Fluoride is one of the main reasons tooth decay has become less common and less severe in the United States. But swallowing too much while teeth are forming can cause dental fluorosis — visible discoloring and pitting of the enamel. So the advice for young children is precise:
| Recommendation | |
|---|---|
| Start brushing | when the first tooth comes in — as early as 6 months |
| First dental visit | by age 1 |
| Fluoride toothpaste (CDC) | from age 2; ask a dentist or doctor before using it under 2 |
| Under 3 | a smear the size of a grain of rice |
| 3 to 6 | no more than a pea-sized amount (0.25 g) — by 6, the swallowing reflex usually prevents swallowing it |
| Everyone 2 and older | brush twice a day with fluoride toothpaste, and drink optimally fluoridated water (0.7 mg/L) |
The American Academy of Pediatrics, American Academy of Pediatric Dentistry and American Dental Association recommend fluoride toothpaste for all children, with a rice-grain smear under 3.
What parents reported
CDC analyzed National Health and Nutrition Examination Survey (NHANES) questions, first asked in 2013–2014, for 5,157 children aged 3–15 (2013–2016).
When children started brushing
| Age | Share |
|---|---|
| Under 1 | 20.1% |
| 1 | 38.8% |
| 2 | 26.6% |
| 3 or older | 14.5% |
So nearly 80% started later than recommended.
| Started brushing | By age 1 or younger | At 3 or older |
|---|---|---|
| White children | about 60% | 11.4% |
| Black children | about 60% | 13.9% |
| Mexican-American children | 49.3% | 22.6% |
Children in households headed by someone without a high school education were less likely to start by 1 (44.5%) than those whose household head had more education (63.2%).
How often
60.5% brushed twice a day; about a third brushed once a day.
Toothpaste
Toothpaste use started under 1 for 9.0%, at 1 for 35.2%, at 2 for 32.7%, and at 3 or older for 23.1% (31.2% of Mexican-American children).
How much children aged 3–6 used:
| Amount | Share |
|---|---|
| Smear | 12.4% |
| Pea-sized | 49.2% |
| Half load | 20.6% |
| Full load | 17.8% |
That's more than 38% using a half or full brush load — above the recommendation, and possibly above recommended daily fluoride intake. Across all ages 3–15, about 60% used a half or full load.
What it means
Children are mostly following good daily habits, but not quite as recommended. The advice balances fluoride's protection against cavities with the risk of fluorosis from swallowing too much while the permanent teeth are forming — which is why parents should supervise young children's brushing and watch how much toothpaste they use. CDC and the AAP have begun working on messages for pregnant women and new mothers about brushing, and health professionals can help teach parents the right amount.
Limits
Answers were parents' reports; the amount of toothpaste asked about was current use, which may overstate what younger children used; and the survey didn't ask whether the toothpaste contained fluoride. Future surveys could ask about the amount used when a child started, with pictures to make the amounts clear.
Sources
Based on 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 volume 68, number 4, Centers for Disease Control and Prevention; a work of the United States government in the public domain.
Licence: CC0 1.0 (public domain) · Adapted from www.cdc.gov
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