AAPD Fluoride Therapy best practice (2023 revision): a smear under 3, a pea from 3 to 6, varnish only under 6, and supplements only after counting every other source

What it says#

The best practice, first adopted in 1967 and last revised in 2023 by the AAPD's Councils on Clinical Affairs and Scientific Affairs, is meant to help practitioners decide how to use fluoride in comprehensive care for infants, children, adolescents and persons with special health care needs. The update screened 116 new systematic reviews or trials since 2017 after an initial search returned 4,077 papers, and relied on expert opinion where the evidence ran out. Its abstract sets the frame: fluoride is an effective therapy against caries, community water at 0.7 ppm balances caries protection against fluorosis, and the patient's needs decide which systemic and topical products to use.

Community water fluoridation is called the most equitable and cost-effective way to deliver fluoride; as of 2018, 73% of the US population on community water systems had access to it, and in 2015 the Department of Health and Human Services standardized the level at 0.7 ppm. The document reviews the IQ literature and concludes that current evidence does not support an association between water at 0.7 ppm and reduced IQ. The cost of too much is fluorosis: children 15 to 30 months old are most susceptible for the permanent incisors, and 23% of Americans aged 6 to 49 had very mild or mild fluorosis in NHANES 1999 to 2004.

Supplements are effective and may be considered for children at high caries risk who drink fluoride-deficient water, defined as under 0.6 ppm F. The schedule, unchanged since the early 1990s: nothing from birth to 6 months; from 6 months to 3 years 0.25 mg a day if the water is under 0.3 ppm; from 3 to 6 years 0.50 mg (under 0.3 ppm) or 0.25 mg (0.3 to 0.6 ppm); from 6 to at least 16 years 1.00 mg or 0.50 mg on the same split; nothing at any age when the water is over 0.6 ppm. The AAPD notes the table was never adjusted for the 0.7 ppm standard or for toothpaste from the first tooth, so all dietary sources (home, day care and school water, soda, juice, reconstituted infant formula, prepared food, toothpaste) are to be counted first, and caution is indicated under age 6.

Professionally applied topical fluoride is efficacious. The agents are 5% sodium fluoride varnish (2.26% F, 22,600 ppm F) and 1.23% acidulated phosphate fluoride (12,300 ppm F). Meta-analyses of 23 trials, mostly twice-yearly application, favor varnish in primary and permanent teeth; varnish appears effective in higher-risk children under 5; unit doses of 5% varnish are the only professional agent recommended for children younger than 6, for safety; gels applied at 3-month to 1-year intervals reduce caries in permanent teeth; there are no trials showing efficacy for application times shorter than 4 minutes; evidence for foam in children is limited; and children at risk should receive a professional fluoride treatment at least every 6 months. Silver diamine fluoride gets its own section: 38% SDF (5% F, 44,800 ppm F) is FDA-cleared as a dentin desensitizer in adults and is frequently used to arrest cavitated lesions, with trial arrest rates of 35% to 80%, high risk of bias and heterogeneity, and therefore conditional recommendations; biannual application arrests more dentin caries than varnish; it is best used inside an ongoing caries management plan in a dental home; it is cytotoxic to pulp cells when applied directly to pulp tissue; and its side effects are black staining of the lesion and temporary staining of skin and gingiva.

Home use aims for lower-dose, higher-frequency contact. Toothbrushing with fluoridated toothpaste reduces caries in the primary dentition; no more than a smear or rice-sized amount (0.1 mg F) for children under 3 may lower fluorosis risk, a pea-sized amount (0.25 mg F) is appropriate from 3 to 6, brushing should be supervised twice a day, and rinsing after brushing should be minimal or avoided. Prescription-strength home products (0.5% F gels and pastes, 0.09% F rinse) benefit higher-risk patients such as adolescents, adolescents with special health care needs and patients in fixed orthodontic appliances, and are recommended from age 6. On safety: over 20,000 fluoride ingestion reports reach poison control centers each year, over 80% in children under 6; the probably toxic dose is 5 mg/kg of body weight and 15 mg/kg could be fatal for a small child; over-the-counter pastes contain 1,000 to under 1,500 ppm F and prescription pastes may contain 5,000 ppm F; parents should dispense toothpaste for children under 3, supervise any child who cannot spit, and keep supplements and prescription products out of reach.

The recommendations, verbatim in substance: use fluoride for caries prevention and control because it is safe and highly effective; consume optimally fluoridated community water; brush at least twice daily with an age-appropriate amount of over-the-counter fluoride toothpaste as the first line; apply professional 5% NaF varnish or 1.23% F gel at least twice a year; use 38% SDF to arrest cavitated lesions in primary and permanent teeth within a comprehensive caries management program; prescribe 0.5% F gels and pastes and 0.02 to 0.09% F rinses for high-risk patients over 6; base every fluoride decision on the individual's risks and benefits; and consider dietary supplements cautiously for children at caries risk on less-than-optimally fluoridated water, because supplementation on top of other sources could exceed the recommended daily intake.

Who it applies to#

Every pediatric patient from the first tooth through adolescence, including persons with special health care needs, and every team member who touches fluoride: the hygienist applying varnish, the assistant explaining toothpaste amounts, the dentist writing a supplement or a 5,000 ppm paste. The ages in the document are the lines that matter: under 3, 3 to 6, 6 and older, and the supplement bands at 6 months, 3 years, 6 years and 16 years.

Adults are outside its population. The document does not recommend foam on its own or short application times for gel, and it treats the supplement table as inherited rather than re-derived, which is the reason for the repeated caution under 6.

What changed#

The 2018 revision (Pediatric Dentistry 2018;40(6):250-3) was the last before this one; the 2023 text was rebuilt from a fresh search and now includes a dedicated silver diamine fluoride section and an SDF recommendation, the 2015 HHS 0.7 ppm standard as the reference level, a review of the maternal fluoride and IQ studies with the conclusion that 0.7 ppm water is not associated with reduced IQ, and the explicit note that the supplement schedule predates both the 0.7 ppm standard and toothpaste from the first tooth. This entry did not compare the 2018 and 2023 texts line by line.

Where the source is#

The link under the title is the AAPD's page for Fluoride Therapy, which shows the abstract and opens the Reference Manual PDF; the seven-page PDF, latest revision 2023 and printed at pages 372 to 378 of the 2025 manual, was downloaded and read in full for this entry, and its How to Cite line is the citation above. The AAPD web page labels the chapter for the 2026-2027 manual with page numbers to be determined, so the 2025 pagination is the one cited here. The supplement table, the toothpaste figure and the recommendation list are all in the PDF; no subscription is needed.