The objectives of the current review were to determine the effectiveness and safety of fluoride toothpastes in the prevention of caries in children, and to examine factors potentially modifying their effect. In contrast to many other Cochrane reviews, a considerable number of studies fulfilling the inclusion criteria were available for review. The pooled estimate for the observed percentage-difference in caries increment was 24% and its 95% CI was narrow enough to leave no doubt about the beneficial effect of brushing with fluoride toothpaste compared with brushing with a nonfluoride paste. The intention was to assess effectiveness. As a matter of fact, many of the studies included in the review were explanatory trials with the aim of finding out the effect of fluoridated toothpaste under ideal conditions (efficacy). Pragmatic trials with an explicit aim to assess the effect under the everyday conditions in real life (effectiveness) are regrettably still rare. With such a firm efficacy, however, one can safely assume that even the effectiveness is considerable. It is noteworthy that even children who had a low level of caries increment and who were exposed to fluoridated water or fluoride from other sources did benefit from using fluoridated toothpaste. At the moment the evidence on the beneficial effect of fluoride toothpastes is so strong that ethical reasons prevent further RCT in which brushing with a fluoride toothpaste is compared with brushing with a nonfluoride paste.

The clear and statistically significant heterogeneity of the studies calls for further examination of the role of factors that are modifying the effect of fluoridated toothpastes. For instance, the implication of fluoride concentration still remains somewhat unclear since an overwhelming majority of the studies have considered the effect of toothpastes containing 1000 ppm fluoride against a nonfluoride paste. The fact that toothpaste containing 1000 ppm fluoride has become a sort of golden standard does not imply that this concentration would be the ideal one. Among the reviewed studies, only a few had considered the effect of 1500 and 2500 ppm pastes and none included any greater concentrations than those. Consequently we still do not know whether toothpastes with higher fluoride concentrations would be preferable and, if so, whether they should be used generally or only by individuals at high risk of caries. The same uncertainty holds for the low-fluoride toothpastes. For infants and toddlers we need to balance the risk of developing carious lesions with the risk of dental fluorosis, and more evidence is still required with regard to optimal fluoride concentrations for children of different ages and with different levels of exposure to fluoride from other sources. Even the effect-modification by the daily frequency of brushing with fluoridated toothpaste needs to be studied in more detail. We know for sure that two times a day is better than once, but the marginal utility of each of the additional daily brushing times is not known. There is still a need for good quality RCT examining different aspects of fluoridated toothpastes.

Practice point

  • Fluoride toothpaste prevents caries and has a greater effect in people with more disease.