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

Abstract This study aims to synthesise and interpret evidence relating to fluoride-free toothpaste alternatives for caries prevention, examining how these products have been studied, the outcomes used to evaluate them, and how this evidence may inform discussions with children and families. A scoping review was undertaken. Electronic searches of major bibliographic databases identified peer-reviewed studies published between January 2020 and March 2026 evaluating fluoride-free toothpaste formulations. Data were extracted on intervention type, study design, outcome measures, and population characteristics and synthesised narratively with emphasis on patterns of evidence generation rather than comparative effectiveness. A total of 122 studies were included, comprising predominantly laboratory and mechanistic investigations, with only 20 studies providing direct paediatric evidence. Fluoride-free formulations were associated with antimicrobial activity, biofilm modulation, and surrogate remineralisation outcomes. Direct assessment of clinical caries outcomes was uncommon, and substantial heterogeneity was observed in formulation composition, study design, and outcome selection. Conclusion : Fluoride-free toothpaste formulations demonstrate measurable biological effects, but evidence is dominated by surrogate outcomes and short-term study designs. While hydroxyapatite-based products have the most consistent evidence base, no fluoride-free category currently has evidence comparable to fluoride for long-term caries prevention in children. What is Known: • Fluoride toothpaste has strong evidence for long-term caries prevention. • Fluoride-free alternatives are increasingly used, but existing evidence is largely based on surrogate or short-term outcomes. What is New: • Across formulations, observed effects are driven more by study design, delivery context, and outcome selection than by specific ingredients. • No fluoride-free category shows equivalent clinical evidence to fluoride for long-term caries prevention, although hydroxyapatite demonstrates relatively more consistent, yet still limited data.