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Fluoride: A Nuanced Discussion on Its Role in Dental Health
- Beth Rosellini
- Mar 28
- 11 min read
Fluoride has long been heralded as a cornerstone in the fight against dental decay, with its addition to public water supplies considered a significant public health achievement. However, the narrative surrounding fluoride is complex, encompassing a rich history, ongoing controversies, and evolving scientific insights. This is my attempt to consolidate and summarize the most pertinent arguments around this. If you have questions or want to discuss further, please email us at admin@doradodentalwellness.com .
A Brief History of Fluoride Use
The practice of water fluoridation began in the United States in the 1940s, aiming to reduce dental caries (tooth decay) among the population. By the 1950s and 1960s, many communities had adopted this measure, influenced by studies suggesting a decline in cavities. However, even during its inception, fluoridation faced opposition from various groups concerned about potential health risks and ethical implications.
The Controversy: Systemic vs. Topical Fluoride
Before delving into the risks and benefits of fluoride, it is essential to distinguish between systemic fluoridation and topical fluoride application.
Systemic Fluoride refers to fluoride ingested through fluoridated water, foods, beverages, or supplements. The controversy surrounding systemic fluoride stems from its classification as a neurotoxin, endocrine disruptor, and environmental toxin, with growing research linking high fluoride exposure to cognitive decline and other health concerns.
Topical Fluoride includes fluoride-containing toothpaste, mouth rinses, and professional applications. Studies suggest that topical fluoride can enhance enamel resistance to acid attacks and reduce cavity formation. However, the long-term effects on the oral microbiome remain largely unexplored.
While fluoride’s antimicrobial properties help combat harmful bacteria, they are non-selective, potentially disrupting beneficial oral flora that play a crucial role in maintaining oral health. The key question is: At what cost?
Scientific Scrutiny and Evolving Perspectives
The scientific community continues to scrutinize the efficacy and safety of fluoride. Notable findings include:
Neurotoxicity: Recent studies have raised alarms about fluoride’s potential impact on neurodevelopment, particularly in children. High-quality research indicates that excessive fluoride exposure may be associated with a reduction in IQ levels, comparable to the effects observed with lead exposure.
Endocrine Disruption: Fluoride has been identified as a potential endocrine disruptor, interfering with thyroid and hormonal functions, which can lead to metabolic and developmental issues. It induces oxidative stress, apoptosis, and inflammation in endocrine tissues. It causes changes in the level of hormones released from endocrine tissues and changes in the morphology of endocrine tissues.
Cavity Prevention: The Cochrane Collaboration, renowned for its rigorous reviews, found that water fluoridation results in a reduction of approximately one cavity per four individuals—a statistic that some argue lacks significant public health impact.
Global Trends: Countries like Japan, which do not fluoridate their water, have some of the lowest cavity rates globally. This observation suggests that factors beyond fluoridation, such as diet and oral hygiene practices, play crucial roles in dental health.
Dental and Skeletal Fluorosis
While mild dental fluorosis may appear as faint white streaks on teeth, moderate to severe cases can lead to brown discoloration, surface irregularities, and even pitting of the enamel—ultimately compromising the strength and aesthetics of the teeth. Beyond cosmetic concerns, skeletal fluorosis is a more serious condition resulting from prolonged high fluoride intake, where fluoride accumulates in bones over time. This can cause joint stiffness, pain, and in advanced cases, calcification of ligaments and skeletal deformities. Risk factors for developing fluorosis include high consumption of fluoridated water (especially in hot climates or among athletes), swallowing fluoridated toothpaste, and excessive intake of tea or certain pharmaceuticals that contain or interact with fluoride. With fluoride now found in multiple sources—water, food, dental products, and industrial emissions—the risk of chronic overexposure is higher than ever, especially for vulnerable populations like infants and young children.
“Approximately 65% of adolescents aged 12–19 in the United States show some level of dental fluorosis.”
— CDC, National Health and Nutrition Examination Survey (NHANES), 2011–2016
The Halo Effect of Fluoride Exposure
The halo effect refers to the unintended and widespread ingestion of fluoride from multiple sources beyond just drinking water. Even if a community does not fluoridate its municipal water supply, its residents can still consume fluoride through processed foods and beverages made in fluoridated areas. For example, a soda manufactured in a fluoridated city and sold in a non-fluoridated area still contains fluoride, creating a “halo” of exposure.
This means that people may be unknowingly consuming fluoride through:
Bottled drinks (soda, juice, tea, coffee, etc.)
Packaged foods processed with fluoridated water
Toothpaste (especially if swallowed)
Certain pharmaceuticals
Black and green tea (naturally high in fluoride)
As a result, total fluoride exposure can significantly exceed intended limits, especially for infants, children, and individuals with high fluid intake (like athletes or people living in hot climates). This undermines the assumption that a specific fluoridation level in tap water equals a safe or optimal dosage.
EPA Guidelines: Designed for Risk, Not Benefit
The Environmental Protection Agency (EPA) sets maximum contaminant levels (MCLs) for fluoride in drinking water based on toxicological data—that is, how much fluoride causes harm over time. These guidelines are aimed at preventing adverse health outcomes, such as skeletal fluorosis or bone fractures, and do not consider the amount of fluoride required to prevent cavities.
Importantly, EPA’s limits are not health goals or therapeutic recommendations. They represent a threshold of “not likely to cause harm” rather than an amount proven to optimize dental health. So when fluoride is added to water supplies for the stated purpose of reducing cavities, it uses an exposure level just below the risk threshold—not a dosage proven safe or necessary for all individuals, especially considering total fluoride intake from all sources.
The Misleading “25% Reduction in Cavities” Claim
A common pro-fluoride claim is that community water fluoridation reduces cavities by 25%. However, this statistic is outdated and has been challenged by modern research methodologies. Here’s why this claim is problematic:
Cochrane Review (2015) – This highly respected systematic review analyzed only the highest-quality studies on water fluoridation. It found that most of the studies showing cavity reduction were conducted before the widespread use of fluoride toothpaste and other fluoride sources. When controlling for modern fluoride exposure from non-water sources, the impact of water fluoridation was significantly smaller—in some cases, as little as one cavity reduction per four people over years, which was not considered clinically significant.
Confounding Factors – Many older studies did not account for variables like diet, income, access to dental care, or the presence of other fluoride sources. This weakens the causative link between water fluoridation and cavity reduction.
Secular Trend Confusion – Tooth decay rates began declining in many countries—including those that never fluoridated their water—due to better nutrition, oral hygiene, and increased dental awareness. Yet fluoridation was credited for this broader public health improvement.
Improper Statistical Interpretation – The 25% figure often refers to a relative reduction rather than an absolute reduction. For example, reducing the average number of cavities from 4 to 3 is a 25% relative reduction, but the absolute difference is only one cavity per person—which may not justify mass medication of a population.
If water fluoridation is so good, then why aren't other vitamins & minerals added to the water supply "in the interest of public health"?
If one were to argue logically for adding a nutrient to water for the sake of public health, a few candidates might surface — but all raise the same ethical, medical, and logistical concerns as fluoride. Here are some that have been considered or proposed:
Magnesium
Why it might make sense: Over 50% of people are estimated to be deficient, and it's critical for muscle function, neurological health, and over 300 enzymatic processes.
Why it doesn’t work in practice: Like with fluoride, individuals absorb magnesium differently, and excess intake can cause diarrhea or imbalances. Some forms (like magnesium sulfate) are water-soluble, but dosing remains a challenge.
Folate (Vitamin B9)
Why it might make sense: Prevents neural tube defects in pregnancy and supports methylation processes. Folate deficiency is common, especially in people with MTHFR gene mutations.
Why not water?: Already added to flour in many countries. Risk of masking B12 deficiency and interfering with methylation pathways in sensitive individuals. Again, dosage would be uncontrolled.
The Core Problem
Even when a nutrient is essential and deficiency is widespread, the logic of putting it in water fails at the point of consent, dosage precision, and context. Different people have different:
Needs (e.g. a child vs. a pregnant woman vs. an athlete)
Genetics (e.g. MTHFR polymorphisms, vitamin D receptor mutations)
Exposure levels (via food, supplements, environment)
Risks (e.g. kidney disease, metabolic disorders)
Water is consumed by everyone, every day, without control over the dose — which makes it a problematic delivery system for any nutrient or compound meant to modify biology.
Where is the FDA in all of this?
The FDA has never approved fluoride supplements as safe and effective through its standard New Drug Application (NDA) process. Fluoride tablets were grandfathered in before modern drug approval laws and are only “marketed” legally, not fully FDA-approved.
Surprisingly, the FDA does not regulate fluoride in drinking water — that’s under the jurisdiction of the Environmental Protection Agency (EPA).
The EPA sets the Maximum Contaminant Level (MCL) and the Maximum Contaminant Level Goal (MCLG) for fluoride in water, based on toxicity thresholds rather than health benefits.
The fluoride used in water fluoridation (typically fluorosilicic acid or sodium fluorosilicate) is considered an industrial additive, not a drug — and thus escapes FDA oversight.
For virtually all vitamins, minerals, and supplements, the FDA (Food and Drug Administration) is the regulatory body — not the EPA (Environmental Protection Agency). Fluoride is a unique case.
Fluoride is not classified as a nutrient by the FDA when used in public water systems. Instead:
It’s treated as a water treatment chemical regulated by the EPA, just like chlorine or lead.
When it's in toothpaste, tablets, or drops, it is regulated by the FDA as a drug.
This dual regulation — drug when ingested intentionally (like tablets), but industrial additive when added to water— is unprecedented for something with systemic biological effects.
🚨 No other vitamin, mineral, or nutrient is regulated by the EPA.
The EPA regulates pollutants, contaminants, and water additives.
It does not regulate substances used to enhance health — that’s the FDA’s role.
⚠️ Why this matters:
This regulatory inconsistency means fluoride bypasses the safety and efficacy standards that would apply if it were being used like a nutrient or drug. This has led to growing concern among health professionals and researchers who question why fluoride is the only biologically active compound intentionally added to water with the goal of treating human tissue, but without FDA oversight.
Fluoride That’s Effective Topically
✅ Most effective topical forms for remineralization and early cavity reversal:
Sodium fluoride (NaF)
Common in over-the-counter toothpaste and prescription gels.
Strengthens enamel and can help reverse early (non-cavitated) lesions.
Often combined with calcium and phosphate to enhance efficacy.
Stannous fluoride (SnF₂)
Offers both anti-caries and antimicrobial properties.
Used in some toothpastes and rinses (e.g., Crest Pro-Health).
Can stain teeth over time but effective at reducing sensitivity and biofilm.
Fluoride varnish (usually 5% NaF)
Professionally applied.
Strong evidence for use in children and high-risk adults to prevent and arrest caries.
📌 How it works: These fluorides work by helping the enamel reabsorb minerals and become more acid-resistant. They also slow down bacterial metabolism, reducing acid production.
Fluoride Used in Systemic Water Fluoridation
💧 Types commonly added to public water supplies:
Fluorosilicic acid (H₂SiF₆)
Sodium fluorosilicate (Na₂SiF₆)
Sodium fluoride (NaF) — less common due to cost
These compounds are industrial byproducts, often derived from phosphate fertilizer production.
📌 Important distinction: These forms are ingested systemically, not applied directly to the tooth. Any topical benefit from drinking fluoridated water occurs only during consumption (as water passes over the teeth), and very little of it reaches the teeth in a therapeutically significant way — especially in adults.
⚖️ Summary Comparison:
Fluoride Form | Delivery Method | Main Use | Effectiveness in Cavity Reversal |
Sodium fluoride (NaF) | Topical (toothpaste, varnish) | Enamel strengthening | ✅ High (but with undesireable side effects) |
Stannous fluoride (SnF₂) | Topical (toothpaste) | Anticaries, antimicrobial | ✅ High (but with undesirable side effects) |
Fluorosilicic acid | Systemic (water fluoridation) | Mass public health strategy | ⚠️ Limited topical benefit |
Sodium fluorosilicate | Systemic (water) | Same as above | ⚠️ Limited |
The 17-Year Gap: From Research to Clinical Practice
A critical aspect of the fluoride debate is the lag between emerging scientific evidence and its integration into clinical practice. On average, it takes about 17 years for research findings to influence standard medical procedures. This delay can result in prolonged endorsement of practices that newer evidence may deem less effective or potentially harmful.
More specifically, we often have patients inquire about the ongoing support of water fluoridation by professional entities such as the American Academy of Pediatric Dentists and the American Dental Association. These entities can be a great source of information; however, they are also large, bureaucratic organizations who are slow to update paradigms and also receive considerable funding from corporations that may have a vested interest in perpetuating claims that fluoride is the best and only solution.
What to Do If Your Dentist Recommends Fluoride for Everyone
If your dentist still recommends fluoride for all patients or supports water fluoridation without nuance, ask thoughtful questions:
“Are you familiar with the recent findings from the National Toxicology Program?”
“How do you assess individual risk before recommending fluoride?”
“What alternatives do you offer for remineralization?”
“Do you consider the impact of fluoride on the oral microbiome or overall health?”
It’s okay to seek a second opinion. A progressive, evidence-informed dentist should be open to conversation and willing to tailor recommendations to your unique needs—not rely on outdated, one-size-fits-all protocols.
A Patient-Centered Approach: Educating on Risks, Benefits, and Root Causes
While fluoride, particularly in its topical form, may offer short-term benefits in preventing decay, it is crucial to educate patients on its potential risks and long-term impact on the oral microbiome. Fluoride should not be viewed as a universal solution but rather as an option with clear trade-offs.
Patients should be supported in understanding the root causes of dental decay & safer/more effective alternatives, such as:
Nutritional Interventions: Addressing deficiencies such as vitamin D and magnesium is vital. Modern diets often lack essential nutrients due to soil depletion and consumption of processed foods, contributing to dental issues.
Oral Microbiome Balance: Supporting beneficial oral bacteria while mitigating harmful strains can prevent decay. This approach emphasizes the importance of a balanced oral microbiome in maintaining dental health.
Breath and Hydration: Encouraging nasal breathing over mouth breathing and ensuring adequate hydration are simple yet effective measures to support oral health.
Innovative Remineralization Agents: Biomimetic materials such as hydroxyapatite, calcium-phosphate compounds, theobromine, and xylitol offer promising alternatives to fluoride for strengthening tooth enamel.
Environmental and lifestyle factors (e.g., processed food consumption, high sugar intake, and exposure to emulsifiers and surfactants in commercial oral care products)
As an example, if a very young patient (<3 years old) presents with evidence of generalized decay, the family can be educated on identifying and resolving the root causes as well as the risks and benefits of different treatment options which could include using silver diamine fluoride and/or proceeding with restorative treatment under a variety of different anesthetic options. Of course, it is preferred to never have to use these therapeutic interventions because of them introduce a risk/benefit ratio that is not as desirable as prevention. Our role as your clinical care team is to be up-to-date on all of the information available and relevant to provide this patient family with a comprehensive picture so that they can make the best decision for their child.
For further consideration, when we are optimizing for longevity and thinking about "the whole patient", it's important not to have blinders on. As another example, when I have a 4 year old female patient with caries, I want to find the root cause and address that. I do not think it serves that child well to have the EPA be the leader in her care, and possibly set her up for an increased risk of precocious puberty (due to the cumulative endocrine disruption caused by environmental toxins) nor do I want to increase risk for osteopenia or osteoporosis. This patient would be best served to address the nutritional deficiencies, the habits or lifestyle, or whatever other root causes that are contributing to her condition at this age so she can live a life with optimized health, and even more importantly, with the knowledge and the philosophy of "healthcare" that will keep her healthy the rest of her life. And this approach only positively benefits her, her family, and her community.
Final Thoughts
The fluoride debate is nuanced and requires a personalized approach to dental care. While systemic fluoridation presents significant health and ethical concerns, topical fluoride remains a debated option, particularly regarding its effects on the oral microbiome. Fortunately, patients today have access to a range of alternative, biomimetic, and holistic strategies to support long-term oral health.
At Dorado Dental Wellness, we prioritize informed consent, education, and individualized care to ensure our patients make the best decisions for their health. By focusing on the root causes of oral disease and utilizing the latest scientific insights, we empower patients to achieve optimal dental wellness—fluoride-free or otherwise.
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