Enhancement of Remineralization

Fluoride ions attract calcium and phosphate ions to the tooth surface, facilitating the formation of fluorapatite, a more acid-resistant mineral than hydroxyapatite.

Fluorapatite promotes the repair of incipient carious lesions.

Inhibition of Demineralization

By adsorbing onto the enamel surface, fluoride reduces the solubility of enamel in acidic conditions. This makes the enamel more resilient to the acids produced by cariogenic bacteria.

Interference with Bacterial Metabolism

At higher concentrations, fluoride can inhibit critical enzyme systems in cariogenic bacteria (e.g., Streptococcus mutans), which reduces their acid production capacity.

Low-Risk

Over-the-counter strength (1000 ppm to 1500 ppm) fluoridated toothpaste: Brushed twice daily

*See administration for additional recommendations

Patients at low risk of developing caries may not need additional topical fluorides other than over-the-counter fluoridated toothpaste and fluoridated water.

Increased-Risk (<6 years)

2.26% fluoride varnish at every 3 to 6 months

NO ALTERNATIVE

Increased-Risk (6+ years)

2.26% fluoride varnish every 3 to 6 months

OR

1.23% fluoride (APF*) gel for 4 minutes every 3 to 6 months

0.09% fluoride mouthrinse weekly

OR

0.5% fluoride gel or toothpaste twice daily

Cavitated Primary Teeth - Coronal Surface (Occlusal, Approximal, Facial, or Lingual)

38% SDF solution applied every 6 months

NONE

Cavitated Permanent Teeth - Coronal Surface (Occlusal, Approximal, Facial, or Lingual)

38% SDF solution applied every 6 months

NONE

Cavitated Permanent Teeth - Root Surface

0.5% fluoride gel or toothpaste twice daily

2.26% fluoride varnish at least every 3 to 6 months

OR

38% SDF solution applied every 6 months

 Birth-6 months

 None

 None

 None

 6 months-3 years

 0.25 mg/day**

 None

 None

 3-6 years

 0.50 mg/day

 0.25 mg/day

 None

 6-16 years

 1.0 mg/day

 0.50 mg/day

 None

*1.0 part per million (ppm) = 1 milligram per liter (mg/L)
 **2.2 mg sodium fluoride contains 1 mg fluoride ion

Toothpaste

Generally available over-the-counter as 1000 ppm to 1500 ppm (0.1 - 0.15%)

Adults & Children >6 years old: 1000 ppm to 1500 ppm

Children < 6 years: <500 ppm if available

Educate patients on proper brushing technique and appropriate toothpaste quantity: 

Adults & children over 3 years: pea-sized amount brushed BID

*Children 3-6 should be supervised to ensure proper amount of toothpaste used

Children <3 years: smear/rice grain sized brushed BID

Toothpaste (Prescription)

Available by prescription as 5000 ppm (0.5%)

Adults: 5000 ppm

Adults: pea-sized amount brushed BID

Water

Available generally from drinking water (tap or bottled)

0.7 mg/L community water fluoridation concentration

Be aware of local water fluoridation status. Advise patients on benefits and address misconceptions.

Varnishes

High-concentration (2.26% 22,600 ppm) topical application.

Indicated for individuals at moderate to high risk of caries, including young children, adolescents, and adults. Effective for preventing both smooth surface and root caries. Can be applied quickly and is well-tolerated.

Apply a thin layer to clean, dry tooth surfaces. Advise patients to avoid brushing, flossing, or eating hard/hot foods for several hours post-application.

Mouth rinses

0.09% fluoride mouthrinse

Available as daily low-concentration (e.g., 0.05% NaF, 230 ppm) or weekly high-concentration (e.g., 0.2% NaF, 900 ppm) rinses. Indicated for individuals with increased risk of carries

Ensure patients understand proper rinsing technique (swish for 1 minute, then spit). 

Avoid eating/drinking for 30 minutes. 

Not for children < 6 years

Gels and foams

High-concentration topical fluoride (e.g., 1.23% Acidulated Phosphate Fluoride (APF) or 2% Neutral Sodium Fluoride) delivered via trays.

Historically common for professional in-office treatments.

Due to ingestion risk and comparable efficacy, fluoride varnishes are generally preferred, especially for younger patients.

Apply product to custom or disposable trays, place over teeth for 1-4 minutes. Ensure patient is upright to minimize ingestion. Advise patients to avoid brushing, flossing, or eating hard/hot foods for several hours post-application.

Supplements

Tablets and lozenges available with 1.0, 0.5, or 0.25 mg fluoride.

Prescribed for children (typically from 6 months to 16 years) living in areas with non-fluoridated water who are at high risk for dental caries. Dosage prescribed based on age and existing fluoride exposure from other sources to prevent fluorosis.

Conduct a thorough fluoride history for patients. Emphasize strict adherence to prescribed dosage to prevent dental fluorosis.

Silver Diamine Fluoride (SDF)

Available as 38% solution

Indicated and applied for the nonrestorative treatment of dental carries

Applied to cavitated surfaces. Ensure patient is upright to minimize ingestion. Advise patients to avoid brushing, flossing, or eating hard/hot foods for 30 minutes post-application.

Caused by excessive fluoride exposure during the formative stages of tooth enamel, leading to hypomineralization.

Ranges from mild (barely perceptible white flecks or streaks) to severe (pitting, brown staining, and enamel hypoplasia). Mild fluorosis is primarily a cosmetic concern and does not impact tooth function or longevity.

Careful monitoring of fluoride intake from all sources, especially in children under 8 years, and appropriate prescribing of fluoride supplements.

A rare and severe condition resulting from chronic, excessive systemic fluoride intake (typically >10 mg/day for many years), leading to fluoride accumulation in bones, causing increased bone density and compromised bone strength.

Manifests as bone pain, joint stiffness, and in severe cases, crippling deformities.

Exceedingly rare in optimally fluoridated communities; primarily observed in populations consuming naturally high-fluoride water (e.g., some parts of India, China, or Africa) or in industrial fluoride exposure.