When preparing for your first baby and picking out those delicate rubber duckie-patterned washcloths, you probably imagined a gorgeous baby giggling in a tub, not a hellbeast raging in front of the mirror as you tried to wipe its gums.

But it’s a good thing you got in all those scrimmages, because the gum wiping was just practice for the full-scale battles waged over twice-daily brushing with your toddler.

If you’re following the American Dental Association’s (ADA) guidelines, you’ll be fighting this fight until age six or seven – when children are thought to be sufficiently coordinated to brush solo. Assuming your child’s first teeth came in around six months, that’s about 4,700 brushing sessions.

As you rinse tonight’s flailed toothpaste off your neck, you start to wonder if it’s really so bad to only brush once a day, or every other day, or once baby teeth start falling out.

Grading dental health interventions

Mercifully for all those parents locked in nightly brushing battles, toothbrushing is not the only component of dental health. 

Brushing can remove plaque. Fluoride can remineralize teeth, helping strengthen their enamel against decay. Fluoride can be delivered systemically (like through the water we drink) or topically (like the varnishes you probably remember from your childhood).

The ADA asserts that systemic fluoride is a stronger protectant against future decay in teeth that haven’t erupted yet; that is, kids who ingest fluoride while their teeth are developing will have stronger teeth than kids who do not ingest fluoride. This is why most areas of the U.S. have water supplies supplemented with additional fluoride.

One organization that has studied systemic and topical fluoride treatments for young children is the US Preventive Services Task Force (USPSTF), whose members conduct extensive medical literature reviews to make recommendations about clinical preventive services. They publish their results in the form of grades (A-D, I), which guide clinicians regarding whether or not to provide or offer a particular service.

An “A” grade means “there is a high certainty that the net benefit is substantial,” while a “D” means “there is moderate or high certainty that the service has no net benefit or that harms outweigh the benefits.” An “I” statement means there is not yet enough evidence to determine how beneficial a service may be: it could be helpful, harmful, or neutral.

In 2014, the USPSTF reviewed and revised its study of dental caries (that’s cavities to all of us not in the dental field) in children up to age five. When we think of childhood illness, tooth decay probably doesn’t top the list, but the USPSTF asserts that “dental caries is the most common chronic disease in children in the United States.” The authors then cite the 1999-2004 National Health and Nutrition Examination Survey that found just under half of the U.S. population of two- to 11-year-olds have dental caries. Those dental caries can have effects long after primary teeth have fallen out. The USPSTF lists pain, tooth loss, future cavities, and school absence among the consequences of cavities in early childhood.

The case for fluoride

The USPSTF recommends two dental health services that pediatricians, who are the main point of contact between kids and the health system, should offer their patients. First, they should prescribe fluoride supplements for children aged six months or older who live in areas where the water is not fluoridated. Second, they should apply fluoride varnish to teeth once children begin teething.

The USPSTF’s recommendations have two implications for parents. First, find out whether your water is fluoridated. If your water is not fluoridated, talk to your pediatrician about supplements, which will help strengthen your child’s teeth even before they erupt. Second, even if your water is fluoridated, talk to your clinician about fluoride varnish, which provides an additional layer of protection for your child’s erupted teeth.

One concern raised by fluoride detractors is that consuming too much fluoride can cause fluorosis, which in the U.S. typically presents as white spots on teeth. In its review of the literature on fluorosis, the USPSTF found that fluorosis is a mild cosmetic issue in over 99% of cases. Parents concerned about this cosmetic risk can buy children’s toothpaste, which has a lower concentration of fluoride than adult toothpaste.

Five strategies for successful brushing

No dentist or pediatrician is going to tell you to stop brushing your child’s teeth, but the USPSTF fluoride recommendations should make each individual brushing session feel less dire. Fluoridated water and fluoride varnishes from the pediatrician act as another line of defense to remineralize your child’s teeth.

At these early ages, brushing is likely to be imperfect no matter who is doing it: either a child is using poor technique or a parent is attempting to brush a flailing child. But at this age, the value of brushing might be a little less about preventing decay and more about cementing future behaviors. Imperfect brushing at the hand of an enthusiastic two-year-old may be better than a parent’s perfect brushing of a protesting child.

Knowing that you have good fluoride backup, consider relaxing the brushing routine and using these strategies to help create positive long-term dental habits:

  • Offer toothbrushing choices. Yes/no questions are a parent’s worst enemy. “Do you want to brush your teeth?” is not a real question because there is only one answer: “Yes, you’re going to brush your teeth, whether you want to or not.” But you can offer choices by asking, “Which toothbrush do you want: Snoopy or Olaf?” or, “Should we use blue toothpaste or red toothpaste?” or “How many times should we spit in the sink?”
  • Brush alongside your child. Keep a spare toothbrush wherever your child brushes his teeth so you can brush when he does. After a few sessions, you’ll notice him start to copy your behaviors, so make sure you brush well!
  • Make brushing a conversation. Ask your child “Which of your teeth likes…” and run through a list of all your child’s favorite foods as you brush a tooth or two at a time. Over a few brushing sessions, ask your child to start telling you which foods his teeth likes. This conversation can morph into discussions of the importance of brushing. (“We really need to clean those teeth that ate all those donuts today!”) Create new themes with each brushing session to make the brushing time fly by. Maybe one day all of the foods are green. Maybe one day they’re all desserts. Maybe one day they all start with the letter C.
  • Make a deal about who brushes when. If all other strategies are failing, consider giving in for a week and telling your child its his job to brush (supervised, of course) in the morning and your job to brush at night. The additional responsibility may make him more interested in brushing, and you can do an extra thorough job in the evenings until he’s up for morning brushing again. The short-term loss of missed brushings will be offset by the long-term gains of your child’s practice with independent brushing.

What strategies do you use for brushing your child’s teeth? Share your thoughts with us in the comments, or snap a pic of your #happybrusher and share it with us on instagram @helloparentco.