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Fluoride vs fluoride free toothpaste

Toothbrush with toothpaste

As a dentist, I always recommend using a fluoride toothpaste.

However, here at Electric Teeth we do respect that some people prefer not to use it, so throughout our content you will see both fluoride and fluoride free toothpaste options.

Why is fluoride in toothpaste?

There seems to be some controversy about the use of fluoride in toothpaste. But let me get it out there, it is the only ingredient that has been proven to reduce the risk of developing cavities.

It’s true, you can have too much of a good thing, and I will discuss more about the risks of too much fluoride later on.

But fluoride is added to toothpaste because it protects your teeth. It is the most efficient way to protect your teeth from painful decay.

In fact, fluoride is such a vital ingredient to toothpaste that the Australian Dental Association (ADA) Seal of Approval will only be awarded to toothpastes which contain fluoride.

Keep reading to find out more about fluoride’s role in toothpaste. You can also watch a video summary below from Dr. Chhaya Chauhan.

Fluoride Toothpaste - Why Is It Good For Your Teeth?

Sources of fluoride

Aside from your toothpaste and mouthwash, fluoride can be found naturally in food and water.

Fluoride actually occurs naturally in many water sources. Some areas have naturally higher concentrations of fluoride in the water, much closer to the recommended level of 1.0mg/L.  Approximately 13.5 Million people in Australia have access to water which is at this optimum concentration, naturally, or through water fluoridation. Water fluoridation is the process of adding fluoride to water. This water fluoridation has been ongoing since the 1960s and has been linked to drastic fall in the number of cavities people develop.

Because of the known benefits, many other countries also have water fluoridation, including:

  • Ireland, where the average concentration is 0.65 mg/L.
  • Canada, where the Maximum Acceptable Concentration of 1.5 mg/L.

Fluoride is also found in the soil, and so most vegetables and fruit will contain fluoride. In fact, a report from the Food Safety Authority of Ireland, entitled Total Diet Study 2014-2016: Assessment of Dietary Exposure to Fluoride in Adults & Children in Ireland  investigated fluoride in the diet.

There is a lot of variation as shown in the graph below (click here to see the full size version in a new tab), with black tea having surprisingly high concentrations of fluoride. 

Fluoride vs fluoride free toothpaste 1
A graph showing fluoride distribution in food categories (click here to see larger version)

The take home message from this is that fluoride is found widely in your day to day diet, and it is nothing to be feared. It is something that humans have been exposed to since we started to exist.

When it comes to fluoride added to toothpaste, it will take one of three forms:

  • Sodium fluoride
  • Sodium monofluorophosphate
  • Stannous fluoride

And these are manufactured to ensure safety and purity.

How does fluoride prevent cavities?

Tooth decay is where the enamel surface of the tooth is dissolved by acids, produced by bacteria in the mouth. This enamel surface is made up of crystals containing hydroxyapatite. The bacteria are fed by sugars we consume as part of our diet.

So why is it important to use toothpaste containing fluoride? Fluoride prevents cavities by:

  1. Inhibiting demineralisation. The presence of fluoride in an acidic environment reduces the dissolution of calcium hydroxyapatite in the enamel surface. In highly acidic environments the fluoride ions attach to the hydroxyapatite crystals and protect them from the acid attack.
  2. Promoting remineralisation. In more neutral environments the fluoride ions incorporate themselves into the demineralised surface, creating fluorapatite.
  3. Inhibiting bacteria associated with tooth decay. Fluoride is able to create damage to the bacteria themselves and prevent the bacteria converting sugars in the diet into damaging acids.

What are the benefits of fluoride toothpaste?

Fluoride protects against cavities.

Original studies into fluoride related to water fluoridation, with protection against cavities noted in teeth with dental fluorosis. In fact, fluoride within water decreased caries rates by 50%.

However later studies showed an even greater level of protection against cavities with topical fluoride, without the negative effects of dental fluorosis.

The greatest effect is with topical use – direct contact on the tooth surface. This is why toothpaste is useful in addition to fluoridated water.

In fact, it is recognised that frequent exposures to small amounts of fluoride, on a daily basis, is the best way to reduce your risk of cavities.

In addition to the anti-cavity effects of sodium fluoride and sodium monofluorophosphate, Stannous fluoride has some additional benefits in the mouth.

Stannous fluoride is actually recognised as better than the two other forms of fluoride because it has so many more benefits. These benefits include:

  • Preventing dental calculus, when added with Sodium hexametaphosphate (SHMP).
  • Reduction in dental plaque (with positive anticavity and antigingivitis effects).
  • Reducing signs and symptoms of gingivitis directly as it is thought to be anti-inflammatory.
  • Reducing halitosis (bad breath), possibly due to the antibacterial effects.
  • Reducing staining of teeth, when used alongside SHMP.
  • Treating dentine hypersensitivity.

How much fluoride is safe?

So now that I’ve explained how fluoride works, and why a toothpaste with fluoride is a good thing…time to discuss how much fluoride you need!

There are recommended levels of fluoride in toothpaste so that you can get the positive effects of protection against cavities. But there are also maximum safe levels of fluoride, as if you swallow too much fluoride you can experience negative side effects.

Fluoride concentrations in toothpaste

Toothpastes and mouthwashes will display the amount of fluoride in parts per million (ppm) of fluoride, or a percentage (%) of fluoride.

This can be confusing when you are looking to compare different products.

To be able to convert between the % fluoride and ppm fluoride, you can use the following table, adapted from data produced by Colgate.

Type of fluoride%ppm
Sodium Fluoride0.221000
Sodium Fluoride0.321450
Sodium monofluorophosphate0.761000
Sodium monofluorophosphate0.8361100
Stannous fluoride0.41000
Stannous fluoride0.4541100

Is fluoride toothpaste safe?

In moderation, yes, fluoride toothpaste is safe.

Most concerns about safety of fluoride relate to the amount actually swallowed, or ingested.

Because toothpaste is a topical form of fluoride, and should not be swallowed, it is of limited concern.

Children in particular may be more prone to swallowing toothpaste, and this is why dentists and manufacturers advise that children are supervised when brushing their teeth.

If too much fluoride is swallowed in one go, it can be unsafe. A high amount can lead to fluoride poisoning (this is the same for many natural ingredients!). Which is also why dentists recommend only a pea sized amount of toothpaste at a time.

Long term, if there is a higher than recommended amount of fluoride, such as from water and food, conditions such as dental fluorosis and skeletal fluorosis may develop. This is why we need to take into consideration other exposure to fluoride as well as toothpaste.

Harmful levels of fluoride

So how much fluoride do you need to swallow or ingest before it becomes a problem?

  • Skeletal fluorosis: This damage to the bones can create weakened bones, but requires long term exposure to very high levels of fluoride. Typically this is seen only in parts of India, China or Africa where drinking water has a very high fluoride content, typically 7 mg/day or more.
  • Dental fluorosis: This causes marks that vary from mild white spots to brown pits on the teeth, and is caused by excess fluoride intake whilst the adult teeth are developing (risk is typically ages 0-8 years). Studies have been undertaken, concluding that harm of this is minimal if fluoride dose is less than 0.1 mg of fluoride per kilogram of bodyweight per day in children up to 8 years old. After 8 years old this safe level is upped to 10mg per kg of bodyweight per day.
  • Poisoning: This occurs when too much fluoride is swallowed as a one off, such as a whole tube of toothpaste. Effects start within the stomach, but can ultimately lead to death.

Recommended levels

Because you can have side effects of dental fluorosis, skeletal fluorosis or even poisoning when having too much fluoride, there are some restrictions and recommendations to protect you from unintentionally ingesting too much.

After lots of research into diet habits and side effects, limits were placed on the fluoride content in the water supply as well as maximum concentrations of fluoride in toothpaste.

In water

To help prevent too much fluoride being ingested, there is a limit of how much fluoride can be contained in water. In Australia this is regulated by  Australian Drinking Water Guidelines. At present the maximum limit is 1.5 mg/L.

In toothpaste

When it comes to how much fluoride in toothpaste is recommended, guidelines vary by country.

Generally speaking as an adult you should be aiming for a toothpaste containing 1500ppm fluoride, or as close as possible to this. The stronger the concentration, the higher the benefits of the fluoride, and the more it can protect you from cavities.

Children’s toothpastes may contain lower concentrations of fluoride, especially if they are targeted at children under 6 years old. This is because it has been proven that swallowing toothpaste can affect the developing adult teeth by causing dental fluorosis.

Over the age of 8, children’s toothpastes may well have the same concentration of fluoride as an adult toothpaste.

Different guidelines from around the world include:

Age groupADA recommendationUK recommendationEuropean Academy of Paediatric Dentistry
Babies0-17 months:
Start brushing their teeth as soon as they start to appear in the mouth with no toothpaste
0-3 years:
At least 1000ppm. Minimal smear. Advised if the child swallows the toothpaste.

0-3 years:
1350-1500ppm. Minimal smear. Only use if you can prevent them swallowing the toothpaste

6 months – 2 years:
500ppm. Pea sized amount
Young Children18 months – 5 years:
Use no more than a pea-sized amount of fluoride toothpaste 500-550ppm
3 – 6 years:
At least 1000ppm. Pea sized amount, Advised if the child swallows the toothpaste.

3-6 years:
1350-1500ppm. Pea sized amount. Only use if you can prevent them swallowing the toothpaste
2 – 6 years: 1000ppm. Pea sized amount
All ages – children over 6 and adult1000ppm
Smear of toothpaste, do not swallow
1350-1500ppm. Smear of toothpaste, do not swallow1450ppm. 1-2cm smear

The take home message here is that the amount of fluoride toothpaste recommended varies depending on your location, and you should do some research before you decide which is best for you and your children.

Safety and support for fluoride

Don’t just take my word about the benefits of fluoride, and whether or not fluoride is safe. If you want even more information you could go to a number of reputable organisations from around the world.

At present the overwhelming evidence supports the use of fluoride in toothpaste, and in particular I would like to draw your attention to the following pages to help inform you about fluoride:

Scottish Intercollegiate Guidelines Network: Dental interventions to prevent caries in children

Why do some people prefer fluoride free toothpaste?

Over recent years there has been a shift towards “natural toothpastes”, with similar searches for organic and also fluoride free.

Natural toothpastes do not necessarily exclude fluoride and excluding fluoride does not necessarily guarantee a toothpaste to be natural either. It can be helpful to make a list of what you are looking for in a toothpaste and then try searching for what you want. Here at Electric Teeth, we have actually compiled a list of the best natural toothpastes with some advice to go with it.

So why would someone want a fluoride free toothpaste?

Personally, I believe some people may have misconceptions about the evidence behind fluoride and about just how safe it is.

Let’s delve into some of the concerns I have heard about using fluoride.

People’s beliefs about why to avoid fluoride in toothpaste

People have genuine concerns about using fluoride in their toothpaste, and many of these are also relevant to fluoride in water. There are some common beliefs, which often come about because of confusing messages across the media, as well as misinformation from anti-fluoride groups.

Belief: “Fluoride can give you cancer”

The American Cancer Society reviewed available evidence and studies and advises: “no strong evidence of a link between water fluoridation and cancer”. Fluoride does not appear on any list of known carcinogens. This is also supported by the European Commision who state there is no evidence to support a link between fluoride and cancers, stating “Fluoride should therefore be classified as non-carcinogenic.”. The Cancer Council of Western Australia also delves into this topic, stating that there is no link between fluoride and cancer.

Belief: “Fluoride is just a waste product from other chemical processes”

The Irish Expert Body on Fluorides and Health believe this misinformation comes from the use of Hydrofluosilicic Acid (HFSA) as the source of fluoride for water. This is actually the primary ingredient, made specifically for water fluoridation and is not a waste product from the fertilizer industry.

Belief: “Water fluoridation is mass medication”

This is incorrect because HFSA is not a medicine. The Irish Expert Body on Fluorides and Health also explain how courts have ruled against this argument in the US and around the world. saying that this is a Public Health Measure which has overarching “greater common good arising from decreased dental disease.” Also, consider the fact that not everywhere has fluoridated water. And just as no one is forced to drink tap water, you are able to choose whether or not you have a fluoride toothpaste.

Belief: “I am exposed to too much fluoride already”

Food Safety Authority of Ireland, released a detailed Total Diet Study 2014-2016 to assess fluoride in food and drink and concluded “no scientific basis for concerns about the safety of children and adults in Ireland from exposure to fluoride from foods and beverages.” Whilst this is specific to Ireland, a similar western diet eaten elsewhere will have similar numbers, including by the USDA (US Department of Agriculture).

Belief: “Fluoride in water harms the environment”

Changing the make-up of water rightfully concerns anyone who cares for the environment. Non-profit organisation GreenFacts looked into the evidence and found that excess fluoride from industrial or natural sources can affect some wildlife, birdlife and plantlife. The recognise that it is often difficult to attribute this to fluoride alone due to presence of other pollutants also present.

Reasons to avoid fluoride in toothpaste

Having delved into some of the beliefs behind why people might want to avoid fluoride, and explained some science behind them, it is also important to recognise some issues with too much fluoride.

It is important to see that with each of these issues, they relate to swallowing too much fluoride, either in the short term or long term.

So why should you avoid too much fluoride?

Fluoride Poisoning

There is a risk of actual toxicity if swallowing too high a dose in a short period of time, and this primarily affects the stomach. The amount depends on your body weight, and probable toxic dose (PTD) is defined at 5 mg/kg of body mass. This PTD is the minimal dose that could trigger serious and life-threatening signs and symptoms and requires immediate treatment and hospitalization.

Example: PTD is 5mg/kg body weight

For a 20 kg child would be achieved at ingesting a total of 100mg.

This equates to a 3.8oz/100g tube of toothpaste which containing 1000-1500 ppm.

Dental Fluorosis

Too much fluoride over an extended period of time can cause dental fluorosis. This fluorosis can range from mild – barely noticeable white spots on teeth – to severe – affecting the overall structure of teeth. Dental fluorosis occurs due to systemic overexposure to fluoride during the first six years of life, when the enamel of the crowns of permanent teeth is formed, be that from water or swallowing toothpaste or other fluoride sources. It is avoided by ensuring children have lower concentrations of fluoride in toothpaste and supervising to avoid swallowing.

Skeletal fluorosis

Skeletal fluorosis is a severe side effect of long term overexposure to fluoride. It is rare, but can have life changing effects including very brittle bones that are prone to fracture. Usually this would only occur in areas of very high fluoride in the water, as shown in the map below (click here to see a larger version) which shows probable areas of higher than recommended fluoride, which was taken from research by Amini et al.

Map of the world showing probably areas of higher than recommended fluoride
Map of the world showing probably areas of higher than recommended fluoride (click here to see a larger version)

Can you prevent cavities without fluoride?

Technically, no you do not need fluoride to prevent cavities.

Cavities are created by acid released by bacteria in plaque in the mouth, and the bacteria feed on sugars in the diet.

So if you have a sugar free diet and are able to physically remove all the plaque on your teeth, then you would not develop cavities.

In the real world though, this just isn’t realistic. There is a constant back and forth of demineralisation by bacteria and remineralisation from saliva and fluoride.

The most recent research, from Valkenburg et al, revealed that using a toothpaste in addition to brushing does result in less plaque growth compared to brushing with just a toothbrush. So you do need toothpaste. In fact even fluoride free toothpaste is better for preventing plaque re-growth than no toothpaste at all.

Fluoride helps to tip the balance further in favour of protecting the teeth.

However there are some alternatives to fluoride toothpaste for avoiding cavities.

For example, the Australian Institute of Health and Welfare outline their recommendations for preventing dental disease, and recognises that pit and fissure sealants (as well as meticulous oral hygiene and appropriate dietary practices) do contribute to caries prevention and control.

There are also other ingredients that can help prevent cavities, which can help by killing the bacteria found in plaque. These ingredients include:

  • Calcium phosphates, including hydroxyapatite.
  • Xylitol.
  • Natural ingredients, such as essential oils.

Does fluoride free toothpaste work?

The main benefit of having fluoride in toothpaste is that it helps to prevent dental cavities. Unless you have some sort of remineralizing ingredient, a toothpaste will not have this effect.

However if you want a toothpaste for another reason, such as whitening, help managing gum disease, controlling dentin hypersensitivity, then the focus is no longer on fluoride. Examples of these active ingredients are in the table below.

This means that yes, fluoride free toothpaste can work on helping other conditions in the mouth. But only fluoride is really recommended for prevention of cavities.

Tooth conditionActive ingredients ingredient
Cavitiesstannous fluoride
sodium fluoride
sodium monofluorophosphate
Calcium phosphates (hydroxyapatite)
Gum diseaseChlorhexidine
Hyaluronic acid
Peptides
Sodium Bicarbonate
Stannous Fluoride
Zinc
SensitivityArginine
Calcium phosphate
Potassium nitrate
Stannous fluoride

See the following posts of ours for fluoride-free toothpaste recommendations for the above conditions:

Fluoride toothpaste alternatives

Whilst I don’t normally recommend fluoride free toothpaste, as you miss out on the known anti-cavity properties of fluoride, I respect that some people may still wish to avoid toothpastes containing fluoride.

In which case, there are two main options available to you:

  1. A fluoride free toothpaste that contains no fluoride and no major source of remineralizing agent.
  2. A fluoride free toothpaste that contains no fluoride and which does contain an alternative remineralizing agent.

There has been research into a variety of potential anticavity ingredients to use either in addition to fluoride, or as a replacement for fluoride. These ingredients include:

  • Calcium Phosphates
  • Chlorhexidine
  • Natural ingredients
  • Ozone
  • Xylitol

Calcium phosphates

Given that human teeth comprise mostly of calcium and phosphate ions, in the form of hydroxyapatite, it makes sense that incorporating them into an ingredients list will have some benefit. Both are also found naturally within the saliva to aid remineralisation of enamel.

Calcium phosphates are a range of minerals, including Dicalcium phosphate dihydrate, α-tricalcium phosphate, Amorphous calcium phosphate (ACP), and Hydroxyapatite (HAP).

A range of studies, included in a review by Meyer et al, have looked at calcium phosphates both including and excluding fluoride, and there are a number of positive outcomes, including:

  • HAP is as effective as Chlorhexidine in plaque reduction.
  • HAP is as effective as Sodium Fluoride in remineralizing initial enamel lesions.
  • HAP shows the same remineralization properties as 1100 ppm sodium fluoride.
  • Long-term, ACP has a superior effect on remineralizing carious lesions compared to placebos and equivalent to fluorides.
  • ACP protects against acidic and erosive attacks.

Calcium phosphates have very few side effects because of the concentrations in which they are found naturally within the body. They are certainly the most promising alternative to fluoride, with a wealth of evidence to support them. Hopefully it is only a matter of time before the toothpastes containing these ingredients become more mainstream, as they have certainly got promise as an effective anticavity product!

Chlorhexidine

The use of chlorhexidine alone is not recognised as providing benefit against tooth decay, according to multiple papers, including this systematic review by the Journal of American Dentistry.

Chlorhexidine is a known antibacterial ingredient, and is useful in mouthwashes, for example for the treatment of gum disease.

However the Cochrane Collaboration reviewed available studies and came to the conclusion that the use of chlorhexidine is no more effective than a placebo or no treatment for reducing the levels of cavity causing bacteria.

Natural toothpaste vs fluoride toothpaste

There is no definitive definition of a natural toothpaste, and it is actually possible to have a natural toothpaste which also contains fluoride. Generally speaking though, natural toothpaste can have a few different meanings, including:

  • Avoiding unnecessary chemicals and artificial ingredients.
  • Searching for naturally derived and naturally sourced ingredients.
  • Wanting a herbal toothpaste.

When it comes to fluoride free natural toothpastes, we can look to herbal ingredients and potential anticavity effects of these. Commonly used herbal ingredients include Neem, Acacia and Meswak.

It is thought that the anticavity effects come from the antimicrobial potential of herbal ingredients, with substances such as alkaloids, flavonoids, polyphenols, and lectins helping to reduce the number of cavity causing bacteria in the mouth.

The antimicrobial effect of some of these ingredients is known to control gum disease.

There are some limited studies available with relevance to cavities. They are produced mainly in Asia, and investigate commercially available herbal dentifrices, but overall the scientific evidence is weak for the effectiveness of these ingredients over fluoride.

The overall message is that there is potential for the use of herbal ingredients in addition to fluoride, but should not be used as a replacement as they are simply not as effective.

Ozone

For some time, Ozone was touted as the next best thing for dentistry. It is a gas made up of three oxygen atoms.

It was believed that it could be used for a variety of dental conditions, from gum disease, to decay. The thought behind this was the fact that ozone was antibacterial, but also biocompatible. It was touted as a natural product with wide ranging applications.

But overall, evidence and support seems to be lacking. The acclaimed Cochrane Collaboration, known for their independent reviews, recently withdrew their review on Ozone due to lack of evidence, although the previous review failed to find evidence to support the use of ozone against caries, as explained by McComb.

Within the UK, the National Institute for Health and Care Excellence (NICE) also states that “HealOzone is not recommended for the treatment of tooth decay”

Xylitol

Xylitol is a promising ingredient, with lots of different researchers looking into its anti-cavity effects. It occurs naturally as an alcohol sugar, found in both trees and plants. It has two benefits:

  • Use as an alternative to sugar and therefore remove dietary sugar to reduce cavities.
  • Antibacterial effect, killing the cavity causing bacteria.

As a sweetener, xylitol can be used as a sugar free alternative added to food and drink. Therefore reducing the sugars available to the damaging bacteria, and protecting against decay. Xylitol is a good sugar substitute, and is recommended to be used rather than traditional sugar.

It can also be added specifically for it’s anticavity effects, for example in chewing gums. In fact, the use of sugar free chewing gum is included as one of the key messages in Australia’s National Oral Health Plan.

At present there is limited evidence to support the fact that Xylitol alone is as effective as fluoride for reducing decay. And to have an effective dose of xylitol, it is generally accepted that 5mg or more would need to be consumed. It also needs to be consumed often throughout the day. For example, using sugar free chewing gum in addition to the toothpaste.

Overall, the evidence seems to suggest a positive effect for the use of xylitol, with the Cochrane Collaboration stating that fluoride toothpaste containing xylitol may be more effective than fluoride‐only toothpaste for preventing caries. But still be aware that there is not evidence to support xylitol being as effective as fluoride.

Best fluoride free toothpastes

When it comes to fluoride free toothpastes, it is difficult to recommend using them over a fluoride containing toothpaste.

The evidence supporting the use of fluoride is strong, and I hope I have been able to clearly explain this for you. That said, if you still have any questions or concerns, I would invite you to leave a comment.

Overall, if you still wish to use a fluoride free toothpaste I would recommend using something with calcium phosphate technology. My top recommendations would be:

  • Biomin C – contains calcium and phosphate ions, and is Oral Health Foundation Approved
  • Biomed toothpastes – which contain calcium and phosphate ions and come in a variety of flavours, as well as containing majority natural ingredients.
  • GC tooth mousse – also contains calcium and phosphate ions and comes in a wide range of non-mint flavours, and is great for sensitive teeth.
  • Grant’s Of Australia Xylitol toothpaste – uses xylitol to help prevent plaque build up and the damaging effects of this.

FAQ

Is fluoride bad for your teeth?

When used in the correct doses, fluoride is not bad for your teeth.

Is fluoride in toothpaste toxic?

An excess of fluoride can be toxic. For an adult this would normally involve swallowing more than a whole tube of toothpaste in one sitting!

Does all toothpaste have fluoride?

Not all toothpaste contains fluoride. There are fluoride free options available and newer ingredients that have the potential to protect against cavities.

What type of fluoride is best?

Of the three types of fluoride available, stannous fluoride has the most benefits.

About Dr. Gemma Wheeler, BDS (Hons)

Gemma qualified from Cardiff University School of Dentistry in 2015. She went on to complete her Foundation Training and a further two years in the Armed Forces, primarily based around Wiltshire. She now works in a private practice in Plymouth.

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