents in three countries" Int Dent J 63(Suppl 2):25-30 (2013) doi: 10.1111/idj.12074
https://linkinghub.elsevier.com/retriev ... 20)33706-0
"When asked to dispense the amount they would normally for their child, the majority of parents dosed substantially more than 0.25 g; in Germany, all parents over-dispensed."

Drummond BK, Curzon MEJ - "Urinary Excretion of Fluoride Following Ingestion of MFP Toothpastes by Infants Aged Two to Six Years" J Dent Res 64(9):1145-1148 (1985)
https://doi.org/10.1177/00220345850640091001
"Previous investigations on urinary fluoride levels after brushing with fluoride toothpastes have generally shown little change, presumably because the urine was collected as 24-hour samples, which would make small changes within a few hours difficult to detect...If the average amount of fluoride ingested in toothpaste at each brushing by infants is approximately 0.3 mg (Hargreaves et al., 1972; Barnhart et al., 1974), which may be totally absorbed, then this additional fluoride may give an intake of 0.6 mg F- from swallowed toothpaste over and above that from other dietary sources, such as food, water, and/or fluoride supplements. This is considerably more than the recommended daily supplement of 0.25 - 0.5 mg F-/day for three-year-olds (American Academy of Pediatrics, 1979)."

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• NOTE: This is toothpaste at 500 ppm. Childsmile toothpaste is 1450 ppm.

Franzman MR, Levy SM, Warren JJ, Broffitt B - "Fluoride dentifrice ingestion and fluorosis of the permanent incisors" J Am Dent Assoc 137(5):645-52 (2006) doi: 10.14219/jada.archive.2006.0261
"Mild fluorosis was significantly related to ingestion of fluoride dentifrice at ages 24 and 36 months (P = .02 for both). After the authors adjusted for fluoride ingested from dietary sources, logistic regression showed a significant association between fluorosis and dentifrice ingestion at age 24 months (P = .04)."

Hargreaves JA, Ingram GS, Wagg BJ - "A gravimetric study of the ingestion of toothpaste by children" Caries Res 6(3):237-243 (1972) doi: 10.1159/000259804
https://karger.com/cre/article-abstract ... Toothpaste

Kobayashi CA, Belini MR, Italiani Fde M, Pauleto AR, Araújo JJ, Tessarolli V, Grizzo LT, Pessan JP, Machado MA, Buzalaf MA - "Factors influencing fluoride ingestion from dentifrice by children" Community Dent Oral Epidemiol 39(5):426-432 (2011) doi: 10.1111/j.1600-0528.2011.00615.x
https://onlinelibrary.wiley.com/doi/10. ... 11.00615.x

Levy SM, McGrady JA, Bhuridej P, Warren JJ, Heilman JR, Wefel JS - "Factors affecting dentifrice use and ingestion among a sample of U.S. preschoolers" Pediatr Dent 22(5):389-394 (2000)
https://pubmed.ncbi.nlm.nih.gov/11048307/

Martin M, Rosales G, Sandoval A, Lee H, Pugach O, Avenetti D, Alvarez G, Diaz A - "What really happens in the home: a comparison of parent-reported and observed tooth brushing behaviors for young children" BMC Oral Health 19(1):35 (2019)
https://doi.org/10.1186/s12903-019-0725-5

Moraes SM, Pessan JP, Ramires I, Buzalaf MA - "Fluoride intake from regular and low fluoride dentifrices by 2-3-year-old children: influence of the dentifrice flavor" Braz Oral Res 21(3):234-240 (2007) doi: 10.1590/s1806-83242007000300008
https://www.scielo.br/j/bor/a/FT63tQf4H ... M/?lang=en
"Children ingested around 60% of the dentifrice loaded onto the brush."

Oliveira MJ, Paiva SM, Martins LH, Ramos-Jorge ML, Lima YB, Cury JA - "Fluoride intake by children at risk for the development of dental fluorosis: comparison of regular dentifrices and flavoured dentifrices for children" Caries Res 41(6):460-466 (2007) doi: 10.1159/000107933
https://karger.com/cre/article-abstract ... sk-for-the?
"The average fluoride intake using regular dentifrices and those flavoured for children was 0.567 +/- 0.300 and 0.630 +/- 0.320 mg F/day, respectively, corresponding to doses of 0.046 +/- 0.023 and 0.051 +/- 0.026 mg F/kg/day (p > 0.05). Fluoride intake was slightly higher with the use of dentifrices flavoured for children. Moreover, the dose to which children were exposed with either type of dentifrice was very close to that which is considered the limit (0.05-0.07 mg F/kg/day)."

O'Mullane DM, Ketley CE, Cochran JA, Whelton HP, Holbrook WP, van Loveren C, Fernandes B, Seppä L, Athanassouli T - "Fluoride ingestion from toothpaste: conclusions of European Union-funded multicentre project" Community Dent Oral Epidemiol 32(Suppl 1):74-76 (2004) doi: 10.1111/j.1600-0528.2004.00143.x
https://onlinelibrary.wiley.com/doi/10. ... 04.00143.x

Petrović B, Kojić S, Milić L, Luzio A, Perić T, Marković E, Stojanović GM - "Toothpaste ingestion-evaluating the problem and ensuring safety: systematic review and meta-analysis" Front Public Health 11:1279915 (2023) doi: 10.3389/fpubh.2023.1279915
https://www.frontiersin.org/journals/pu ... 79915/full

Simard PL, Lachapelle D, Trahan L, Naccache H, Demers M, Brodeur JM - "The ingestion of fluoride dentifrice by young children" ASDC J Dent Child 56(3):177-181 (1989) CANADA

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Thornton-Evans G, Junger ML, Lin M, Wei L, Espinoza L, Beltran-Aguilar E - "Use of Toothpaste and Toothbrushing Patterns Among Children and Adolescents: United States, 2013–2016" MMWR Morb Mortal Wkly Rep 68(4):87-90 (2019) doi: 10.15585/mmwr.mm6804a3
https://www.cdc.gov/mmwr/volumes/68/wr/mm6804a3.htm

US DATA:

• Approximately 60% of children and adolescents aged 3–15 years reported using a half load (28.7%) or full load (31.4%) of toothpaste when brushing. Among children aged 3–6 years, the reported amount of toothpaste varied: 12.4% used a smear, 49.2% used a pea-sized amount, 20.6% used a half load, and 17.8% used a full load.

• Nearly 80% of children aged 3–15 years began toothbrushing at age ≥1 year.

• Overall, 60.5% of children aged 3–15 years were reported to brush their teeth twice a day.

van Loveren C, Ketley CE, Cochran JA, Duckworth RM, O'Mullane DM - "Fluoride ingestion from toothpaste: fluoride recovered from the toothbrush, the expectorate and the after-brush rinses" Community Dent Oral Epidemiol 32(Suppl 1):54-61 (2004)
https://doi.org/10.1111/j.1600-0528.2004.00140.x
"Fluoride ingestion from toothpaste is significantly reduced by rinsing and/or spitting during toothbrushing. Recommendations that younger children use small amounts of toothpaste (< 0.5 g) and that children using toothpaste with > or = 1000 ppm F rinse their mouths after brushing continue to be valid."

Repeatedly, one hears from “experts” like Limeback that fluoride use (toothpaste and varnish) benefits young, high-risk children.

A recent RCT in high-risk Swedish toddlers found no benefit from fluoride varnish every 6 months, and fluoride toothpaste from age 1 was associated with lower odds but could not stop caries progression; social factors and sugar intake dominated risk.

• Anderson M, Dahllöf G, Warnqvist A, Grindefjord M - "Development of dental caries and risk factors between 1 and 7 years of age in areas of high risk for dental caries in Stockholm, Sweden" Eur Arch Paediatr Dent 22(5):947-957 (2021) doi: 10.1007/s40368-021-00642-1
  https://link.springer.com/article/10.10 ... 21-00642-1

Abstract

Purpose: To explore caries predictors at age 1 year and caries development at ages 5 and 7 years in two groups of children following different fluoride-based preventive programs.

Methods: We conducted a prospective cluster-randomized controlled intervention trial with two parallel arms comparing two prevention programs: one program included fluoride varnish applications every 6 months, the other did not; otherwise, the programs were the same. Participants were 1- and 3-year-old children enrolled at 23 dental clinics in high-risk areas in Stockholm, Sweden. The baseline examination included structured interviews. Caries data were extracted from dental records. The primary outcome measures were ICDAS 1-6 > 0 at baseline (age 1 year) and defs > 0 at ages 2, 3, 5, and 7 years. The secondary outcome measure at age 7 was DFS > 0.

Results: Continuous caries development occurred: defs > 0 in 23% at 5 years and in 42% at 7 years. We found no difference in caries development between children who had or had not received fluoride varnish as toddlers. At age 1-year, significant predictors for dental caries in later preschool years were immigrant background, family income, and sweets consumption. Fluoride toothpaste > once a day at 1 year had an OR < 1 for defs > 0 at 5- and 7 years.

Conclusions: For toddlers, fluoride varnish does not seem to be an adequate prevention tool. Brushing with fluoride toothpaste from 1 year of age could not arrest caries development. Immigrant background was the strongest predictor. A new toolbox as well as collaborative upstream actions for reducing free-sugar intake are needed.

Although numerous studies, including RCTs [see above], have shown that fluoride varnish has no effect on caries, it has become the standard of care in pediatric primary care - regardless if the child is at high or low risk of caries (Clark et al., 2020).


Here are the AAP recommendations: there is absolutely no difference in recommendations for fluoride varnish or toothpaste by caries risk, whether high or low.

• 

• Clark MB, Keels MA, Slayton RL; SECTION ON ORAL HEALTH - "Fluoride Use in Caries Prevention in the Primary Care Setting" Pediatrics 146(6):e2020034637 (2020)
  https://doi.org/10.1542/peds.2020-034637
  "Fluoride varnish application is now considered the standard of care in pediatric primary care."
  Medicaid pays both physicians and dentists for the application of fluoride varnish in all 50 states. In North Carolina, a leader in the field, these services reached 60,000 children under age 4 in 2007." [60,000 x $30 = $1,800,000]

• PEW 2011: "Medicaid pays both physicians and dentists for the application of fluoride varnish in all 50 states. Most Medicaid programs pay between $15 and $30 for the procedure, and some also separately reimburse for screening, anticipatory guidance, and risk assessment."
  https://www.pew.org/en/research-and-ana ... de-varnish

• PEW: "This information is up-to-date as of April 6, 2017. In 2015, the Medicaid programs in Delaware and New Hampshire began to compensate pediatric health professionals for tooth decay prevention services. In 2017, Indiana became the final state to compensate pediatric health professionals for this oral health service.

NOTES: It should be stated here that, in the US, fluoride varnish is most often applied during a "well-child" visit which start at the age of 6 months. The AAP claims that "fluoride varnish is a proven tool in early childhood caries prevention" - which, of course, it is not.


Regarding the "Spit, Don't Rinse" advice now given world wide to parents of infants, toddlers, and young children - the following item from the 2020 AAP Recommendations deserves attention:

OTC Fluoride Rinse

OTC fluoride rinse provides a lower concentration of sodium fluoride than toothpaste or varnish. The concentration is most commonly 230 ppm (0.05% sodium fluoride). Expert panels on this topic have concluded that OTC fluoride rinses should not be recommended for children younger than 6 years because of their limited ability to rinse and spit and increased risk of swallowing higher than recommended amounts of fluoride.32 A teaspoon (5 mL) of OTC fluoride rinse contains approximately 1 mg of fluoride. For children older than 6 years, OTC rinses provide additional topical fluoride that may assist in the prevention of enamel demineralization. However, the evidence for an anticaries effect is limited, and decisions to recommend OTC fluoride rinses should be made in consultation with the child’s dental health care provider.33,34

The AAP warns that children under 6 should not use fluoride rinses because swallowing a teaspoon can deliver about 1 mg fluoride, yet it endorses “Spit, Don’t Rinse” toothpaste use in the same age group even though typical real-world brushing can lead to similar or higher swallowed doses.

Other Facts on Fluoride Varnish:

The Affordable Care Act requires health insurance coverage of fluoride varnish applied to the baby teeth of all children ages 5 and younger at no cost.

Delta Dental Insurance:

How to talk to hesitant parents

Preventive dental care is important at any age, and you should always inform patients and parents about the role that fluoride plays in that care. Some parents, though, may object to fluoride applications.

Ask them questions about why they want to opt out of treatment, and listen closely to help build trust. Reassure them that you respect their health care decisions, and make sure they understand the risk involved if their children do not get treated.

https://www1.deltadentalins.com/dentist ... -2024.html

Kranz AM, Opper IM, Stein BD, Ruder T, Gahlon G, Sorbero M, Dick AW - "Medicaid Payment and Fluoride Varnish Application During Pediatric Medical Visits" Med Care Res Rev 79(6):834-843 (2022)
https://doi.org/10.1177/10775587221074766

- Higher Medicaid payment was positively associated with receipt of fluoride varnish during pediatric medical visits. The higher the payment, the more fluoride varnish treatments were applied.

- The US Preventive Services Task Force recommends non-dental providers apply fluoride varnish to the teeth of children all children younger than six years of age during medical visits. The rationale for this service to be delivered in medical settings is that young children are more likely to visit medical offices than dental offices.

What parents see:

Basch CH, Hammond R, Guinta A, Rajan S, Basch CE - "Advertising of toothpaste in parenting magazines" J Community Health 38(5):911-914 (2013)
https://doi.org/10.1007/s10900-013-9700-2

We assessed advertisements for children's toothpaste in two widely read US parenting magazines. Data on the number and type of toothpaste advertisements in two parenting magazines were collected from 116 magazine issues between 2007 and 2011. The number of children's toothpaste advertisements per year and across magazines was computed. The amount of toothpaste presented in each advertisement was categorized. We noted whether the toothpaste advertisement stated that the toothpaste was fluoridated. We identified a total of 117 children's toothpaste advertisements in these magazines and confirmed that the majority of the magazine issues contained at least one toothpaste advertisement. Of the 31 advertisements that depicted a picture of a toothbrush with toothpaste, all but one (96.8 %) depicted a full swirl of toothpaste covering the entire toothbrush head, which is well over the recommended amount. The pictures on the advertisements show an excessive amount of toothpaste on the brush, which directly conflicts with the instructions on many toothpastes and dentist recommendations. Those advertisements with photographs that depict a toothbrush with a full brush head of toothpaste are showing over four times the recommended amount for children.

Basch CH, Rajan S - "Marketing strategies and warning labels on children's toothpaste" J Dent Hyg 88(5):316-319 (2014)
https://pubmed.ncbi.nlm.nih.gov/25325728/

The overconsumption of toothpaste has negative consequences, particularly for children. This study's objectives were to describe misleading marketing strategies used in selling children's fluoridated toothpaste and identify warning label characteristics. Two researchers independently coded the packaging from 26 over-the-counter toothpastes that are specifically marketed for children. Aggressive marketing strategies targeting children were identified: every toothpaste in this sample displayed at least 1 children's animated character, 50% had at least 1 picture of a food item, 92.3% stated they were flavored and 26.9% depicted a full swirl of toothpaste, directly contradicting dentist recommendations for young children. Further, on most toothpaste tubes, warnings regarding fluoride overconsumption for young children were only listed on the back and in very small font. Misleading marketing strategies are regularly used in selling children's toothpaste as if it is a food product, while warnings regarding overconsumption among youth are minimized. Dental hygienists are in an important position to help parents of young children implement safe oral care practices.