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Lisa Black

Long before a baby’s first tooth erupts, the pediatrician can start guiding families on how to develop healthy oral health habits, including optimal use of fluoride to prevent decay

The most common chronic disease of early childhood is responsible for millions of school hours lost each year due to illness -- and it is largely preventable.

Dental caries, or tooth decay, disproportionately affects poor, young, Black and Hispanic populations, and children with special healthcare needs. The impact of the COVID-19 pandemic has intensified health inequities, as dental visits and well child care visits declined significantly.

The American Academy of Pediatrics recognizes that pediatricians are uniquely positioned to provide oral health guidance to families and apply fluoride varnish to prevent disease in an updated clinical report, “Fluoride Use in Caries Prevention in the Primary Care Setting.” The report, from the AAP Section on Oral Health, marks the first update in recommendations since 2014 and is published in the December 2020 Pediatrics (published online Nov. 30).

“Fluoride has consistently been proven effective at preventing tooth decay, which, when left untreated, can lead to pain, loss of teeth and serious infections,” said Melinda B. Clark, MD, FAAP, lead author of the report. “Pediatricians can prevent dental disease by applying fluoride varnish, counseling families on nutrition and how to care for their children’s teeth and referring to a dentist.”

The clinical report helps pediatricians maximize the use of fluoride for caries prevention while minimizing the risk of enamel fluorosis, a largely cosmetic condition that can cause discoloration of the teeth.

The AAP recommends that pediatricians:

  • Perform oral health risk assessments on all children at every routine well-child visit beginning at 6 months of age.
  • Recommend use of fluoridated toothpaste starting at eruption of the first tooth. A smear or grain of rice sized amount is recommended for children younger than 3 years, and a pea-sized amount of toothpaste is appropriate for most children starting at 3 years of age.
  • Apply fluoride varnish according to the recommended periodicity schedule. Fluoride varnish is a proven tool in early childhood caries prevention.
  • Know how to determine the concentration of fluoride in a child’s primary drinking water and determine the need for systemic supplements.
  • Advocate for water fluoridation in the local community.
  • Understand indications for silver diamine fluoride and be able to recognize the clinical appearance of teeth treated with silver diamine fluoride, which is a minimally invasive, low-cost liquid solution that is painted on cavity lesions.

“Families can help children adopt healthy habits from a very young age with simple routines, including the appropriate use of fluoride to prevent dental disease,” Dr. Clark said. “We encourage parents to talk to their pediatricians about getting fluoride varnish at their well child visit and how much fluoride toothpaste to use for their children.”

For parents, an article in is available: FAQ: Fluoride and Children.


The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents and young adults.

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