Navigating fluoride hesitancy: mapping the evidence base for fluoride-free toothpaste alternatives

Area of Science:

• Dental Public Health
• Caries Prevention Research
• Toothpaste Formulation Science

Background:

• Fluoride toothpaste is a proven method for long-term caries prevention.
• Fluoride-free alternatives are gaining popularity, yet their evidence base relies on surrogate or short-term outcomes.

Purpose of the Study:

• To synthesize and interpret evidence on fluoride-free toothpaste alternatives for caries prevention.
• To examine how these products are studied and their outcomes.
• To inform discussions with families regarding oral hygiene choices.

Main Methods:

• A scoping review was conducted.
• Searches identified peer-reviewed studies from January 2020 to March 2026 evaluating fluoride-free toothpaste formulations.
• Data were extracted and narratively synthesized, focusing on evidence generation patterns.

Main Results:

• 122 studies were included, mostly laboratory-based, with limited direct pediatric evidence (20 studies).
• Fluoride-free options demonstrated antimicrobial activity, biofilm modulation, and surrogate remineralization effects.
• Clinical caries outcomes were rarely assessed, with significant heterogeneity in formulations, designs, and outcomes.

Conclusions:

• Fluoride-free toothpastes exhibit biological effects, but evidence relies heavily on surrogate outcomes and short study durations.
• Hydroxyapatite-based products have the most consistent data among fluoride-free options.
• No fluoride-free category currently matches fluoride's evidence for long-term caries prevention in children.