Hydroxyapatite Toothpaste vs Fluoride: Key Differences

Hydroxyapatite toothpaste has gained attention as a fluoride-free alternative for cavity prevention and enamel care. But does it work as well as traditional fluoride toothpaste?

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The answer is more nuanced than simply choosing one ingredient over the other. Fluoride has the strongest and longest-established evidence for preventing dental caries, while recent clinical research suggests that hydroxyapatite can also provide meaningful protection against caries.

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Understanding how each ingredient works can help patients and dental professionals make a more informed choice.

🔘 What Is Hydroxyapatite Toothpaste?
Hydroxyapatite (HAp) is a calcium-phosphate mineral that closely resembles the mineral naturally found in tooth enamel and dentin.
When used in toothpaste, hydroxyapatite particles can interact with the tooth surface and contribute calcium and phosphate to areas affected by early mineral loss. Some formulations use nano-hydroxyapatite, which contains very small particles designed to interact closely with the enamel surface.
Unlike fluoride toothpaste, fluoride-free hydroxyapatite toothpaste does not depend on fluoride ions to provide its anticaries effect.
Recent evidence is encouraging. A 2024 systematic review and meta-analysis identified 13 clinical and in situ studies suitable for meta-analysis and concluded that fluoride-free hydroxyapatite products can reduce caries risk. However, the evidence base remains smaller than that supporting fluoride.

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🔘 How Does Fluoride Toothpaste Work?
Fluoride toothpaste works primarily by maintaining fluoride availability in the mouth.

Fluoride helps:
▪️ Reduce enamel demineralization
▪️ Promote remineralization of early carious lesions
▪️ Make tooth mineral more resistant to acid attacks
▪️ Maintain a protective fluoride reservoir in plaque and saliva
This is why fluoride toothpaste remains the standard recommendation for daily caries prevention. The American Dental Association recommends brushing twice daily with fluoride toothpaste for most people.
For a toothpaste to receive the ADA Seal of Acceptance for a cavity-protection claim, it must contain fluoride.

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🔘 Hydroxyapatite vs Fluoride: What Is the Difference?

Feature	Hydroxyapatite Toothpaste	Fluoride Toothpaste
Main active ingredient	Hydroxyapatite	Fluoride
Contains fluoride?	Usually no	Yes
Main action	Provides calcium-phosphate mineral and supports surface repair	Enhances remineralization and increases acid resistance
Caries prevention	Promising clinical evidence	Extensive, established evidence
Evidence base	Growing	Large and long-standing
Early enamel lesions	May support remineralization	Well-established benefit
Suitable for children	Potential alternative in selected situations	Standard recommendation
Best-established role	Alternative for patients who prefer fluoride-free products	Routine caries prevention

The important point is that “effective” does not automatically mean “equally well established”. Hydroxyapatite has demonstrated encouraging results, but fluoride has decades of clinical research and remains the better-supported option for routine caries prevention.

🔘 What Does the Clinical Evidence Show?
One important randomized clinical trial followed 189 adults for 18 months, comparing fluoride-free hydroxyapatite toothpaste with toothpaste containing 1,450 ppm fluoride. Among participants who completed the study per protocol, 89.3% of the hydroxyapatite group and 87.4% of the fluoride group had no increase in DMFS. The investigators concluded that the hydroxyapatite toothpaste was not statistically inferior to the fluoride toothpaste for the study's primary outcome.
More recently, the 2024 systematic review found that the clinical evidence supporting hydroxyapatite has expanded. Nevertheless, the authors also noted that the evidence comes from a relatively limited number of studies, and some researchers involved in the review had industry relationships that should be considered when interpreting the findings.
Therefore, the current evidence supports hydroxyapatite as a promising alternative, but it does not justify claiming that it has definitively replaced fluoride as the gold standard.

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🔘 Which Toothpaste Is Better?
For most people, particularly those with moderate or high caries risk, fluoride toothpaste remains the most evidence-supported choice.
Hydroxyapatite toothpaste may be reasonable for patients who strongly prefer a fluoride-free product, provided they maintain good oral hygiene, limit frequent sugar exposure, and receive appropriate dental monitoring.
The decision may also depend on age, caries risk, diet, previous caries experience, oral hygiene, and other fluoride exposures.
Importantly, patients should not interpret hydroxyapatite toothpaste as a treatment for an established cavity. A cavitated lesion generally requires professional evaluation and appropriate treatment.

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💬 Discussion
The comparison between hydroxyapatite and fluoride should not be framed as “natural versus chemical” or “safe versus unsafe”. Both are scientifically studied ingredients, and the more useful question is how strong the evidence is for each specific clinical purpose.
Fluoride remains the benchmark for caries prevention because its effectiveness has been demonstrated across a much larger body of clinical research and has been incorporated into evidence-based dental guidelines.
At the same time, the growing evidence for hydroxyapatite is clinically relevant. For patients seeking a fluoride-free option, it offers a scientifically plausible and increasingly supported alternative rather than simply being a conventional toothpaste without fluoride.
Future research should clarify its effectiveness across different age groups and caries-risk levels and determine whether specific hydroxyapatite formulations provide benefits comparable to fluoride under different clinical conditions.

✍️ Conclusion
Hydroxyapatite toothpaste and fluoride toothpaste work through different mechanisms, but both can help protect teeth.
Current evidence suggests that hydroxyapatite is a promising fluoride-free alternative, while fluoride toothpaste remains the most established choice for caries prevention.
For patients at elevated caries risk, replacing fluoride should therefore be considered carefully and ideally discussed with a dental professional rather than based solely on marketing claims.

🎯 Clinical Recommendations
▪️ Use fluoride toothpaste as the first-line choice for routine caries prevention in most patients.
▪️ Consider hydroxyapatite toothpaste when a patient specifically prefers a fluoride-free option and understands the current evidence.
▪️ For patients with high caries risk, active caries, or recurrent caries, prioritize evidence-based fluoride strategies and individualized preventive care.
▪️ Do not assume that “fluoride-free” means “caries-free”: diet, plaque control, saliva, and regular dental care remain essential.
▪️ When recommending hydroxyapatite, evaluate the specific product formulation and available clinical evidence, rather than relying solely on the ingredient name.

📚 References

✔ Pawinska, M., Paszynska, E., Amaechi, B. T., Meyer, F., Enax, J., & Limeback, H. (2024). Clinical evidence of caries prevention by hydroxyapatite: An updated systematic review and meta-analysis. Journal of Dentistry, 151, 105429. https://doi.org/10.1016/j.jdent.2024.105429
✔ Paszynska, E., et al. (2023). Caries-preventing effect of a hydroxyapatite-toothpaste in adults: A 18-month double-blinded randomized clinical trial. Frontiers in Public Health, 11, 1199728. https://doi.org/10.3389/fpubh.2023.1199728
✔ American Dental Association. (2025). Toothpastes. ADA Oral Health Topics.
✔ American Dental Association. (2024). Home oral care. ADA Oral Health Topics.
✔ American Dental Association. (2023). Fluoride: Topical and systemic supplements. ADA Oral Health Topics.

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Whitening strips enamel safety: Do they damage teeth?

Achieving a brighter, whiter smile is a common goal, and over-the-counter whitening strips have become one of the most popular methods to get there.

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However, many people wonder if these convenient plastic strips come at a cost to their dental health. Specifically, a major concern is whether the active ingredients can harm the protective outer layer of the teeth.

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Understanding how these products interact with your teeth is essential for keeping your smile both radiant and healthy.

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✅ Do Whitening Strips Damage Tooth Enamel?
The short answer is no, when used correctly according to the manufacturer's instructions. Standard whitening strips typically use low concentrations of hydrogen peroxide or carbamide peroxide.
These active agents penetrate the microscopic pores of the enamel to break down and oxidize deep-set stain molecules, rather than stripping away or dissolving the physical tooth structure.

However, improper use or overuse can indeed pose risks:
▪️ Temporary Enamel Softening: Leaving strips on longer than recommended or using them too frequently can temporarily reduce enamel micro-hardness.
▪️ Increased Tooth Sensitivity: When the enamel is temporarily compromised, external stimuli can more easily reach the internal nerve pathways, causing sharp discomfort.
▪️ Cumulative Damage: Saliva naturally helps remineralize and protect teeth after a whitening session, but continuous, back-to-raced applications interrupt this vital recovery cycle.

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💬 Discussion
Scientific evaluations and dental associations generally agree that commercial whitening strips are safe for short-term cosmetic use. Clinical studies demonstrate that standard concentrations (usually under 10% to 14% hydrogen peroxide) do not cause permanent structural damage if the user respects recovery times.
The main controversy in recent literature involves the compounding effects of aggressive over-the-counter routines. When users try to accelerate results by doubling the daily application time or repeating kits consecutively without breaks, the protective mechanisms of saliva and natural remineralization cannot keep pace.
Furthermore, individuals with pre-existing micro-cracks, untreated cavities, or exposed root surfaces experience much higher vulnerability because the peroxide travels deep into the inner layers of the tooth much faster. Therefore, safety depends less on the product itself and more on disciplined moderation and proper application.

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✍️ Conclusion
Whitening strips are a practical and effective tool for enhancing smile aesthetics when approached with care. While controlled application preserves structural integrity and keeps side effects minimal, excessive use invites enamel weakening and persistent sensitivity. Respecting product timelines and prioritizing overall dental health over rapid results will ensure your teeth remain strong and bright for years to come.

💡 Clinical Pearls
▪️ Adhere Strictly to Time Limits: Never leave whitening strips on longer than directed; prolonged exposure increases enamel porosity and soft-tissue irritation without improving color.
▪️ Enforce Recovery Windows: Allow at least several months of rest between whitening cycles to give saliva and natural minerals adequate time to fully remineralize the enamel.
▪️ Screen for Pre-existing Conditions: Inspect teeth for untreated decay, defective restorations, or exposed dentin prior to treatment to prevent the bleaching agent from directly irritating the dental pulp.

📚 References

✔ American Dental Association. (2023). Risks of frequent teeth whitening. ADA News. https://adanews.ada.org/huddles/risks-of-frequent-teeth-whitening/
✔ Greenwall, L. H., Greenwall-Cohen, J., & Wilson, N. H. (2019). Tooth whitening: An evidence-based perspective. British Dental Journal, 226(4), 271-276.

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Soft Tissue Injuries in Pediatric Dentistry: Assessment and Care

Soft tissue injuries in pediatric dentistry are common consequences of falls, sports-related trauma, collisions, and accidental biting.

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They may involve the lips, gingiva, buccal mucosa, tongue, frenula, and oral vestibule, and can occur with or without associated dental or facial injuries.

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Epidemiological data indicate that soft tissue trauma is particularly frequent in children younger than 3 years.
Although many oral soft tissue injuries heal without intervention, careful assessment is essential to identify deep lacerations, foreign bodies, neurovascular injury, significant hemorrhage, tissue avulsion, mandibular trauma, and injuries requiring surgical repair.
The clinician should also consider the possibility of non-accidental injury when the history and clinical findings are inconsistent.

✅ Types of Pediatric Oral Soft Tissue Injuries
Common injuries include:

▪️ Lacerations: Partial- or full-thickness tissue tears affecting the lips, tongue, gingiva, or buccal mucosa.
▪️ Contusions: Blunt trauma producing localized swelling, bruising, or tenderness without tissue disruption.
▪️ Abrasions: Superficial epithelial injuries caused by friction.
▪️ Puncture wounds: Penetrating injuries that may retain foreign material.
▪️ Frenulum injuries: Often associated with falls or direct impact to the upper lip.
▪️ Gingival degloving injuries: Separation of the gingiva from the underlying alveolar bone, which may be clinically subtle.
▪️ Tongue lacerations: Frequently caused by falls or accidental biting.
The injury should always be interpreted in the context of the mechanism of trauma and the possibility of concomitant dental, alveolar, mandibular, or head injuries.

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✅ Assessment of Soft Tissue Injuries

1. Establish the Mechanism and Timing
The history should document the mechanism of injury, time elapsed, location, witnessed circumstances, initial bleeding, previous first aid, medical history, medications, allergies, and tetanus immunization status. The clinician should determine whether the trauma was accidental and whether the reported mechanism adequately explains the observed injuries.

2. Perform a Systematic Examination
A complete examination should include:

▪️ Extraoral inspection for swelling, bruising, asymmetry, and lacerations.
▪️ Intraoral inspection of the lips, gingiva, mucosa, tongue, floor of the mouth, and palate.
▪️ Assessment of wound depth, tissue separation, contamination, and foreign bodies.
▪️ Evaluation of hemostasis and tissue perfusion.
▪️ Assessment of occlusion and mandibular movement.
▪️ Examination of teeth for fracture, mobility, displacement, or avulsion.
▪️ Evaluation for neurological symptoms or associated facial injuries.
The lips should be carefully retracted to identify injuries hidden within the vestibule or gingival tissues. Missing teeth or fragments should be accounted for because they may be embedded in soft tissue or, less commonly, aspirated.

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✅ When Does a Soft Tissue Injury Require Repair?
Most minor oral lacerations can heal by secondary intention because the oral mucosa has a favorable blood supply and healing capacity. Suturing should therefore not be automatic.

Repair or specialist evaluation should be considered when there is:
▪️ Persistent or uncontrolled bleeding.
▪️ Significant tissue separation or a large flap.
▪️ Deep or through-and-through laceration.
▪️ Injury involving important anatomical structures.
▪️ Significant contamination or retained foreign bodies.
▪️ Tissue avulsion or compromised vascularity.
▪️ Functional impairment.
▪️ Facial laceration requiring precise anatomical alignment.
▪️ Suspected associated fracture or penetrating injury.
Deep oral lacerations and gingival degloving injuries may require operative irrigation, debridement, and closure to reduce complications.

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✅ Tongue Lacerations in Children
Tongue injuries deserve particular consideration because clinicians may overestimate the need for suturing. Evidence indicates that many uncomplicated tongue lacerations heal satisfactorily without primary closure.
In a retrospective pediatric study, suturing was generally unnecessary for gaping tongue lacerations smaller than 2 cm that did not involve the tongue tip. Larger wounds, wounds with significant gaping at rest, through-and-through injuries, or injuries involving the tip may require repair depending on their anatomical and functional characteristics.
Therefore, wound size alone should not determine treatment. Location, depth, tissue loss, bleeding, functional impairment, and wound configuration should guide the decision.

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✅ Management and Wound Care
Initial treatment consists of:

1. Hemostasis using direct pressure when appropriate.
2. Irrigation and removal of visible foreign material.
3. Assessment for associated dental and maxillofacial injuries.
4. Adequate local anesthesia and analgesia before wound manipulation.
5. Primary closure when clinically indicated.
6. Appropriate postoperative instructions and follow-up.
In children requiring extensive examination or repair, behavioral cooperation may be insufficient for safe treatment under local anesthesia alone. Depending on the injury and clinical setting, sedation or general anesthesia may be necessary.
Routine systemic antibiotics are not indicated for every uncomplicated oral laceration. Their use should be based on wound contamination, tissue damage, operative management, associated injuries, and patient-specific risk factors. Antibiotic prophylaxis may be considered for contaminated soft tissue injuries requiring operative intervention.

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✅ Special Considerations in Pediatric Patients
Children present unique challenges because of their age, developmental stage, limited ability to cooperate, and the potential psychological impact of traumatic procedures. Treatment should therefore combine adequate pain control, efficient wound assessment, appropriate behavior guidance, and avoidance of unnecessary invasive procedures.
The clinician should also recognize that an oral injury in a non-mobile infant, particularly when the reported mechanism is unclear or inconsistent with the clinical findings, warrants careful consideration of possible child maltreatment. Oral injuries associated with physical abuse may include frenulum trauma, bruising, lacerations, and injuries to the oropharyngeal region.

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💬 Discussion
The management of pediatric oral soft tissue injuries is primarily determined by clinical assessment rather than by wound size alone. Contemporary evidence supports a conservative approach for many uncomplicated mucosal injuries, avoiding unnecessary suturing when spontaneous healing is expected to provide an equivalent outcome.
The main clinical challenge is distinguishing injuries appropriate for observation from those requiring intervention. Particular attention should be directed toward deep lacerations, tissue avulsion, persistent hemorrhage, functional impairment, contaminated wounds, gingival degloving, and associated facial or dental trauma.
For tongue lacerations specifically, available evidence suggests that routine suturing may increase treatment burden without improving outcomes in selected uncomplicated wounds. However, the evidence base remains limited, and management should be individualized according to anatomical involvement and clinical severity.

🎯 Clinical Recommendations
▪️ Prioritize airway, neurological status, hemorrhage, and associated facial trauma before focusing exclusively on the oral wound.
▪️ Document the injury with a precise description of location, dimensions, depth, contamination, tissue loss, and associated dental findings.
▪️ Avoid routine suturing of uncomplicated oral mucosal wounds when secondary healing is clinically appropriate.
▪️ Consider repair for wounds with significant gaping, tissue loss, persistent bleeding, functional compromise, or important anatomical involvement.
▪️ For tongue lacerations, evaluate location, depth, gaping at rest, tip involvement, and through-and-through extension rather than relying solely on length.
▪️ Use adequate analgesia and anesthesia before wound exploration or repair; consider sedation when cooperation is inadequate for safe treatment.
▪️ Maintain a low threshold for referral when deep facial/oral structures, mandibular injury, vascular compromise, or complex soft tissue trauma is suspected.
▪️ Reassess the reported mechanism when the injury pattern is inconsistent, particularly in non-mobile infants.

✍️ Conclusion
Soft tissue injuries in pediatric dentistry require a structured clinical assessment to determine whether observation, wound care, primary repair, or specialist referral is appropriate. Most uncomplicated oral mucosal injuries heal effectively without surgical intervention. However, deep lacerations, degloving injuries, significant tissue loss, uncontrolled bleeding, functional impairment, and associated maxillofacial trauma require more intensive management.
A conservative, evidence-informed approach can minimize unnecessary procedures while preserving function, tissue integrity, and the child's overall experience of dental care.

📚 References

✔ American Academy of Pediatric Dentistry. (2025). Acute traumatic injuries: Assessment and documentation. In The reference manual of pediatric dentistry. American Academy of Pediatric Dentistry.
Hwang, M., Engelstad, M., & Chandra, S. R. (2023). Management of soft tissue injuries in children—A comprehensive review. Oral and Maxillofacial Surgery Clinics of North America, 35(4), 619–629. https://doi.org/10.1016/j.coms.2023.06.003
✔ Lamell, C. W., Fraone, G., Casamassimo, P. S., & Wilson, S. (1999). Presenting characteristics and treatment outcomes for tongue lacerations in children. Pediatric Dentistry, 21(1), 34–38.
✔ Olszewska, A., Kensy, J., Czajka-Jakubowska, A., Pergolini, D., Bossù, M., Romeo, U., & Matys, J. (2026). Diagnosis and management of traumatic injuries in pediatric patients secondary to dental local anesthesia: A systematic review. Advances in Clinical and Experimental Medicine, 35(1), 175–190. https://doi.org/10.17219/acem/204391
✔ Seiler, M., Massaro, S. L., Staubli, G., & Schiestl, C. (2018). Tongue lacerations in children: To suture or not? Swiss Medical Weekly, 148, w14683. https://doi.org/10.4414/smw.2018.14683
✔ The Royal Children's Hospital Melbourne. (2024). Clinical practice guidelines: Dental trauma.
✔ The Royal Children's Hospital Melbourne. (2022). Clinical practice guidelines: Lacerations.
✔ Warnakulasuriya, S., Muthukrishnan, A., et al. (2019). World Workshop on Oral Medicine VII: Relative frequency of oral mucosal lesions in children, a scoping review. Oral Diseases, 25(8), 1933–1948. https://doi.org/10.1111/odi.13112

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Silver Diamine Fluoride for Root Caries: Is It Effective?

Root caries is an increasing clinical concern in adults and older adults, particularly when gingival recession exposes root surfaces. Unlike enamel, exposed root dentin and cementum are more susceptible to acid-mediated demineralization.

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Management can be challenging when lesions occur in patients with multiple affected surfaces, limited access to dental care, reduced oral hygiene capacity, or medical and functional limitations.

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Silver diamine fluoride (SDF), particularly the 38% formulation, has emerged as a nonrestorative approach for arresting root caries. Its clinical value is based on the ability to inhibit caries progression without requiring conventional cavity preparation.
Current evidence supports SDF as an option for arresting root caries in permanent teeth, although the certainty of evidence and clinical recommendations vary according to the treatment alternative and patient circumstances.

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✅ Why Is Root Caries Difficult to Manage?
Root caries develops on exposed root surfaces after loss of periodontal coverage. Dentin and cementum have a higher organic content and are less mineralized than enamel, making them more vulnerable to demineralization.
Root caries management may be particularly challenging in older adults because lesions can occur in multiple teeth and may be associated with gingival recession, plaque accumulation, xerostomia, reduced manual dexterity, or difficulty maintaining oral hygiene.
Conventional restorative treatment remains appropriate when a lesion requires restoration because of structural loss, esthetic requirements, function, or other clinical considerations. However, a nonrestorative strategy can be useful when the primary objective is to arrest disease progression.

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✅ How Does SDF Work on Root Caries?
The anticaries effects of SDF are related primarily to its silver and fluoride components.
Silver has antimicrobial properties that can inhibit cariogenic microorganisms and interfere with bacterial activity within the carious lesion. Fluoride contributes to the formation and stabilization of fluoride-containing mineral phases and increases the resistance of dental hard tissues to subsequent acid attack.
For root caries, the objective is not to restore the original anatomy of the tooth. Instead, SDF is used to inactivate the carious lesion and prevent or reduce further progression.
Clinically, an arrested lesion generally becomes harder and darker after treatment. The permanent dark discoloration is an important consequence of SDF therapy and should be incorporated into informed consent.

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✅ What Does the Clinical Evidence Show?
Evidence from randomized clinical trials and systematic reviews supports the effectiveness of SDF for root caries in older adults.
A systematic review and meta-analysis evaluating SDF for exposed root surfaces included three controlled clinical trials involving 895 older adults. Compared with placebo, SDF significantly reduced the number of decayed or filled root surfaces at 24 months and at 30 months or longer. SDF also showed preventive effects comparable to chlorhexidine and fluoride varnish in the included studies.
A subsequent systematic review and meta-analysis published in 2021 similarly concluded that SDF was effective for the management of root caries in older adults, while emphasizing the limitations of the available evidence.

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✅ Evidence From a Recent Randomized Clinical Trial
More recent evidence further supports the caries-arresting effect of 38% SDF.
A 2026 randomized controlled trial included 186 community-dwelling older adults, with 323 root caries lesions assessed at baseline. At the 2-month follow-up, 165 participants with 286 lesions remained in the analysis.
The SDF group demonstrated substantially higher arrest rates than the control group:

▪️ Individual level: 81.2% with SDF vs. 21.3% with control
▪️ Lesion level: 84.9% with SDF vs. 20.7% with control
The study also found that SDF application, baseline lesion status, and absence of plaque on the lesion surface were positively associated with caries arrest.
Although the short follow-up limits conclusions regarding long-term effectiveness, these findings provide additional contemporary clinical evidence supporting 38% SDF for arresting root caries.

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✅ Is SDF Recommended for Root Caries?
The current evidence-based recommendations are nuanced.
The American Dental Association (ADA) guideline on nonrestorative caries treatment identifies 38% SDF as a nonrestorative option for noncavitated and cavitated root caries lesions on permanent teeth.
However, the ADA guideline prioritizes 5,000 ppm fluoride toothpaste or gel used at least once daily over other nonrestorative options, including annual 38% SDF, because of the overall evidence assessment, feasibility, and clinical considerations. The recommendation for root-surface treatment is conditional and based on low-certainty evidence.
Therefore, SDF should not be interpreted as the universally preferred treatment for every root caries lesion. Its value is particularly relevant when a nonrestorative, minimally invasive approach is appropriate.

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✅ Advantages of SDF for Root Caries
Several characteristics make SDF clinically attractive for selected patients:

▪️ Nonrestorative application: no conventional cavity preparation is required to arrest the lesion.
▪️ Minimal invasiveness: treatment can be performed without rotary instrumentation.
▪️ Caries-arresting activity: clinical studies demonstrate significant arrest of root caries compared with placebo.
▪️ Potential usefulness in older adults: particularly when multiple root lesions or treatment limitations are present.
▪️ Simple topical application: the procedure requires relatively limited clinical resources.
▪️ Potential public-health value: SDF may facilitate disease control in populations with barriers to conventional restorative treatment.
These advantages should be considered within a comprehensive caries-management strategy rather than as a replacement for oral hygiene measures, fluoride exposure, dietary management, or restorative treatment when clinically indicated.

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✅ Limitations of SDF for Root Caries
The principal limitation is permanent dark discoloration of the treated carious lesion. This can be particularly relevant when lesions are located on visible root surfaces.
SDF also does not restore lost tooth structure. An arrested lesion may remain cavitated, and the patient may still require restorative treatment when structural integrity, plaque control, function, food impaction, or esthetics are concerns.
Another limitation is the heterogeneity of the available evidence, including differences in lesion characteristics, application protocols, follow-up periods, and patient populations. The ADA therefore assigns a conditional recommendation with low certainty for nonrestorative management of root caries using SDF.
Importantly, evidence from root caries studies should not automatically be extrapolated to every form of dental caries or to every clinical situation.

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Dental Article 🔽 Latest FDA Guidelines (2025) on Fluoride Use in Children: What Dentists Need to Know ... These updates address long-standing concerns surrounding unapproved systemic fluoride products, raising new questions for pediatric dental practice.

💬 Discussion
The available evidence indicates that 38% silver diamine fluoride is effective in arresting root caries, particularly in older adults. Both earlier systematic reviews and more recent randomized clinical evidence demonstrate a substantially greater likelihood of lesion arrest with SDF than with placebo or control treatment.
Nevertheless, effectiveness should be interpreted in the context of the treatment objective. SDF is primarily a disease-arresting intervention, not a restorative procedure. It can stabilize a carious root surface but does not reconstruct missing dental tissue.
The 2026 randomized trial also highlights the importance of plaque control. The absence of plaque on the lesion surface was positively associated with caries arrest, reinforcing that SDF should be integrated into broader preventive and behavioral management rather than used as an isolated intervention.
Current guidelines consequently position SDF as one component of nonrestorative root-caries management rather than a universal substitute for high-concentration fluoride toothpaste, preventive care, or restorations when indicated.

🎯 Clinical Recommendations
1. Consider 38% SDF for active root caries in permanent teeth when a nonrestorative approach is clinically appropriate.
2. Prioritize comprehensive caries management, including plaque control, appropriate fluoride exposure, dietary counseling, and management of contributing risk factors.
3. Discuss permanent discoloration before treatment, particularly for lesions on visible root surfaces, and obtain appropriate informed consent.
4. Do not regard SDF as a restorative substitute when substantial structural rehabilitation, function, esthetics, or plaque-retentive cavitation requires restoration.
5. Monitor treated lesions clinically for changes in hardness, activity, plaque accumulation, and progression.
6. Use patient-specific decision-making. The ADA currently gives a conditional recommendation with low-certainty evidence for SDF on root surfaces, while prioritizing daily 5,000 ppm fluoride toothpaste or gel as the preferred nonrestorative strategy when feasible.


✍️ Conclusion
Silver diamine fluoride, particularly 38% SDF, has demonstrated clinically significant caries-arresting activity on exposed root surfaces. Evidence from systematic reviews and a recent randomized clinical trial supports its use as a nonrestorative option, especially in older adults and patients for whom conventional restorative treatment may be difficult or undesirable.
However, SDF does not restore lost tooth structure and produces permanent dark staining of treated carious lesions. Its use should therefore be based on lesion characteristics, patient preferences, caries risk, plaque control, functional and esthetic considerations, and the feasibility of alternative preventive or restorative treatments.

📚 References

✔ American Dental Association. (2018). Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: A report from the American Dental Association. Journal of the American Dental Association, 149(10), 837–849.e19. https://doi.org/10.1016/j.adaj.2018.07.002
✔ Fontana, M., & Weyant, R. J. (2025). Silver diamine fluoride for caries management: An executive summary of the clinical practice guideline. Journal of the California Dental Association, 53(1), Article 2588948. https://doi.org/10.1080/19424396.2025.2588948
✔ Grandjean, M.-L., Maccarone, N. R., McKenna, G., Müller, F., & Srinivasan, M. (2021). Silver diamine fluoride (SDF) in the management of root caries in elders: A systematic review and meta-analysis. Swiss Dental Journal, 131(5), 417–424. https://doi.org/10.61872/sdj-2021-05-02
✔ Zhang, W., McGrath, C., Lo, E. C. M., & Li, J. Y. (2016). Silver diamine fluoride: A systematic review of clinical trials. Journal of Dental Research, 95(5), 512–519. https://doi.org/10.1177/0022034516630671

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Can Testosterone Affect Orthodontic Tooth Movement?

A 2026 animal study published in the Journal of Periodontology investigated how altered testosterone levels affect orthodontic tooth movement (OTM), alveolar bone remodeling, periodontal tissues, and root resorption.

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The findings indicate that both testosterone deficiency and high-dose anabolic-androgenic steroid exposure can modify the biological response to orthodontic force in a pubertal male rat model.

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The study provides experimental evidence that testosterone-related disturbances may influence the tissues involved in orthodontic tooth movement. However, because the research was conducted in rats, the findings cannot be directly applied to human orthodontic treatment.

🔹 Study Design
The researchers used a pubertal male rat model to investigate the effects of testosterone dysfunction during orthodontic tooth movement.
Testosterone deficiency was induced through orchiectomy. The researchers subsequently administered testosterone undecanoate, an anabolic-androgenic steroid (AAS), at replacement and high doses.
Orthodontic tooth movement was produced by applying a closed-coil spring to the maxillary right first molar. The surrounding alveolar bone and periodontal ligament were evaluated at 5 and 10 days after orthodontic force application.
The investigators used several analytical methods, including micro-computed tomography (micro-CT), reverse-transcription quantitative polymerase chain reaction (RT-qPCR), and immunohistochemistry. Root resorption and plasma concentrations of testosterone and adrenocorticotropic hormone were also evaluated.

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🔹 Testosterone Dysfunction Altered Bone Microarchitecture
Both testosterone deficiency and high-dose AAS exposure produced significant changes in bone microarchitecture.
The researchers reported reductions in trabecular thickness and bone connectivity, together with changes involving bone lacunae.
These findings indicate that altered testosterone conditions affected the alveolar bone response during the experimental orthodontic procedure.
The study also found that testosterone dysfunction was associated with greater rotation and intrusion of the orthodontically moved tooth. These observations were obtained from the animal model and should not be interpreted as evidence that testosterone manipulation produces predictable changes in the rate or direction of orthodontic tooth movement in humans.

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🔹 High-Dose Anabolic Steroids and Root Resorption
One of the clinically relevant findings involved inflammatory changes and root resorption.
According to the study, high-dose AAS exposure intensified the inflammatory infiltrate and root resorption associated with orthodontic tooth movement.
Root resorption is a biological consequence that can occur during orthodontic tooth movement. In this experimental model, the researchers found that high-dose androgen exposure was associated with a greater resorptive response.
The study therefore identifies a potential relationship between androgen disturbance and orthodontically induced tissue changes. However, it does not establish that anabolic-androgenic steroid use causes clinically significant root resorption in human orthodontic patients.

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🔹 Changes in Bone-Related Gene Expression
The investigators also examined molecular markers associated with bone metabolism.
Testosterone dysfunction altered the expression of several genes, including:
▪️ Runx2
▪️ Bmp2
▪️ Spp1
▪️ Bglap
The study also identified deregulation of the RANK/RANKL/OPG pathway following testosterone disturbances.
These molecular findings provide additional evidence that altered testosterone conditions affected biological pathways involved in bone remodeling during orthodontic tooth movement.

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🔹 Testosterone Replacement Did Not Fully Restore the Response
An important finding was that administration of AAS at replacement doses did not normalize the inflammatory infiltrate, orthodontic tooth movement, or the expression of the studied genes to control levels.
Therefore, the experimental response observed in testosterone-deficient animals was not simply reversed by testosterone administration at the replacement dose used in the study.
This finding suggests that the biological effects associated with testosterone disturbance were not completely restored under the experimental conditions evaluated.

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🔹 What Do These Findings Mean for Orthodontics?
The study provides evidence that testosterone dysfunction can influence several biological processes associated with orthodontic tooth movement, including:
▪️ alveolar bone microarchitecture;
▪️ periodontal inflammatory response;
▪️ tooth movement characteristics;
▪️ root resorption; and
▪️ expression of genes involved in bone metabolism.
However, the study does not establish a clinical protocol for modifying testosterone levels during orthodontic treatment.
It also does not demonstrate that testosterone supplementation can accelerate orthodontic treatment or that testosterone deficiency necessarily causes slower tooth movement in humans.
The experimental findings should therefore be interpreted as evidence of a biological relationship that requires further investigation.

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🔹 Important Study Limitation
The principal limitation is the experimental model.
The study was conducted in pubertal male rats, and orthodontic tooth movement was produced experimentally using a closed-coil spring on a maxillary first molar. The observation periods were limited to 5 and 10 days.
Human orthodontic treatment differs substantially from this experimental model in anatomy, skeletal development, treatment duration, biomechanics, hormonal physiology, and clinical management.
Consequently, the findings cannot currently be used to predict how an individual human patient will respond to orthodontic treatment based on testosterone levels.

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💬 Discussion
The 2026 study by Reis et al. provides experimental evidence that testosterone dysfunction can modify bone remodeling, periodontal inflammation, orthodontic tooth movement, and root resorption in a pubertal male rat model.
Both testosterone deficiency and high-dose anabolic-androgenic steroid exposure produced alterations in alveolar bone microarchitecture. High-dose AAS exposure was additionally associated with increased inflammatory infiltration and root resorption, while testosterone disturbances affected several genes and signaling pathways involved in bone metabolism.
These findings expand the experimental understanding of systemic hormonal influences on orthodontic tooth movement. Nevertheless, human clinical studies are required before the findings can be translated into orthodontic treatment recommendations.

📚 References

Reis, C. L. B., Galisteu-Luiz, K., Pedroso, G. L., Puls, G. L., Cassaro, L., Vieira, B. B., Lourenço Romano, F., Küchler, E. C., Kirschneck, C., de Oliveira, D. S. B., Stuani, M. B. S., & Matsumoto, M. A. N. (2026). Effects of testosterone and high-dose anabolic steroids on orthodontic-induced bone remodeling and root resorption: An animal study. Journal of Periodontology. Advance online publication. https://doi.org/10.1002/jper.70068

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