New Study “Proves” Fluoride-Free Toothpaste “Doesn’t” Work

New Study "Proves" Fluoride-Free Toothpaste "Doesn't" Work

I shake my head when most mainstream health articles come across my news feed. Facebook friends share them occasionally and most of the time, the articles and the studies most of these articles reference are flawed. Very few people read the articles, let alone the studies. Most people read the headlines and from that reinforce or form their beliefs. An article was shared on my Facebook recently with the link text, “Oral Care has “no impact” without fluoride, report finds”. Most people will just read the link text and conclude that fluoride toothpaste is the only way for proper oral health. However, if you click on the actual article, the headline is “Experts question benefits of fluoride-free toothpaste.” There is a big difference between those two headlines. The first headline states that oral care without fluoride has no impact. The second heading in the article states that “experts” question the benefits of fluoride-free toothpaste but does not make any statement that fluoride-free oral care products do not make an impact on cavity prevention in the headline (it is mention in the sub-header). I should stop writing right now. There is bias in the reporting just based on the headings, but I would be no better than the mainstream news. We are going to break down the Associated Press article and the study to see if it is conclusive that fluoride-free toothpaste is useless for oral health.1

Associated Press Article, “Experts Question Benefits of Fluoride-Free Toothpaste” and The Truth About Fluoride

“Dental health experts worry that more people are using toothpaste that skips the most important ingredient — fluoride — and leaves them at a greater risk of cavities.”2

Who are these dental health experts? Oh, we are going to find out, and it is going be a wild ride. But first, what about fluoride, is it good for oral health?

Fluoride is a mineral added to some municipal water supplies in specific amounts (0.7-1.2 parts per million on average), to improve our dental health. The most common form of fluoride added to our supply in the United States is fluorosilicic acid, which is a byproduct of fertilizer production. The more-expensive form, sodium fluoride, is found in toothpaste and used in dentistry. It is interesting how they use a manufacturing byproduct to “improve” the quality of the public supply and reserve the pricier medical grade sodium fluoride for oral care products and dentist offices.3 4

Daily fluoride ingestion is hard to quantify, with concentrations varying widely from the unfiltered water we consume, our dental health products, some of the prescription medicine we take, and even the food we eat. A lot of food is grown using fluoridated water, and depending on the food, it might have naturally occurring fluoride like tea leaves (which accumulates calcium fluoride—supposedly less of a problem). In 2015, the Department of Health and Human Services recommended a 0.7 mg/liter limit on fluoride in drinking water—way below the FDA maximum of 4 mg/liter—out of concern for excess fluoride consumption. That is a considerable spread in recommended amounts for something added to the supply as a medication to “improve” oral health. All differing regulations in place, the average municipality supply has ended up with around 1–2 mg/liter.5 6 7 8 9

An estimated 40% of Americans suffer from dental fluorosis, ranging from mild to severe, which can lead to dental damage. Dental fluorosis is hypomineralization of the teeth that comes from ingesting excessive amounts of fluoride. Dental fluorosis changes the enamel, it causes discoloration, pitting, damage to the enamel, and even CAVITIES. Excessive fluoride ions in maturing enamel alter the rate at which enamel matrix proteins are enzymatically broken down leading to issues with enamel structure. Excessive fluoride ions also might also reduce the rate at which the subsequent breakdown products are removed. Finally, excessive fluoride ions may also indirectly alter the action of the enzyme protease by decreasing the availability of free calcium ions in the mineralization environment. Because of the excess of ingested fluoride our teeth and bones are unable to remodel and remineralize leaving them appropriately weakened. Excessive fluoride consumption can do more than cause dental fluorosis. It can weaken our bones, weaken our teeth, calcify the pineal gland, and disrupt thyroid function by interfering with its uptake and use of iodine.10 11 12 13 14

We can easily prevent dental caries without fluoride, by merely brushing with a xylitol-containing essential oil toothpaste, consuming less refined sugar, avoiding low pH drinks like soda and energy drinks, and oil pulling. Our teeth need adequate amounts of calcium, magnesium, phosphorus, boron, potassium, vitamin D, and vitamin K2 for proper health from diet or supplementation. But I guess instead of living healthier lives we should have a chemical mandated by the government to be added to our water and food supply so that we can be lazy. We should have that same government fail to regularly monitor the average American’s daily consumption of fluoride or consider how it might be affecting their health, right? Finally, I guess the media also known as the 4th column should reinforce standard beliefs for the “good” of the people.15 16 17

One of the so-called “dental care experts” is a dentist who is the oral care directory for Procter & Gamble who produces Crest, one of the bestselling brands of fluoride toothpaste in the world. Dentist J. Leslie Winston, oral care director for Crest-toothpaste maker Procter & Gamble, said the review “serves as an important reminder.” “Despite a large body of scientific evidence, there are growing numbers of consumers who believe that all toothpastes are the same and that as long as you clean your teeth effectively with a toothbrush or other device which cleans in-between the teeth, you can prevent decay,” he said in a statement. It appears to me that Winston feels threatened that people are buying less Crest, and the AP article talks references his fear. “The market share for fluoride-free toothpaste is closely held company data. Industry sources estimate it at no more than 5 percent of all toothpaste sold, but with projected growth of over 5 percent annually. On Monday, Tom’s of Maine antiplaque and whitening toothpaste, which is fluoride-free, was listed as the second-best selling toothpaste on Amazon’s online buying platform.”18

The article quotes Paul Jessen that he states that Tom’s toothpaste does not promise to help fight cavities. “Paul Jessen, a brand manager at Tom’s of Maine, said “the products that don’t contain fluoride that we offer do not promise that benefit” to fight cavities. He said his company’s customers generally understand this.” Well, yeah, he cannot make the statement that Tom’s fluoride free toothpaste or any brand of fluoride free toothpaste can fight cavities because the Food and Drug Administration has not ruled that fluoride free toothpaste reduces cavitation formation. Remember, just because the FDA has not ordered that fluoride free toothpaste fights cavities do not mean that it does not work, our government is not omniscient. Most of Europe uses xylitol containing toothpaste over fluoridated toothpaste, and they do not have a severe epidemic of dental caries.19

The article also quotes Gerald Curatola a dentist who founded Revitin, a company that produces a fluoride free probiotic toothpaste. “Gerald Curatola, the dentist who founded Revitin and now serves as chief science officer, called the review “misleading.” He said that the latest science suggests that a healthy mix of oral bacteria is key to dental health. “I don’t think fluoride makes a difference at all,” he said. However, referring to his company’s decay-fighting claim, he added: “After this call, I’m probably going to remove that from the website, because I don’t think that should be on there, because I didn’t know that was on there.” I agree with Dr. Curatola, but I could see where some people would argue his quote and logic is biased because of the toothpaste his company sells. However, I think it is a shame that he cannot claim his toothpaste fights decay because it does not contain fluoride. Revitin appears to fight decay by providing probiotic bacteria for the oral cavity, CoQ10/vitamin C/ silica to reduce gum inflammation, and vitamin K2 to help prevent cavity formation. However, there is no xylitol used in Revitin, because it would reduce the chances of colonization of the probiotic bacteria used in the toothpaste.20

The article concludes:21

“The review also cited a 2009 analysis of studies involving 60,000 people that found fluoride rinse prevents cavities about as well as fluoride toothpaste.

In 2016, The Associated Press reported on the poor scientific evidence for the benefits of flossing. As a result, the federal government removed its long-standing flossing recommendation from Dietary Guidelines for Americans.

The review raises questions about how cavities form. Cavities have long been thought to develop in a poorly cleaned mouth when acids left by food start to wear away tooth enamel. The idea is that clean teeth do not decay. This review, though, argues for an alternate model: cavities grow in tiny crevices in the enamel that can’t easily be reached with a toothbrush or dental floss alone.

Despite the clear benefit of fluoride, some studies have also challenged the belief that fluoridated drinking water stops dental decay as well as fluoride toothpaste or rinses. In any event, it makes sense to combine fluoridated water and dental products for amplified protection, said Niederman, the NYU dentist.

Some dentists also said the most effective way to prevent cavities is simply to reduce sugars in the diet.”

So what is the information that can be gathered from the study and is it legit?

The Study, “Personal oral hygiene and dental caries: A systematic review of randomised controlled trials”

Ever scrapped off that white film of your teeth if you have not been able to brush in a while. The white film is biofilm. We brush our teeth to break up bacterial biofilm colonies and prevent them from producing acids that degraded our demineralize and degrade our enamel which forms cavities. Cariogenic bacteria that produce acids prefer simple carbohydrates for survival. Cariogenic bacteria preferring simple carbohydrates are why we are indoctrinated after birth that eating large amounts of sugar, usually in the form of candy will “rot your teeth.” Cariogenic bacteria prefer simple carbohydrates because they do not have time to ferment complex carbohydrates that we ingest like other bacteria further in your digestive tract. Food does not stay long enough in our oral cavity to be fermented before it is swallowed. Depending on the depth of a cavity in a tooth cariogenic bacteria are eventually able to colonize the dentin and the pulp of a tooth causing an infection. Once a tooth is infected, it may need to be removed, or the infection can spread to other parts of the body through the bloodstream including the heart. The above information on the formation of cavities is known as the oral hygiene hypothesis.22

The new study “Personal oral hygiene and dental caries: A systematic review of randomised controlled trials,” puts forth information to prove a newer hypothesis for the formation of cavities, known as the dental defect hypothesis. “The dental defect hypothesis posits that dental caries starts in microscopic cracks or crevices in teeth, and not on defect-free or sound enamel. The biofilm within the dental defects is also thought to become cariogenic in the presence of dietary carbohydrates. However, the biofilm cannot be removed with a toothbrush or interproximal cleaning devices; hence, oral hygiene is believed to be ineffective. Under this alternative hypothesis, prevention of dental caries must focus on preventing the formation of dental defects during odontogenesis, by repairing the defects from the pulpal side, or by sealing or surgically eliminating surface defects in the enamel. Historically, the motto of the proponents for the dental defect hypothesis was that “sound teeth do not decay”.23

I believe that the dental defect hypothesis is a refined version of the oral hygiene hypothesis. It might be possible that teeth that are healthy and strong without any defects would not succumb to dental carries if the person ate a healthy diet (Perfect Health Diet for example), ingested or supplemented adequate amounts of calcium, magnesium, phosphorus, boron, potassium, vitamin D, vitamin K2, and avoided consuming very low pH sugary beverages like soda. That being said I still believe that brushing is important for oral health, to reduce biofilm formation even on healthy teeth, but I do find the dental defect hypothesis to be fascinating. Where I disagree with the rest of the study is that instead of suggesting ways to make sure the body has enough of the correct vitamins and minerals to make healthy teeth or changes in diets (which in Figure 1 they briefly list on a diagram) the study instead focuses on the need and importance for fluoride in preventing caries.24 25 26

The study is a meta-study, which means it is a study that analyzes other studies that have been done and reaches a conclusion based on the information. “A total of 984 unique citations from 3 sources were identified. Thirteen references of interest were identified for full-text review, which included 12 published articles and one abstract for which we obtained the NIH grant report. After full-text review, three randomized trials were included. Four non-randomized trials were retained for the purpose of sensitivity analyses” So, out of 984 records, 13 full-text articles were assessed for eligibility and out of those six were excluded, leaving 7 full-text articles. Out of those articles “three randomised trials on 743 participants (children) were identified” and were what were used to justify the results of the meta-study. For big academia a study based off of 743 participants is a small sample size, even the author of the study admits that in the AP article. “Even without fluoride, dentists say there’s some value in brushing. Philippe Hujoel, the dentist and University of Washington professor who led the dental review, said oral hygiene without fluoride might produce real cavity-fighting effects too small to detect in a study, or adults might conceivably benefit where the children in the studies did not, and tooth brushing did reduce swollen gums in Hujoel’s review. Brushing the teeth may also dislodge stuck food and help patients recover from oral surgery.” Finally, the meta-study did not analyze the referenced studies for bias “Meta-regression or statistical assessment of publication bias was not performed due to the limited number of trials and minimal variability in terms of duration or quality of the randomised trials.”27

The first study that is referenced is also a meta-study “Mechanical and chemical plaque control in the simultaneous management of gingivitis and caries: a systematic review”, the study did look for biases in the studies (data reference point inconsistency, but not funding to my knowledge) that were referenced and there was a conflict of interest and source of funding statement, so I applaud them for fact checking and honesty. My main issue with this meta-study is like the current meta-study I am writing about, the meta-study uses the next two studies as trusted references to show evidence that fluoride use is the main way to improve oral health. The other two studies that are referenced in the study for the statistics have major flaws. The second study that was referenced is “Effects of supervised daily dental plaque removal by children after 3 years”. For one, this study was performed between 1979-1980. It is rare that I will reference earlier studies (thirty years or more) in my work because research and theories constantly change. There is no consideration of biases listed in the study, conflict of interest statement, or source of funding statement in the study. The ingredients of the fluoride-free toothpaste used in the study are unknown or if xylitol was even used in the study. In addition, the study had big potential conflicts of interest with the National Caries Program and the NIDR (National Institute of Dental Research) being acknowledged in the study for helping with the study and one of the authors of the study being involved with the NIDR. The NIDR funded studies that advocated how to protect teeth from excessive sugar consumption instead of promoting the hypothesis that excessive sugar consumption can cause health issues including dental carries. For more information on the NIDR and how they were sponsored by sugar manufacturers, read this great blog article and study. Finally, the third “study” “Effect of Supervised Deplaquing on Dental Carries, Gingivitis, and Plaque,” contains an abstract of what appears to be a presentation? If anyone can find the actual presentation or study, I would love to analyze it. The presentation was funded by the NIDR (NIDR Contract N01-DE-32424) and is listed at the bottom of the abstract.28 29

Interestingly the study does mention in conclusion the importance of vitamin D in the prevention of dental caries. “According to the dental defect hypothesis, the dramatic decline of caries in wealthier countries that occurred in the second half of the 20th century is attributed to the widespread use of dietary vitamin D supplements to overcome epidemics of pediatric malnutrition” “The dental defect hypothesis is also consistent with the effectiveness of vitamin D” Vitamin D, among other important vitamins and minerals can lead to healthy teeth that are resistant to developing dental caries. I believe vitamin D should be endogenously produced if possible through proper sunlight exposure. I find it interesting nonetheless that even the study admits it is crucial for the health of our teeth.30

The study concludes “This review does not question whether clinicians should provide advice on the potential benefits of oral hygiene for preventing dental caries. There is still substance to the arguments that small therapeutic effects of personal oral hygiene remained undetected in statistically underpowered trials, that findings in healthy paediatric populations with no exposed cementum do not extrapolate to adults with exposed cementum or decreased saliva flow, or that adults with other systemic diseases or disorders may benefit from personal oral hygiene in terms of dental caries prevention. Indeed, oral hygiene can be a pleasant and cost-effective way to deliver fluoride, reduce gingivitis, remove food impactions, or to help patients in their recovery from oral surgical procedures. The dangers in the unqualified promotion of oral hygiene for dental caries prevention are that it may lead individuals to select fluoride-free toothpastes, to sacrifice effective fluoride exposure for interproximal cleaning without fluoride, or to forego effective therapeutics such as fluoride rinses. Such beliefs which reduce fluoride exposure increase dental caries risk and are most dangerous when used as a justification to promote sugar consumption, and to perpetuate the myth that sugar is safe to eat as long as one brushes their teeth.” I do have some issues with the studies conclusion. First, I rarely have seen anyone advocating that habitual sugar consumption is safe for your health as long as one brushes their teeth, except for sugar manufactures that funded the NIDR for that exact purpose. The study bases its conclusions on two studies that had a strong relationship with the NIDR. I find it biased that the most important and first listed part of proper oral hygiene is that it is a “cost effective fluoride delivery system”. Using that logic why not consume public fluoridated water, because obtaining fluoridated from public water fountains is free? There was no critical examination of fluoride in the study, let alone any mention of the known issues fluoride use even incorrectly by their standards like dental fluorosis. Finally, there are no disclosure or mention conflicts of interest or sources of funding in this study.31

Conclusion

Even of the hypothesized cause of dental caries changes from the hygiene hypothesis to the defect hypothesis my recommendations still stand the same for oral hygiene. I recommend brushing at least once or twice daily with a xylitol-containing essential oil toothpaste, avoid or consume less refined sugar, avoid low pH sugary drinks like soda and energy drinks, using correctly a water flosser with non-fluoridated filtered water, using a copper tongue scraper, and oil pulling for ten to twenty minutes once daily. Adequate amounts of calcium, magnesium, phosphorus, boron, potassium, vitamin D, and vitamin K2 are essential for proper teeth health from diet or supplementation. I believe, do, and recommended all of these methods for proper oral hygiene and to prevent dental caries. I do not endorse or think that fluoride is needed for proper oral health and I also believe that ingestion of fluoride, especially not knowing the amounts you are ingesting can cause health issues.

  1. https://www.nytimes.com/aponline/2018/08/07/us/ap-toothbrushing-cavities.html
  2. https://www.nytimes.com/aponline/2018/08/07/us/ap-toothbrushing-cavities.html
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3956646/
  4. http://origins.osu.edu/article/toxic-treatment-fluorides-transformation-industrial-waste-public-health-miracle
  5. https://www.ewg.org/enviroblog/2011/02/fluoride-your-water-how-much-too-much#.WW5-gemQyUk
  6. https://www.ada.org/~/media/EBD/Files/PHS_2015_Fluoride_Guidelines.pdf?la=en
  7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3956646/
  8. https://www.epa.gov/sites/production/files/2015-10/documents/2011_fluoride_questionsanswers.pdf
  9. https://www.npr.org/sections/health-shots/2015/04/27/402579949/feds-say-its-time-to-cut-back-on-fluoride-in-drinking-water
  10. http://fluoridealert.org/studies/bone11_/
  11. http://www.icnr.com/articles/fluoride-deposition.html
  12. http://www.icnr.com/articles/fluoride-deposition.html
  13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3890436/
  14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3956646/
  15. Nagel, Ramiel. Cure Tooth Decay, CreateSpace, Nov. 11, 2010.”>Nagel, Ramiel. Cure Tooth Decay, CreateSpace, Nov. 11, 2010
  16. Artemis, Nadine. Holistic Dental Care: The Complete Guide to Healthy Teeth and Gums, North Atlantic Books; 1 edition, 2013
  17. https://onlinelibrary.wiley.com/doi/epdf/10.1111/ger.12331?redirect_to=https%3A%2F%2Fwww.nbcnews.com%2Fhealth%2Fhealth-news%2Fexperts-question-benefits-fluoride-free-toothpaste-n898311%3Fcid%3Dsm_npd_nn_fb_ma
  18. https://www.nytimes.com/aponline/2018/08/07/us/ap-toothbrushing-cavities.html
  19. https://www.nytimes.com/aponline/2018/08/07/us/ap-toothbrushing-cavities.html
  20. https://www.nytimes.com/aponline/2018/08/07/us/ap-toothbrushing-cavities.html
  21. https://www.nytimes.com/aponline/2018/08/07/us/ap-toothbrushing-cavities.html
  22. https://onlinelibrary.wiley.com/doi/epdf/10.1111/ger.12331?redirect_to=https%3A%2F%2Fwww.nbcnews.com%2Fhealth%2Fhealth-news%2Fexperts-question-benefits-fluoride-free-toothpaste-n898311%3Fcid%3Dsm_npd_nn_fb_ma
  23. https://onlinelibrary.wiley.com/doi/epdf/10.1111/ger.12331?redirect_to=https%3A%2F%2Fwww.nbcnews.com%2Fhealth%2Fhealth-news%2Fexperts-question-benefits-fluoride-free-toothpaste-n898311%3Fcid%3Dsm_npd_nn_fb_ma
  24. https://onlinelibrary.wiley.com/doi/epdf/10.1111/ger.12331?redirect_to=https%3A%2F%2Fwww.nbcnews.com%2Fhealth%2Fhealth-news%2Fexperts-question-benefits-fluoride-free-toothpaste-n898311%3Fcid%3Dsm_npd_nn_fb_ma
  25. Nagel, Ramiel. Cure Tooth Decay, CreateSpace, Nov. 11, 2010.”>Nagel, Ramiel. Cure Tooth Decay, CreateSpace, Nov. 11, 2010
  26. Artemis, Nadine. Holistic Dental Care: The Complete Guide to Healthy Teeth and Gums, North Atlantic Books; 1 edition, 2013
  27. https://onlinelibrary.wiley.com/doi/epdf/10.1111/ger.12331?redirect_to=https%3A%2F%2Fwww.nbcnews.com%2Fhealth%2Fhealth-news%2Fexperts-question-benefits-fluoride-free-toothpaste-n898311%3Fcid%3Dsm_npd_nn_fb_ma
  28. https://www.ncbi.nlm.nih.gov/pubmed/6936116
  29. https://www.ncbi.nlm.nih.gov/pubmed/28266113
  30. https://onlinelibrary.wiley.com/doi/epdf/10.1111/ger.12331?redirect_to=https%3A%2F%2Fwww.nbcnews.com%2Fhealth%2Fhealth-news%2Fexperts-question-benefits-fluoride-free-toothpaste-n898311%3Fcid%3Dsm_npd_nn_fb_ma
  31. https://onlinelibrary.wiley.com/doi/epdf/10.1111/ger.12331?redirect_to=https%3A%2F%2Fwww.nbcnews.com%2Fhealth%2Fhealth-news%2Fexperts-question-benefits-fluoride-free-toothpaste-n898311%3Fcid%3Dsm_npd_nn_fb_ma

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