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Strong evidence supports anti-caries effect of fluoride toothpastes

Steven Bender DDS; Candice McMullan-vogel D.D.S., Dr. med. dent. .


Systematic Review Conclusion

Regular use of fluoride toothpaste reduces caries in the permanent dentition of children.

Critical Summary Assessment

This comprehensive review of more than 70 studies firmly establishes the effectiveness of fluoride toothpaste in caries prevention.

Evidence Quality Rating

Good Evidence

Structured Abstract

Clinical Questions:

Is fluoride toothpaste safe and effective in preventing dental caries in children and adolescents? What factors may modify its effect?

Review Methods:

The authors conducted an all-language search of 10 databases for studies published between 1965 and 2001. In addition, journals were hand searched and selected authors were contacted. The authors selected randomized controlled trials of at least 1 year duration that used blind outcome assessment when comparing fluoride toothpaste with placebo in children. The primary outcome measure was caries increment assessed by the change in decayed missing and filled tooth surfaces (DMFS). Selection of studies for inclusion, evaluation of study quality, and data extraction was duplicated in a random sample of one-third of the studies, and agreement achieved by discussion or a third party. Random effects meta-analysis was performed where data could be pooled.

Main Results:

Seventy-four studies were included. Data pooled from 70 studies, involving 42,300 children aged 5 to 16 years, suggested an average reduction in caries increment of 24% (95% CI, 21 to 28%; P< 0.0001) with the use of fluoride toothpaste. The beneficial effect of fluoride toothpaste increased with higher initial levels of caries, higher fluoride concentration, and higher frequency of use and with supervised brushing, but was not influenced by exposure to water/salt fluoridation. In 5 trials, the only adverse effect, reported was extrinsic tooth staining associated with the use of stannous fluoride toothpaste formulations.


Regular use of fluoride toothpaste effectively inhibits caries development in children and adolescents. This beneficial effect is greater among those with higher initial levels of decay. Fluoride toothpaste use provides additional caries reduction beyond that provided by water fluoridation. The caries preventive effect of fluoride toothpastes can be expected to increase with higher fluoride concentration and more frequent use. There was little information provided concerning caries prevention in deciduous dentition or adverse effects such as fluorosis.

Source of Funding:

CAPES-Ministry of Education Brazil, Department of Epidemiology and Public Health (UCL) UK, Systemic Reviews Training Unit, Institute of Child Health (UCL) UK, Medical Research Council UK


Importance and Context:

Many studies on the caries-reducing effect of fluoride toothpastes in children have been conducted and summarized in narrative reviews, but this is the first systematic quantitative evaluation of the effectiveness and safety of fluoride toothpastes compared to placebo. Brushing with fluoride toothpaste is the most common form of caries control. In many countries, the widespread use of fluoride toothpaste is linked to the decrease in caries prevalence. Although dental decay has declined significantly, as the most common dental disease it remains a significant problem in certain segments of the population.

Strengths and Weaknesses of the Systematic Review:

The search criteria and methods suggest that a comprehensive review identified the most relevant published studies. Also, the evidence was properly interpreted.

Strengths and Weaknesses of the Evidence:

In this review, the quality of the included trials generally was high, and the reviewers used appropriate well defined, and clinically relevant methods in evaluating the efficacy of fluoride toothpastes in caries prevention. The majority of the studies were conducted in the 60s and 70s, and the only noted adverse effect of fluoride toothpaste use was extrinsic tooth staining from stannous fluoride toothpastes. 56 trails tested toothpaste with the 1000/1100ppm Fluoride concentration. Although the objective as stated in the clinical question was to assess both safety and effectiveness, this review found no information on fluorosis.

Implications for Dental Practice:

Fluoride toothpastes are highly effective in preventing dental caries in permanent teeth in children and adolescents. This effect is even greater with high-risk populations. There is strong support from the current evidence that dentists should advise patients to use a fluoridated toothpaste. Patients at high risk for caries also should be counseled to brush at a minimum of twice daily. This systematic review found little information on the effects of fluoride toothpaste on caries prevention in the deciduous dentition or the risk of fluorosis. The risk of developing fluorosis in the permanent dentition decreases with age and is effectively gone after age 8. Toothpaste use in young children should be closely supervised to limit ingestion.

Critical Summary Publication Date:


These summaries are not intended to, and do not, express, imply, or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs. American Dental Association © 2019