Both sides of water fluoridation are passionate. One side believes it to be one of the ten most important public health advances of the 20th century. This group includes organized dentistry, politicians, and public officials.

water flouride problemOn the other side are a few concerned scientists who somehow have the courage or the protection from political fall-out to take a minority position in a public health matter. In addition to these scientists there is also a large group of people who tend to not trust authority of any kind. They, in fact, make it more difficult for people on the opposing side to want to ever change, because they don’t want to be identified with these anti-everything groups.

For a good summary of the argument opposing public water fluoridation I recommend you read “50 Reasons to Oppose Fluoride.” The sections I quote below are from this article.

As I was attempting to determine if putting something in the water is a good idea or not, I thought it best to start by creating a logical series of questions. And I started with what I think is the most important question followed by the next most important and so on. This, to me, is the best way to cut through political fog and most efficiently arrive at a comfortable decision as to which side to support.

Question #1:

Which side has the burden of proof? Does the health benefit reducing tooth decay equal the risk of placing a substance that is a known poison at higher concentrations into public water systems? Most rational minds consider safety more important than possible benefits when looking at treating populations as a whole. In the case of water fluoridation, therefore, I believe the burden proof should be with those who are for water fluoridation rather than those who oppose it. Ironically, it seems currently that the opposite is true.

Question #2:

Does it work? Does fluoridating public water in fact reduce dental decay, and if so, by how much? First, it turns out that there has been no serious research to determine this. Instead, large surveys of dental health are conducted and scientists and other infer cause and effect.

“Despite the fact that fluoride has been added to community water supplies for over 60 years, ‘there have been no randomized trials of water fluoridation.’ (Cheng 2007). Randomized studies are the standard method for determining the safety and effectiveness of any purportedly beneficial medical treatment. In 2000, the British Government’s “York Review” could not give a single fluoridation trial a Grade A classification – despite 50 years of research (McDonagh 2000). The U.S. Food and Drug Administration (FDA) continues to classify fluoride as an ‘unapproved new drug.’”

From the epidemiological surveys I mentioned above, here is a summary of the results.

The largest survey ever conducted in the US (over 39,000 children from 84 communities) by the National Institute of Dental Research showed little difference in tooth decay among children in fluoridated and non-fluoridated communities (Hileman 1989 ). According to NIDR researchers, the study found an average difference of only 0.6 DMFS (Decayed, Missing, and Filled Surfaces) in the permanent teeth of children aged 5-17 residing their entire lives in either fluoridated or unfluoridated areas (Brunelle & Carlos, 1990). This difference is less than one tooth surface, and less than 1% of the 100+ tooth surfaces available in a child’s mouth. Large surveys from three Australian states have found even less of a benefit, with decay reductions ranging from 0 to 0.3 of one permanent tooth surface (Spencer 1996; Armfield & Spencer 2004). None of these studies have allowed for the possible delayed eruption of the teeth that may be caused by exposure to fluoride, for which there is some evidence (Komarek 2005). A one-year delay in eruption of the permanent teeth would eliminate the very small benefit recorded in these modern studies.

A multi-million dollar U.S. National Institutes of Health (NIH) -funded study (Warren 2009) found no relation between tooth decay and the amount of fluoride ingested by children. This is the first time that tooth decay has been investigated as a function of individual exposure as opposed to mere residence in a fluoridated community.

Despite some claims to the contrary, water fluoridation cannot prevent the oral health crises that result from rampant poverty, inadequate nutrition, and lack of access to dental care. There have been numerous reports of severe dental crises in low-income neighborhoods of US cities that have been fluoridated for over 20 years (e.g., Boston, Cincinnati, New York City, and Pittsburgh). In addition, fluoridation has been repeatedly found to be ineffective at preventing the most serious oral health problem facing poor children, namely “baby bottle tooth decay,” otherwise known as early childhood caries (Barnes 1992; Shiboski 2003).

Question #3:

How does it work? How does fluoridating the water work to lower tooth decay? I was taught in dental school that drinking fluoridated water resulted in a stronger, more decay-resistant enamel structure during development. A few weeks ago I came to find out that this was disproved back in 1999 and is no longer taught in dental schools. Instead, it turns out that fluoridating the water simply supplies another source for topical fluoride along with tooth pastes and other topical agents.

Frankly, I’m disappointed that this information was not proclaimed at an intensity and frequency to make sure that all dentists everywhere learned this new information.

If you are a dentist and were aware of this change in understanding about fluoride, I would love to hear from you. Post a comment.

In Conclusion:

Understandably, the public looks to experts to help them know how to live safe and healthy lives. The problem is that once science moves into the public health arena, it ceases to be pure science – meaning it’s harder to debate and adapt to new information. Messages become cloudy and elected and electable officials (as well as those receiving government money) weigh the benefits and disadvantages of changing policy even when new evidence surfaces that current programs no longer make a lot of sense. Part of the problem in this particular area has been the fact that most dentists (and I include myself in this) have not been informed (other than a few lectures in dental school) and have not taken the time necessary to study the matter for ourselves.

Finally, let me make it clear that I am not disputing the benefits of topical fluoride. The difference between this and water fluoridation to me is that individuals are free to decide to use it or not for themselves. This is a basic principle of medical ethics known as Informed Consent.