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Let's Talk About Fluoride

Stephen Raines

Everything you need to know about fluoride

Intro

Fluoride is a mineral that is naturally present in water and soil, and it is added to or subtracted from many public water supplies to achieve optimal levels as a way to help prevent tooth decay. Fluoride is 100% safe when used in appropriate amounts, and it has been shown to be effective at reducing the incidence of tooth decay and improving overall oral health.

What is a cavity anyway?

Tooth decay happens when sugar in snacks, food and beverages is converted into acid by the bacteria in dental plaque; a thin, sticky, colorless deposit on teeth. The acid attacks the tooth enamel (the hard surface of the tooth) or root surface. After repeated attacks, the enamel or root surface lose minerals (demineralization) and the acids and bacteria penetrate the dentin (the layer underneath outer enamel) and finally the pulp (innermost layer of the tooth). The soft tissue of the pulp contains nerves and blood vessels. Once the decay enters the pulp, it becomes infected and without treatment, the infection progresses and travels into the surrounding tissues (ouch!). It can enter the bloodstream and potentially spread the infection to other parts of the body which can be life-threatening.

What is fluoride?

The element fluorine is abundant in the earth’s crust as a naturally occurring fluoride compound found in rocks and soil.[1] As ground water moves through the earth, it passes over rock formations and dissolves the fluoride minerals that are present, releasing fluoride ions that are naturally occurring fluoride in the rocks. This increases the fluoride content of the water. The concentration of fluoride in ground water (e.g., wells, springs) varies according to such factors as the depth at which the water is found and the quantity of fluoride-bearing minerals in the area. Fluoride is present at varied concentrations in all water sources including rainwater and the oceans. For example, the oceans’ fluoride levels range from 1.2 to 1.4 mg/L.2 In the United States, the natural level of fluoride in ground water varies from very low levels to over 4 mg/L.3 In comparison, the fluoride concentrations in surface water sources such as lakes and rivers is very low.

Why is fluoride beneficial?

Fluoride works by strengthening the tooth enamel, making it more resistant to the acid attacks that can cause cavities. It is most effective when it is applied directly to the teeth, which is why it is often found in toothpaste and mouthwash. Fluoride can also be applied topically to the teeth in the form of gels, foams, or varnishes, which are typically applied by a dental professional.

One of fluoride’s main mechanism of action is its ability to prevent or delay the loss of minerals from teeth.[5,6] Cavities start to form when minerals are lost due to acid attacks from bacteria in dental plaque (a soft, sticky film that is constantly forming on teeth). Bacteria grow rapidly by feeding on the sugars and refined carbohydrates that we consume. This process of losing minerals is called demineralization. Fluoride’s second mechanism of action is called remineralization, which is the reversal of this demineralization process.[6,7] Teeth gain back the minerals lost during acid attacks through remineralization but with an important difference. Some of the hydroxyapatatite crystal lost is replaced with fluorapatite. This fluoride-rich replacement mineral is even more resistant to acid attacks than the original tooth surface.[6,14] American Dental Association Studies indicate fluoride has a third mechanism of action that hinders the ability of bacteria to metabolize carbohydrates and produce acids.5 It can also hinder the ability of the bacteria to stick to the tooth surface.[8]

Fluoride and minerals, including calcium and phosphate, are present in saliva[6,8] and are stored in dental plaque. To halt the formation of tooth decay or rebuild tooth surfaces, fluoride must be constantly present in low concentrations in saliva and plaque.[6] Frequent exposure to small amounts of fluoride, such as that which occurs when drinking fluoridated water, helps to maintain the reservoir of available fluoride in saliva and plaque to resist demineralization and enhance remineralization.[6,9] In other words, drinking fluoridated water provides the right amount of fluoride at the right place at the right time. Fluoride in water and water-based beverages is consumed many times during the day, providing frequent contact with tooth structures and making fluoride available to fluoride reservoirs in the mouth. This helps explain why fluoride at the low levels found in fluoridated water helps to prevent tooth decay.[6]

How do I know its safe?

For generations, millions of people have lived in areas where fluoride is found naturally in drinking water in concentrations as high or higher than the optimal level recommended to prevent tooth decay. Research conducted among these persons overwhelmingly confirms the safety and efficacy of fluoride in the water supply. As with other nutrients, fluoride is safe and effective when used and consumed as recommended. No charge against the benefits and safety of fluoridation has ever been substantiated by generally accepted scientific knowledge. A number of reviews on fluoride in drinking water have been issued over the years. For example, in 19516 the National Research Council (NRC), of the National Academies, issued its first report stating fluoridation was safe and effective. Additional reviews by the NRC followed in 1977 and 1993 with the most recent NRC review completed in 2006.

Additional reviews completed over the ten year period from 2007- 2017 include:

  • 2017 Australian Government. National Health and Medical Research Council (NHMRC). Information Paper — Water Fluoridation: Dental and Other Human Health Outcomes.

  • 2016 O’Mullane DM, Baez RJ, Jones S, Lennon MA, Petersen PE, Rugg-Gunn AJ, Whelton H, Whitford GM. Fluoride and Oral Health.11

  • 2016 American Water Works Association. Water Fluoridation Principles and Practices. AWWA Manual M4. Sixth edition.

  • 2015 Water Research Foundation. State of the Science: Community Water Fluoridation.

  • 2015 The Network for Public Health Law. Issue Brief: Community Water Fluoridation. American Dental Association

  • 2015 Ireland Health Research Board. Health Effects of Water Fluoridation: An Evidence Review.

  • 2015 U.S. Department of Health and Human Services Federal Panel on Community Water Fluoridation. U.S. Public Health Service Recommendation for Fluoride Concentration in Drinking Water for the Prevention of Dental Caries.

  • 2014 Public Health England. Water Fluoridation: Health Monitoring Report for England.

  • 2014 Royal Society of New Zealand and the Office of the Prime Minister’s Chief Science Advisor. Health Effects of Water Fluoridation: a Review of the Scientific Evidence.

  • 2013 U.S. Community Preventive Services Task Force. The Guide to Community Preventive Services. Preventing Dental Caries: Community Water Fluoridation.

  • 2011 European Commission of the European Union Scientific Committee on Health and Environmental Risks (SCHER). Fluoridation.

  • 2008 Health Canada. Findings and Recommendations of the Fluoride Expert Panel.

  • 2007 Australian Government National Health and Medical Research Council A Systematic Review of the Efficacy and Safety of Fluoridation; Part A: Review Methodology and Results.

Misinformation and fear mongering

Since the dawn of the internet, there has been some concern surrounding the safety of fluoride, with some people claiming that it can cause a variety of health problems, including cancer, bone fractures, and neurological problems. There are even a very small percentage of dentists that will make claims like this about fluoride (and other areas of dentistry that we will save for another time), to strike fear into the hearts of patients to ultimately convince them to do unnecessary (and extremely expensive) work all in the name of being “holistic”. However, these claims have not been supported by scientific evidence. In fact, the overwhelming majority of research supports the safety and effectiveness of fluoride in preventing tooth decay.

It is important to note that like any substance, fluoride can be harmful if ingested in large amounts. Therefore, it is important to use fluoride products as directed and to keep them out of the reach of children, who may be more likely to accidentally swallow them.







More research if you aren’t tired of reading by now:

1. Centers for Disease Control and Prevention. Ten great public health achievements--United States, 1990-1999. MMWR 1999;48(12):241-3. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/00056796. htm. Accessed October 2, 2017.

2. Centers for Disease Control and Prevention. Achievements in Public Health, 1900-1999: Fluoridation of drinking water to prevent dental caries. MMWR 1999;48(41):933-40. Available at: https://www.cdc.gov/mmwr/ preview/mmwrhtml/mm4841a1.htm. Accessed October 28, 2017.

3. American Dental Association. Policy on fluoridation of water supplies. (Trans.2015:274) 2015. Available at: http://www.ADA.org/en/publicprograms/advocating-for-the-public/fluoride-and-fluoridation/adafluoridation-policy. Accessed October 28, 2017.

4. U.S. Department of Health and Human Services. Public Health Service. Surgeon General Vivek H. Murthy. Statement on community water fluoridation. Office of the Surgeon General. Rockville, MD. 2016. Available at: https://www.cdc.gov/fluoridation/guidelines/surgeons-generalstatements.html. Accessed October 3, 2017.

5. American Medical Association Water fluoridation H-440.972. 2011. In: American Medical Association Policy Finder. Available at: https://www. ama-assn.org/about-us/policyfinder. Accessed October 3, 2017.

6. American Academy of Pediatrics Section on Oral Health. Maintaining and improving the oral health of young children. Pediatrics 2014;134(6):1224- 9. Abstract at: https://www.ncbi.nlm.nih.gov/pubmed/25422016. Accessed October 28, 2017.

7. Petersen PE, Ogawa H. Prevention of dental caries through the use of fluoride--the WHO approach. Community Dent Health 2016;33(2):66-8.

8. Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579, 113, S.Ct. 2786 (1993).

9. McKay FS. Mottled enamel: the prevention of its further production through a change of the water supply at Oakley, Ida. J Am Dent Assoc 1933;20(7):1137-49.

10. McClure FJ. Water fluoridation: the search and the victory. Bethesda, MD: National Institute of Dental Research; 1970. Available at: https://www. dentalwatch.org/fl/mcclure.pdf. Accessed October 28, 2017.

11. Smith MC, Lantz EM, Smith HV. The cause of mottled enamel, a defect of human teeth. University of Arizona, College of Agriculture, Agriculture Exp. Station. Technical Bulletin 32. 1931:253-82.

12. Churchill HV. The occurrence of fluorides in some waters of the United States. Ind Eng Chem 1931;23(9):996-998. Available at: http://pubs.acs. org/doi/abs/10.1021/ie50261a007. Accessed October 28, 2017.

13. Dean HT. Chronic endemic dental fluorosis. JAMA 1936;107(16):1269- 73. Article at: https://jamanetwork.com/journals/jama/articleabstract/273186. Accessed October 28, 2017.

14. National Institute of Dental and Craniofacial Research. The story of fluoridation. Available at: http://www.nidcr.nih.gov/oralhealth/topics/ fluoride/thestoryoffluoridation.htm. Accessed September 4, 2017.

15. Dean HT. Endemic fluorosis and its relation to dental caries. Public Health Rep 1938;53(33):1443-52. Article at: https://www.jstor.org/ stable/4582632. Accessed October 28, 2017.

16. Dean HT, Arnold FA, Elvove E. Domestic water and dental caries: V. Additional studies of the relation of fluoride domestic waters to dental caries experience in 4,425 white children, aged 12 to 14 years, of 13 cities in 4 states. Public Health Rep 1942;57(32):1155-79. Article at: https:// www.jstor.org/stable/4584182. Accessed October 28, 2017.

17. Cox GJ, Matuschak MC, Dixon SF, Dodds ML, Walker WE. Experimental dental caries IV. Fluorine and its relation to dental caries. J Dent Res 1939;18(6):481-90.

18. Dean HT, Arnold Jr FA, Knutson JW. Studies on mass control of dental caries through fluoridation of the public water supply. Public Health Rep 1950;65(43):1403-8. Article at: https://www.ncbi.nlm.nih.gov/ pubmed/14781280. Accessed October 23, 2017.

19. Ast DB, Smith DJ, Wachs B, Cantwell KT. Newburgh-Kingston cariesfluorine study: final report. J Am Dent Assoc 1956;52(3):290-325.

20. Brown HK, Poplove M. The Brantford-Samia-Stratford fluoridation caries study: final survey, 1963. Med Serv J Can 1965;21(7):450-6.

21. National Research Council. Drinking water and health, Volume 1. Washington, DC: The National Academies Press;1977. Available at: https:// www.nap.edu/catalog/1780/drinking-water-and-health-volume-1. Accessed October 23, 2017.

22. National Research Council. Health effects of ingested fluoride. Report of the Subcommittee on Health Effects of Ingested Fluoride. Washington, DC: National Academy Press;1993. Available at: https:// www.nap.edu/catalog/2204/health-effects-of-ingested-fluoride. Accessed October 23, 2017.

23. National Research Council of the National Academies. Division of Earth and Life Studies. Board on Environmental Studies and Toxicology. Committee on Fluoride in Drinking Water. Fluoride in drinking water: a scientific review of EPA’s standards. Washington, D.C: The National Academies Press;2006. Available at: https://www.nap.edu/catalog/11571. Accessed October 23, 2017.

24. Australian Government. National Health and Medical Research Council (NHMRC). Information paper – water fluoridation: dental and other human health outcomes. Canberra. 2017. Available at: https://www.nhmrc.gov. au/guidelines-publications/eh43-0. Accessed October 23, 2017.

25. O’Mullane DM, Baez RJ, Jones S, Lennon MA, Petersen PE, Rugg-Gunn AJ, Whelton H, Whitford GM. Fluoride and oral health. Community Dent Health 2016;33(2):69-99. Abstract at: https://www.ncbi.nlm.nih.gov/ pubmed/27352462. Accessed October 3, 2017.

26. American Water Works Association. Water fluoridation principles and practices. AWWA Manual M4. Sixth edition. Denver. 2016.

27. Water Research Foundation. State of the science: community water fluoridation. 2015. Available at: http://www.waterrf.org/ PublicReportLibrary/4641.pdf. Accessed October 1, 2017.

28. The Network for Public Health Law. Issue brief: community water fluoridation. 2015. Available at: https://www.networkforphl.org/ resources_collection/2015/07/17/664/issue_brief_community_water_ fluoridation. Accessed October 2, 2017.

29. Sutton M, Kiersey R, Farragher L, Long J. Health effects of water fluoridation: an evidence review. 2015. Ireland Health Research Board. Available at: http://www.hrb.ie/publications/hrb-publication/ publications//674. Accessed October 28, 2017.

30. U.S. Department of Health and Human Services. Federal Panel on Community Water Fluoridation. U.S. Public Health Service recommendation for fluoride concentration in drinking water for the prevention of dental caries. Public Health Rep 2015;130(4):318-331. Article at: https://www. ncbi.nlm.nih.gov/pmc/articles/PMC4547570. Accessed October 24, 2017.

31. Public Health England. Water fluoridation: health monitoring report for England 2014. Available at: https://www.gov.uk/government/ publications/water-fluoridation-health-monitoring-report-forengland-2014. Accessed October 28, 2017.

32. Royal Society of New Zealand and the Office of the Prime Minister’s Chief Science Advisor. Health effects of water fluoridation: a review of the scientific evidence. 2014. Available at: https://royalsociety.org.nz/ what-we-do/our-expert-advice/all-expert-advice-papers/healtheffects-of-water-fluoridation. Accessed October 28, 2017.

33. U.S. Community Preventive Services Task Force. Oral Health: Preventing Dental Caries (Cavities): Community Water Fluoridation. Task Force finding and rationale statement. 2013. Available at: https://www. thecommunityguide.org/findings/dental-caries-cavities-communitywater-fluoridation. Accessed October 24, 2017.

34. Scientific Committee on Health and Environmental Risks (SCHER) of the European Commission. Critical review of any new evidence on the hazard profile, health effects, and human exposure to fluoride and the fluoridating agents of drinking water. 2011. Available at: http://ec.europa.eu/health/ scientific_committees/opinions_layman/fluoridation/en/l-3/index.htm. Accessed October 24, 2017.

35. Health Canada. Findings and recommendations of the fluoride expert panel (January 2007). 2008. Available at: http://www.hc-sc.gc.ca/ewh-semt/ pubs/water-eau/2008-fluoride-fluorure/index-eng.php. Accessed October 24, 2017.

36. Australian Government. National Health and Medical Research Council. A systematic review of the efficacy and safety of fluoridation. Part A: review of methodology and results. 2007. Available at: https://www. nhmrc.gov.au/guidelines-publications/eh41. Accessed October 24, 2017.

37. U.S. Department of Health and Human Services. For a healthy nation: returns on investment in public health. Washington, DC: U.S. Government Printing Office; August 1994. Available at: https://archive.org/details/ forhealthynation00unse. Accessed October 28, 2017.

38. U.S. Department of Health and Human Services. Oral health in America: a report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. Available at: https://profiles.nlm. nih.gov/ps/retrieve/ResourceMetadata/NNBBJT. Accessed October 28, 2017.

39. Burt BA. Fluoridation and social equity. J Public Health Dent 2002;62(4):195- 200. Abstract at: https://www.ncbi.nlm.nih.gov/pubmed/12474623. Accessed October 24, 2017.

40. Slade GD, Spencer AJ, Davies MJ, Stewart JF. Influence of exposure to fluoridated water on socioeconomic inequalities in children’s caries experience. Community Dent Oral Epidemiol 1996;24(2):89-100. Abstract at: https:// www.ncbi.nlm.nih.gov/pubmed/8654039. Accessed October 24, 2017.

41. Riley JC. Lennon MA. Ellwood RP. The effect of water fluoridation and social inequalities on dental caries in 5-year-old children. Int J Epidemiol 1999;28:300-5. Abstract at: https://www.ncbi.nlm.nih.gov/ pubmed/10342695. Accessed October 24, 2017.

42. Jones CM, Worthington H. The relationship between water fluoridation and socioeconomic deprivation on tooth decay in 5-year-old children. Br Dent J 1999;186(8):397-400. Abstract at: https://www.ncbi.nlm.nih.gov/ pubmed/10365462. Accessed October 24, 2017.

43. U.S. Department of Health and Human Services. A national call to action to promote oral health. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institutes of Health, National Institute of Dental and Craniofacial Research. NIH Publication No. 03-5303, May 2003. Available at: https:// www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/NationalCalltoAction/ nationalcalltoaction.htm. Accessed October 28, 2017.

44. Benjamin RM. Surgeon General’s Perspectives. Oral health: the silent epidemic. Public Health Reports 2010;126(2):158-9. Available at: https://www.ncbi. nlm.nih.gov/pmc/articles/PMC2821841. Accessed October 28, 2017.

45. Murthy VH. Surgeon General’s Perspectives. Community water fluoridation: one of CDC’s “10 Great Public Health Achievements Of The 20th Century.” Public Health Rep 2015;130(4):296-8. Article at: https://www.ncbi.nlm. nih.gov/pmc/articles/PMC4547574. Accessed October 28, 2017.

46. U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. HealthyPeople.gov. Healthy People 2020. About healthy people. Available at: https://www.healthypeople. gov/2020/About-Healthy-People. Accessed October 28, 2017.

47. U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. HealthyPeople.gov. Healthy People 2020. Topics and Objectives. Oral health objectives. Available at: https:// www.healthypeople.gov/2020/topics-objectives/topic/oral-health/ objectives. Accessed October 24, 2017.

48. Centers for Disease Control and Prevention. Community Water Fluoridation. Fluoridation statistics. 2014. Available at: https://www.cdc. gov/fluoridation/statistics/2014stats.htm. Accessed October 24, 2017.

49. Truman BI, Gooch BF, Sulemana I, Gift HC, Horowitz AM, Evans, Jr CA, Griffin SO, Carande-Kulis VG. Task Force on Community Preventive Services. Reviews of evidence on interventions to prevent dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries. Am J Prev Med 2002;23(1S):21-54. Abstract at: https://www.ncbi.nlm.nih. gov/pubmed/12091093. Accessed October 24, 2017.

50. Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of fluoride in preventing caries in adults. J Dent Res 2007;86(5):410-415. Abstract at: https://www.ncbi.nlm.nih.gov/pubmed/17452559. Accessed October 24, 2017.

51. Horowitz HS. The effectiveness of community water fluoridation in the United States. J Public Health Dent 1996;56(5 Spec No):253-8. Abstract at: https://www.ncbi.nlm.nih.gov/pubmed/9034970. Accessed October 24, 2017.

52. Buzalaf MAR, Pessan JP, Honorio HM, ten Cate MJ. Mechanisms of actions of fluoride for caries control. In Buzalaf MAR (ed): Fluoride and the Oral Environment. Monogr Oral Sci. Basel, Karger. 2011;22:97-114. Abstract at: https://www.ncbi.nlm.nih.gov/pubmed/21701194. Accessed October 24, 2017.

53. Garcia AI. Caries incidence and costs of prevention programs. J Public Health Dent 1989;49(5 Spec No):259-71. Abstract at: https://www.ncbi. nlm.nih.gov/pubmed/2810223. Article at: https://deepblue.lib.umich. edu/handle/2027.42/66226. Accessed October 24, 2017.

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56. Mariri BP, Levy SM, Warren JJ, Bergus GR, Marshall TA, Broffitt B. Medically administered antibiotics, dietary habits, fluoride intake and dental caries experience in the primary dentition. Community Dent Oral Epidemiol 2003;31(1):40-51. Abstract at: https://www.ncbi.nlm.nih.gov/ pubmed/12542431. Accessed October 24, 2017.

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58. Tinanoff N, Palmer CA. Dietary determinants of dental caries and dietary recommendations for preschool children. J Public Health Dent 2000:60(3):197-206. Available at: https://www.ncbi.nlm.nih.gov/ pubmed/11109219. Accessed October 24, 2017.

59. Marshall TA. Chairside diet assessment of caries risk. J Am Dent Assoc 2009;140(6):670-4. Abstract at: https://www.ncbi.nlm.nih.gov/ pubmed/19491162. Accessed October 24, 2017.