While fluoride has been a mainstay in dentistry, it has faced its share of criticism. Such revelations have prompted people to look for fluoride alternatives, but how much protection are you getting with fluoride-free toothpaste? This begs the question: Are there alternatives to fluoride? It turns out a biocompatible substance called nano-hydroxyapatite exists, so we asked experts to tell us what they think of nano-hydroxyapatite toothpaste.
Wait, what is fluoride, and why is it in toothpaste
"Fluoride is an essential ion in toothpaste that helps to remineralize tooth structure that has been eroded away by acid-releasing bacteria in the mouth," says Inna Chern, DDS. It helps us tip the scales in our favor, according to Chris Salierno, DDS, chief dental officer at Tend, adding that "it's much harder for the acids from bacteria to dissolve fluoride enamel than regular enamel." He highlights that having more fluoride minerals present in our saliva helps the daily remineralization process.
Just as there is clear evidence in the case for fluoride, it's not without its controversies: some research suggests it's a neurotoxicant that can impact child development. Dr. Chern notes that fluoride in large quantities is toxic but says daily trace amounts in our drinking water and toothpaste are not harmful. The American Dental Association (ADA) backs up her assertion and says that fluoridation is safe and beneficial.
Still, this fear of toxicity has prompted a surge in the use of toothpaste without fluoride, but how much protection can one expect to get without the mighty cavity fighter? According to Dr. Salierno, toothpastes that do not contain fluoride will still have an abrasive effect to scrub away plaque and debris, but will that be enough to prevent tooth decay? "It depends on that person's other risk factors," he says. "If that person has excellent brushing and flossing technique, has a diet that is low in sugar and carbohydrates, and if they naturally have higher mineral content in their saliva, then they will probably be able to keep their risk for tooth decay low, even without using fluoride," he adds. However, he is quick to point out that most of his patients can't check all of those boxes in reality.
is nano-hydroxyapatite toothpaste a good alternative
Nano-Hydroxyapatite (nHAp), a specific form of hydroxyapatite, the primary mineral of which our tooth enamel and dentin are composed. Though it's started cropping up in toothpaste over the last few years, nano-hydroxyapatite isn't technically new. NASA first developed it in 1970 for astronauts, who lost tooth and bone density in the absence of gravity. It has also been a frequent ingredient in Japanese oral care for more than 40 years.
Zohra El Gharbi, co-founder of TANIT Botanics, researched nHAp extensively, relying on science when setting out to develop toothpaste tablets with the substance. "Instead of creating a fluoride-free toothpaste, we looked to nature to find a healthy alternative to fluoride that performs equally well or better as a remineralizing agent," says El Gharbi.
The science is encouraging, with results from a small 2014 randomized clinical trial that found that brushing with a nHAp toothpaste improved tooth sensitivity equal to a fluoride toothpaste after as little as two weeks. A 2012 study published in Contemporary Clinical Dentistry found hydroxyapatite and fluoride comparable, with hydroxyapatite showing promise in its ability to repair early carious lesions. And a similar study published in 2019 in the Journal of Nanobiotechnology found that the coating effect created by hydroxyapatite toothpaste made teeth stronger, with greater resistance to brushing than that formed by fluoride toothpaste.
"Because nHAp is characterized by very tiny particle sizes, it can work into tiny spaces in the tooth's enamel," says El Gharbi, "essentially remineralizing the teeth from within by replenishing minerals that are lost in enamel, making them stronger and more resilient." Another notable benefit of nHAp is its ability to interfere with bacteria adhering to the teeth.
Dentists agree the research is convincing, and nHAp is showing great promise as an alternative to fluoride. "If someone is not comfortable with fluoride, I think nHAp is a terrific alternative," says Dr. Salierno, "it's wonderful to have an increasing number of tools in our toolbox so that we can customize a preventative regimen for our patients." In fact, at Tend, they are in the process of developing a new toothpaste that is made of both hydroxyapatite and fluoride to offer even greater protection against cavities and wear down. "We're thinking about hydroxyapatite as a great complement to, versus a replacement for fluoride," adds Dr. Salierno. Similarly, Dr. Chern considers nHAp a great substitute, and "whether its fluoride or nHAp, it is a win for cavity prevention which is the goal of toothpaste and all oral hygiene practices."
So, with all the rave reviews, why aren't we seeing it used more widely? According to El Gharbi, the reason is the price, explaining that nHAp is ten times more expensive than fluoride, and to ensure effectiveness, it requires a concentration of at least 10 percent, versus 0.22 percent needed for fluoride. "I personally think we will see more nHAp-based toothpastes over time, says El Gharbi. "But for now, the substance's price makes it difficult to use it more widely in the market," says El Gharbi.
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