For many years, fluoride toothpaste was considered the automatic choice for preventing tooth decay. Fluoride has a substantial evidence base and we were taught just this at Dental School.
However, dentistry has moved forward. We now have a credible fluoride-free alternative that supports enamel remineralisation and can help reduce tooth sensitivity: hydroxyapatite.
At Optimal Dental Health, hydroxyapatite is generally my first choice. It provides effective everyday protection while respecting the preferences of patients who wish to reduce their fluoride exposure, including some women during pregnancy and breastfeeding.
What is hydroxyapatite?
Hydroxyapatite is a calcium-phosphate mineral that forms a major part of our enamel, dentine and bones.
When used in toothpaste, hydroxyapatite particles can attach to the tooth surface and fill microscopic defects within weakened enamel. This helps support the natural remineralisation process following the repeated acid attacks our teeth experience each day.
I often describe this as replacing like with like. Hydroxyapatite is considered a biomimetic ingredient because it closely resembles the mineral already present in our teeth. Fluoride is not naturally in our bodies.
Does hydroxyapatite help prevent decay?
The evidence supporting hydroxyapatite toothpaste has grown considerably.
Laboratory research by Amaechi and colleagues found that hydroxyapatite toothpastes could enhance the remineralisation of early enamel caries lesions.
The study also demonstrated that formulations vary, which means the concentration and quality of hydroxyapatite within a toothpaste matter. As this was an in-vitro study, it should not be treated as proof of long-term clinical effectiveness on its own, but it supports our understanding of how hydroxyapatite may help repair early mineral loss. [1]
Fluoride still has a larger and longer-established evidence base. My recommendation is therefore not based on claiming that hydroxyapatite has been proven superior in every situation. It is based on the growing evidence that it can provide a scientifically credible alternative for patients who want fluoride-free oral care.
Why is it helpful for sensitive teeth?
Dentine sensitivity is one of the strongest reasons I recommend hydroxyapatite.
Sensitivity often occurs when enamel becomes worn or gums recede, exposing the dentine beneath. Dentine contains thousands of microscopic tubules leading towards the nerve inside the tooth. Cold drinks, brushing, sweetness or acidity can move fluid through these tubules and produce a short, sharp pain.
Hydroxyapatite particles can help block these open tubules, reducing the transmission of sensations towards the nerve.
In a double-blind randomised controlled trial, Vano and colleagues compared a hydroxyapatite toothpaste with a fluoride toothpaste and a placebo. The hydroxyapatite toothpaste produced a significant reduction in dentine hypersensitivity. [2]
For patients who experience discomfort from cold water, fruit, brushing or professional cleaning, this can make hydroxyapatite particularly useful.
Why do some patients prefer to avoid fluoride?
Some patients simply prefer to minimise their total fluoride exposure. This may reflect their personal health philosophy, concerns about swallowing toothpaste or a desire to use ingredients that more closely resemble the natural structure of the tooth.
There is also continuing scientific discussion about fluoride exposure and cognitive development.
A 2023 systematic review and dose-response meta-analysis by Veneri and colleagues found that many included studies suggested an association between higher fluoride exposure and lower childhood IQ. However, the authors also identified significant uncertainty and limitations in the evidence. The association was stronger among studies at higher risk of bias, while the study judged to have a low risk of bias did not demonstrate an adverse effect. [3]
Crucially, this research mainly concerns total systemic exposure, particularly fluoride from drinking water and other ingested sources. It does not establish that brushing with fluoride toothpaste, spitting it out and avoiding swallowing it causes cognitive harm.
I do not claim that fluoride toothpaste is toxic, however it only has a topical effect, so no reason to swallow it.
What about pregnancy and breastfeeding?
Patients often become more conscious of product ingredients during pregnancy and breastfeeding.
I do not tell women that fluoride toothpaste has been proven unsafe during pregnancy or breastfeeding, because the available evidence does not justify that claim. Correctly used toothpaste is also intended to be spat out rather than swallowed.
However, some women prefer to reduce avoidable exposures during this period. Hydroxyapatite gives them a practical alternative without requiring them to choose a toothpaste that contains no recognised remineralising ingredient.
Pregnancy can also increase the risk of gum inflammation, while nausea, vomiting, reflux and changes in eating patterns may expose the teeth to more acid. Maintaining consistent oral hygiene is therefore particularly important.
The choice is partly clinical and partly about informed patient preference. We do not currently have pregnancy-specific trials proving that hydroxyapatite is superior to fluoride toothpaste. What we do have is evidence supporting hydroxyapatite’s ability to remineralise enamel and reduce sensitivity.
What about young children?
Young children may swallow toothpaste because they have not yet learnt to spit reliably.
Wright and colleagues found that fluoride toothpaste can help prevent tooth decay in children under six, but their review also considered the relationship between fluoride ingestion and dental fluorosis. The amount used and the child’s ability to spit are therefore important. Dental fluorosis can develop when excessive fluoride is ingested while the permanent teeth are forming.
Hydroxyapatite does not contain fluoride, so it avoids this particular concern. However, children should still use only a small amount of toothpaste and brushing should be supervised.
Children with active decay or a high risk of decay require individual professional advice rather than relying on toothpaste alone. [5]
Is Nanohydroxyapatite safe?
In its 2023 assessment, the European Commission’s Scientific Committee on Consumer Safety concluded that the particular form of nanohydroxyapatite it reviewed was safe at concentrations of up to 10% in toothpaste and 0.465% in mouthwash. This conclusion applied to particles meeting the specifications assessed by the committee and should not automatically be extended to every formulation. [4]
Does the source of hydroxyapatite matter?
Yes. Not all hydroxyapatite toothpastes contain the same type, concentration or quality of active ingredient.
Particle size, shape, purity and the way hydroxyapatite is dispersed within the toothpaste may influence how effectively it attaches to enamel and enters exposed dentine tubules. The 2025 study by Amaechi and colleagues found meaningful differences in remineralisation between the hydroxyapatite toothpastes tested, showing that the words “contains hydroxyapatite” do not tell the whole story.
I recommend checking whether the manufacturer identifies the source and specification of its hydroxyapatite.
For this reason, patients should look for a reputable manufacturer that can confirm:
- The source of its hydroxyapatite
- Whether it uses micro- or nano-hydroxyapatite
- The concentration present in the finished toothpaste
- Appropriate particle, purity and safety testing
- Evidence relating to the actual ingredient or formulation used
A recognisable, well-characterised ingredient can provide greater reassurance than a product that simply lists hydroxyapatite without giving any further information.
The Bigger Picture
No toothpaste can compensate for frequent sugar intake, ineffective brushing, poor interdental cleaning, reduced saliva or untreated gum disease.
At Optimal Dental Health, we consider the whole oral environment, including diet, saliva, oral pH, gum inflammation, breathing and the oral microbiome.
For patients seeking a fluoride-free option, hydroxyapatite is my preferred recommendation because it:
Resembles a mineral naturally present in teeth
Supports the remineralisation of early enamel damage
Can help reduce dentine sensitivity
Does not add to fluoride ingestion
Respects individual preferences during pregnancy and breastfeeding
Provides parents with an alternative for children who may swallow toothpaste
Fluoride toothpaste remains an effective option. The exciting development is that the choice is no longer between fluoride and a natural toothpaste without an evidence-based remineralising ingredient. Hydroxyapatite offers a scientifically credible alternative and for many of my patients, that makes it the preferred choice.
Frequently Asked Questions
- Is hydroxyapatite toothpaste as effective as fluoride toothpaste?
Current research suggests that hydroxyapatite toothpaste can effectively remineralise early enamel damage and reduce tooth sensitivity. While fluoride has a longer history of clinical evidence, hydroxyapatite is increasingly recognised as a scientifically supported fluoride-free alternative for everyday oral care.
- Can hydroxyapatite actually rebuild tooth enamel?
Hydroxyapatite cannot regrow lost enamel, but it can help remineralise areas of early enamel demineralisation. It works by depositing calcium and phosphate minerals onto the tooth surface, helping to strengthen enamel before cavities develop.
- Is hydroxyapatite toothpaste safe for children?
Yes. Hydroxyapatite toothpaste is considered a suitable option for children, particularly those who may accidentally swallow toothpaste. As with any toothpaste, brushing should be supervised and children should use only a pea-sized amount.
- Should I switch to hydroxyapatite toothpaste during pregnancy?
Many pregnant and breastfeeding women choose hydroxyapatite toothpaste if they prefer to minimise fluoride exposure. While fluoride toothpaste has not been proven unsafe when used correctly, hydroxyapatite provides an effective fluoride-free alternative for enamel protection.
- Which hydroxyapatite toothpaste do you recommend?
Not all hydroxyapatite toothpastes are the same. We recommend choosing products from reputable manufacturers that disclose the type, concentration and quality of hydroxyapatite they use. Your dentist can advise which formulation is most appropriate for your oral health needs.
- Can I book an appointment to discuss whether hydroxyapatite toothpaste is right for me?
Absolutely. At Optimal Dental Health in Baker Street, London, our dentists assess your individual risk of tooth decay, sensitivity, gum health and overall oral environment before recommending the most suitable toothpaste and home-care routine. Every recommendation is tailored to your specific needs.
About the Author: Dr James Goolnik
Dr James Goolnik is the Clinical Director of Optimal Dental Health, a leading biological and holistic dental practice in Baker Street, London.
With over 30 years of clinical experience, Dr James Goolnik has developed an international reputation for integrating modern evidence-based dentistry with a whole-body approach to health. He has completed advanced training in biological dentistry, oral-systemic health, oral microbiome assessment, airway-focused dentistry, minimally invasive restorative techniques and IAOMT SMART amalgam removal.
His clinical philosophy centres on prevention, patient education and preserving natural teeth wherever possible.
Through Optimal Dental Health, Dr Goolnik and his multidisciplinary team provide comprehensive dental care that combines advanced technology with personalised treatment planning, helping you achieve healthier smiles while supporting long-term wellness.
References:
- Amaechi, B. T., Tan, A. I., Noureldin, A. A. K., Kanthaiah, K., Holladay, E., Obiefuna, A. C., & Vijayaraghavan, M. (2025). In vitro evaluation of the ability of nanohydroxyapatite toothpastes to enhance remineralization of enamel caries lesion. Journal of Dentistry, 161, 106006. DOI: 10.1016/j.jdent.2025.106006.
- Scientific Committee on Consumer Safety. (2023). Opinion on Hydroxyapatite (nano), SCCS/1648/22. Adopted 21–22 March 2023.
- Vano, M., Derchi, G., Barone, A., & Covani, U. (2014). Effectiveness of nano-hydroxyapatite toothpaste in reducing dentin hypersensitivity: A double-blind randomized controlled trial. Quintessence International, 45(8), 703–711. DOI: 10.3290/j.qi.a32240.
- Veneri, F., Vinceti, M., Generali, L., Giannone, M. E., Mazzoleni, E., Birnbaum, L. S., Consolo, U., & Filippini, T. (2023). Fluoride exposure and cognitive neurodevelopment: Systematic review and dose-response meta-analysis. Environmental Research, 221, 115239. DOI: 10.1016/j.envres.2023.115239.
- Wright, J. T., Hanson, N., Ristic, H., Whall, C. W., Estrich, C. G., & Zentz, R. R. (2014). Fluoride toothpaste efficacy and safety in children younger than 6 years. Journal of the American Dental Association, 145(2), 182–189. DOI: 10.14219/jada.2013.37.