Is fluoridated water a boost for public health, or bad for our children?  

Does anybody need fluoride supplements? If so, who?  

Why are manufacturers of toothpaste and mouthwash containing fluoride being forced to defend their advertising practices in court? 

Why is everyone talking about fluoride these days? Hasn’t fluoride already had its 15-minutes of fame? 

There is no question that fluoride has been back in the news ever since President Trump nominated Robert F. Kennedy Jr. to run the nation’s healthcare systems. RFK Jr., who holds very controversial opinions about vaccines, is vocal about wanting to eliminate fluoridation from the nation’s water systems, even though decisions about fluoridation are currently in the hands of state and local governments.  

And one couldn’t be blamed for questioning the water expertise of the guy who took his grandchildren for a Mother’s Day swim in DC’s Rock Creek, which doesn’t allow swimming because it is contaminated with bacteria from raw sewage. 

Meanwhile, there are six lawsuits in Illinois and California against Proctor & Gamble and Colgate Palmolive, the makers of Crest and Colgate products, charging them with leading children to ingest dangerous levels of fluoride. The Texas Attorney General has launched a full-scale investigation into the same companies over the same issue. And this week, the Food and Drug Administration (FDA) said it will conduct a scientific review of children’s fluoridated products by late October with the aim of removing them from the market. 

So, what has happened since the CDC declared fluoridated water to be one of the 20th century’s greatest public health achievements? How did fluoride go from hero to villain? 

A Splash of History 

In the mid1940s, the U.S. Public Health Service, alongside the American Dental Association and forwardthinking local health boards in Grand Rapids, Michigan, spearheaded water fluoridation at 1.0 milligrams per liter (mg/L). This 1945 pilot aimed to reduce rampant childhood cavities. The pilot was wildly successful, reducing children’s cavity rates by 60%. By 1950, other cities were adopting the 1.0 mg/L standard, and today, about 72% of the population is connected to fluoridated water supplies. 

Extra Benefits 

The cavity reduction in children was considered a critical achievement because of the increasing awareness of the ways our dental health affects our overall health. Dental disease doesn’t stay confined to the mouth. Persistent gum inflammation (periodontitis) can seed bacteria into our bloodstream, fueling systemic inflammation linked to heart disease, stroke, diabetes complications, and even adverse pregnancy outcomes. 

Additionally, it turns out that fluoridation is a budget booster. Cavity pain and related dental problems can result in missed work and school days. Water fluoridation helps prevent these issues, reducing absenteeism and its associated costs. Water fluoridation is also a great equalizer, reducing the dental health gap between lower-income and higher-income households. 

Then there are the savings on dental treatment. While the initial investment in fluoridation equipment and chemicals is significant, the long-term savings from reduced dental treatment costs outweigh the initial expenses. Studies consistently show a high return on investment for community water fluoridation, ranging from $20 to $38 saved for every $1 spent.  

Underwhelming Unintended Consequences 

With all interventions based on ingesting something, there is always the possibility of over-ingesting. Too much acetaminophen can cause severe liver issues. Too much hydration can cause kidney failure. Too much ingested fluoride can cause fluorosis, which results in tooth discoloration, enamel discoloration, and even some systemic problems like bone soreness and chronic pain when too much fluoride is ingested during a child’s formative years.  

Scientists have known about fluorosis since the early 20th century. But a person needs to ingest a ton of fluoride to develop the disease, and fluorosis has never been considered enough of a threat to override the benefits of fluoridated water. Still, the CDC has dropped its recommendation for the low end of optimal fluoridation to 0.7 mg/L. 

So, What Has Some People Rethinking Fluoridated Water Now? 

There are four questions that have some scientists reconsidering fluoridated water: 

• Does ingesting fluoride lower children’s IQ? 

• Does ingesting fluoride upset the gut microbiome? 

• Are the many toothpastes and mouthwashes now containing fluoride reducing the need for fluoridated water and pushing some of us over our safe fluoride limits? 

• Are the makers of dental hygiene products encouraging children to ingest unsafe levels of fluoride? 

None of these questions can be answered with a definitive yes (the last one will be settled in a variety of court cases), but they are not completely without merit. 

Fluoride and IQ. The connection between fluoride ingestion and IQ got attention during the late 20th century when researchers in China noticed that some villages had drinking water with very high fluoride levels. They gave IQ tests to children in the high-fluoride villages and compared them with the children in neighboring low-fluoride villages. The high-fluoride children consistently scored lower than the low-fluoride children. Most scientists today say those comparison studies were poorly done, and that there are lots of things besides fluoride that could be affecting any reported differences in IQ. But the consistency of the results raised concerns. 

Fast forward to 2016 when a Canadian scientist named Christine Till studied urine samples of pregnant women. Her team then looked at the IQ scores of the children when they were 3 or 4 years old, to see if there was some kind of link between fluoride in urine during pregnancy and cognitive performance. 

The study found that women with higher urinary fluoride measures during pregnancy were associated with slightly lower levels of IQ in boys, but not girls. 

The Canadian study, like the Chinese studies, showed a correlation between fluoride levels in the urine and a very slightly lower IQ, but did not prove that fluoride ingestion caused the decline. Still, the correlation damaged the reputations of fluoride and fluoridated water. 

Fluoride and the Microbiome. Scientists are discovering that the balance of bacteria in our gut has a huge effect on our health and well-being. Earlier this year, a systematic review in Nutrition Reviews looked at the effects of fluoride on the gut microbiota. The review found that while low-dose fluoride (≤ 2 mg/L) appears safe or even beneficial, high-dose fluoride (≥ 50 mg/L) consistently disrupts microbiota composition, leading to reductions in beneficial bacterial species and increases in potentially harmful ones.  

So, it is possible that high levels of fluoride can cause problems for babies and young children, but are we getting or giving our children too much fluoride?  

That’s a tough one. When municipalities started fluoridating their water, there were fewer products around that had added fluoride. Today it is found in toothpaste, dental floss, and mouthwash, as well as foods and beverages made with fluoridated water. But if you and your children are using your dental products properly, you should have no problem keeping your fluoride intake high enough to help, but well below unsafe levels. 

The One Thing Most of Us are Doing Wrong! 

It’s official! Almost everyone is using too much toothpaste. Manufacturers will not go out of their way to tell you this because if we use the correct amount they will sell less toothpaste. It had to be a print ad or TV commercial (or our mom, who saw an ad or commercial) that suggested we squeeze out enough toothpaste to cover a standard size toothbrush. But we should really be using about 1/3 of that amount. 

A pea-sized dollop (yep!) is the perfect amount of paste.

More Best Practices 

• Don’t swallow toothpaste or mouthwash (this should go without saying). 

• Tell your children not to swallow. Most parents will buy child-friendly toothpaste flavors to encourage children to brush their teeth. We’ll let the courts figure out if manufacturers are encouraging children to eat toothpaste. But it is up to parents to let children know it is not a good idea to do so, and to explain why. 

• Find out the level of fluoride in your local water. You can get a general idea at the CDC’s My Water’s Fluoride page. For specific, up-to-date information, check with your local water provider. Fluoride levels between 0.7 and 1.2 mg/L are considered normal. 

• If your local levels are too high, adjust your intake. If, for some reason, your local levels are high, consider buying toothpaste or mouthwash without fluoride, drinking bottled water, or investing in a water filter. Reverse osmosis and activated alumina filters are most effective for fluoride removal. 

• Stay away from fluoride supplements even if your local water has no fluoride. The State of Utah recently became the first state to ban fluoridated water, over the objections of local dentists and national health organizations. Some other municipalities around the country don’t fluoridate. Residents in those places should be sure to use fluoridated toothpaste and mouthwash but should try to stay away from fluoride supplements. As we regularly mention, supplements are unregulated. Since supplements are meant to be ingested, that’s where you could really get into trouble with fluoride. 
  
  

The Bottom Line on Fluoride and Fluoridated Water 

Fluoridated water has benefitted thousands of municipalities and millions of people for more than half a century. But taking a closer look at fluoridated water is most certainly not the worst water idea Secretary Kennedy has had lately.  

Meanwhile, it’s a good idea to understand how much fluoride you and your family are getting from your local water system, so you can adjust how much you are getting from other sources. When it comes to fluoride, you don’t need to worry but a little common sense goes a long way. And don’t swim in contaminated water.