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Water fluoridation controversy returns



By Stacy Gittleman


On the shores of the Grand River in downtown Grand Rapids, just outside the JW Marriott Hotel, stands a five-ton, 33-foot-tall structure called Steel Water. It was commissioned by the city in 2007 to celebrate the 75th anniversary of an innovation that crowned Grand Rapids with the distinction of becoming the first city on the planet to fluoridate its public water supply in 1945.


At the time, the western Michigan city was seen as the ideal location to attempt fluoridation because of its large population of school-aged children, the fact that Lake Michigan had no sizable deposits of naturally occurring fluoride, and its location to Muskegon, which was the study’s control city. The striking results of improved dental health led the way to engineer optimal levels of fluoride in most of the nation’s public drinking water systems.


Community Water Fluoridation (CWF) is regarded by the Centers for Disease Control (CDC) as one of the 10 greatest achievements in public health in the 20th Century. The practice has reduced tooth decay in the United States by up to 60 percent, according to the American Dental Association (ADA). Globally, half the people on earth who benefit from this practice live in the United States.


After the success in Grand Rapids, the practice became a U.S. Public Health Service policy in 1951, and was widely implemented nationwide by 1960, resulting in further decreases in tooth decay. However, fluoridation of public water supplies is now becoming a point of contention, raising an age-old controversy most may had thought was laid to rest decades ago.


Margherita Fontana, DDS, PhD, is the Clifford Nelson Endowed Professor of Dentistry in the Department of Cariology, Restorative Sciences and Endodontics at the University of Michigan School of Dentistry and director of the Global Initiatives Program in Oral and Craniofacial Health at the School of Dentistry. She spoke with Downtown while attending a cariology research conference in Italy. Incidentally, all waters there are naturally optimally fluoridated for dental health.


Fontana said most of us cannot remember when most of our water was not fluoridated. Putting it bluntly, she said our teeth were in terrible shape.


“Go back 75 years ago, cavities were rampant and we had no idea how to prevent them,” Fontana said. “Many people would have dentures by the time they reached their early 20s. Not having teeth was one of the main reasons people could not join the army.”


Fontana reminded us to think about how much we rely on our teeth throughout the day.


“Teeth allow us to eat and attain the nutrition we need,” Fontana said. “When you smile, healthy teeth give you that self-esteem to go out into the world to socialize, get a job or date. Without teeth, speech becomes garbled because of how your tongue hits your teeth to pronounce words. The presence of teeth affects how your jaw is positioned and how your bite develops, among many other benefits.”


Fontana added that tooth decay causes some of the most excruciating pain a person can endure, is expensive and sometimes impossible to effectively treat, and gives dentists no pleasure to have to treat it.


She continued: “Fixing teeth that are in decay is extremely difficult,” Fontana said. “Plus, the economic ramifications can be detrimental to the patient. The mouth is connected to the rest of the body, so it is clear that cavities have a big impact on our general health and wellbeing.”


With that said, Fontana and many dentists interviewed maintained that in 2024, there is still no better, cost-effective and equitable way to approach dental health and prevention of tooth decay than Community Water Fluoridation, or CWF.


Yet the practice is not completely foolproof. If one eats a lot of sugary treats, does not regularly brush their teeth twice a day, or takes medication that makes one’s teeth prone to decay by interfering with saliva production, you can still get cavities – just not as many as if your water was not fluoridated.


“If you want to make sure that everyone benefits the same way, you don’t want disparities, community water fluoridation is the way to go,” Fontana emphasized.


A mineral deposit, fluoride occurs naturally in water. The Great Lakes have a consistent level of 0.3 to 0.5 parts per million (ppm) of fluoride.  Ocean water is consistent at 1.2 to 1.4 ppm because fluoride has an ionic bond with sodium.


According to the CDC, the mineral helps to rebuild and strengthen the teeth from the bacteria from carbohydrates in our food which interact in our mouths and form enamel-eating acid.


When a public water utility fluoridates its water, that means it is treating it to reach an optimal level between 0.7 to milligrams of fluoride per liter (mg/L) of water, or seven ppm, to 1 mg/L. Drinking fluoridated water is most important during pregnancy, infancy and childhood through the teen years when human teeth are in their bud, baby and adult phases of development. 


In 2015, the CDC changed its optimal recommended level of fluoride concentration in water from 1.2 mg/L or 1.2 ppm to a range between 0.7 mg/L, or seven parts per million as an optimal balance between the prevention of dental caries – commonly known to non-dental professionals as cavities – and the risk of fluorosis, an overexposure to the mineral. Water operators closely monitor and adjust these levels daily. According to the CDC, over 214 million Americans, or 74.7 percent of the U.S. population, live in communities that supply fluoridated water.  


Community Water Fluoridation (CWF) offers a lot of bang for the buck in terms of community health. Every dollar spent on CWF saves the average dental patient around $38 in treatment costs per year, not to mention debilitating pain and suffering. But there are very specific standards for all ages, as excessive fluoride can be harmful, as well.


According to the National Institutes of Health (NIH), these are the daily recommendations of fluoride by age group: Birth to six months: .7 mg; infants seven to 12 months: .9 mg; children 1-3 years: 1.3 mg; children 4-8 years: 2.2 mg; all age nine years through adulthood: 10 mg, including pregnant and breastfeeding women: 10 mg.


In a separate set of limits, as of now, the U.S. Environmental Protection Agency (EPA) has set a maximum contaminant level goal (MCLG), and enforceable maximum contaminant level (MCL) for fluoride at 4.0 milligrams per liter (mg/L) or .4 ppm. The EPA’s secondary maximum contaminant level, a non-enforceable standard, is set at 2.0 mg/L. The MCL was developed to prevent skeletal fluorosis, a bone disease caused by too much fluoride leading to weakened bones, and the secondary MCL was set to mitigate dental fluorosis, faint white lines or streaks on teeth in young children caused by too much fluoride.


Under the Safe Drinking Water Act, the EPA is currently reviewing its National Primary Drinking Water Regulation. As a part of this review, the EPA will be considering the best available information, peer-reviewed science and data before deciding whether or not to update the fluoride drinking water regulations and will announce the outcome later this year.


That’s not to say that CWF cannot be, and isn’t, a controversial topic. Though drinking fluoridated water in pregnancy, infancy and childhood carries lifelong benefits, it has little effect on developed adult teeth. Also, by the 1970s, the availability of fluoridated products, from toothpaste to mouthwashes and rinses became widespread, making the practice of fluoridating the water to some seem like overkill.


Just as the public has begun to question the need for another public health marvel – vaccines – so goes the debate about fluoride in water.


All researchers will tell you that one or two studies compared to a mountain of decades worth of studies should not quickly sway public policy. But in recent years, a few studies have raised the brows of the established dental profession and caught the eye of political contenders, conspiracy theorists and established researchers alike.


Fontana said most European countries fluoridate their water. If they don’t, they have much better access to dental care than those in the United States. Diet – like limiting sweets – is also a big aspect of life for many Europeans.


“There’s a wide way to prevent cavities. Fluoride is not the only way. However, if one does not control their sugar intake and has a lot of sweets and soft drinks and you don’t have access to dental care, then much thought must be put into delivering preventative services in the U.S.,” Fontana said.


She also pointed to the mountain of data from decades of studies by respected institutions, from the National Institutes of Health (NIH) to the American Dentistry Association (ADA). For example, in a 2022 NIH study, there was a rapid rise in tooth decay in Juneau, Alaska. That city stopped water fluoridation in 2007, and previous research found an increase in dental caries-related procedures and treatment costs for children from low-income families in Juneau between 2003 and 2012.


In comparison, the study collected data from the same period on the dental health of children in Anchorage, where water fluoridation remained consistent. Notably different from children in Juneau, between 2003 and 2012, children in Anchorage experienced a nonsignificant modest decrease in the number of cavities they had.


If we have nearly 80 years of evidence that show the rate of cavities in childhood drastically decreased with the widespread practice of fluoridated drinking water – just look into the mouths of young ones today compared to those in their 40s and 50s for proof – then why the sudden cause for concern?


For starters, too much of a good thing can be harmful.


Excessive fluoride exposure in childhood or even in pregnancy can make one susceptible to a condition known as fluorosis. It mostly shows up with mottling of the teeth – white spots that are so tiny the only people who can detect them are dentists. Often this happens when people may have ingested fluoridated toothpaste when they were little. That’s why children are instructed by their dentists and hopefully their caregivers not to swallow, but rather spit out, toothpaste after brushing.


Though this condition is mostly cosmetic, researchers from the Middle and Far East, where fluoride is naturally found at high levels due to the natural mineralization of the water, have found evidence of skeletal fluorosis which can lead to fragile bones.


However, a few studies have grabbed the attention of the same population of anti-vaxxers and conspiracy theorists who objected to the Covid vaccines and other childhood vaccines. After a Harvard professor testified in court in January that fluoride may be a neurotoxin, he posted on social media in February 2024 that if he became president, he would do all in his power to “order the CDC to take every step necessary to remove neurotoxic fluoride from American drinking water.” 


In April 2016, the Harvard T.H. Chan School of Public Health published an article in its journal: “Is Fluoridated Water Safe?” The article pointed to 2015 findings of the Cochrane Collaboration – a global independent network of researchers and healthcare professionals known for rigorous scientific reviews of public health policies – which published an analysis of 20 key studies on water fluoridation. They found that while water fluoridation is effective at reducing tooth decay among children, “no studies that aimed to determine the effectiveness of water fluoridation for preventing caries [cavities] in adults met the review’s inclusion criteria.”


The article graphed cavity rates in 12-year-old children in countries around the world from 1975 to 2012 and found that on average, cavity rates declined regardless of the fluorination of their water systems. 


The article mentioned how in 2015, the United States for the first time in 53 years reduced its recommended levels of the mineral in drinking water because excessive fluoride “causes fluorosis – changes in tooth enamel that range from barely noticeable white spots to staining and pitting. Fluoride can also become concentrated in bone – stimulating bone cell growth, altering the tissue’s structure, and weakening the skeleton.”


It continued: “Perhaps most worrisome is preliminary research in laboratory animals suggesting that high levels of fluoride may be toxic to brain and nerve cells. And human epidemiological studies have identified possible links to learning, memory, and cognition deficits, though most of these studies have focused on populations with fluoride exposures higher than those typically provided by U.S. water supplies.”


Philippe Grandjean, then an adjunct professor of environmental health at Harvard, concluded that while fluoride is beneficial for dental development and protection against cavities, further research needs to be conducted regarding whether it should continue to be added to drinking water supplies if it is entering the bloodstream and then the brain. 


The article was overwhelmingly slammed by many alumni of the Harvard Dental School, as well as leaders of the American Dental Association, the American Association for Dental Research, the American Dental Education Association, the American Academy of Pediatrics, and many other leaders in public health, pediatrics and oral health. They found the article so misleading regarding the safety of fluoride that they demanded a full retraction of the article. 


It remains on the school’s website to this day. 


In letters published with the article, critics said it was filled with misleading and incorrect statements. They wrote that the writers failed to reach out to any oral health experts, including those working next door at the Harvard School of Dental Medicine. They stated that it was false to state that the United States lowered its recommended levels of fluoride in drinking water without clarifying that the guidance changed a 1962 Drinking Water Standard recommendation from a range of 0.7 ppm to 1.2 ppm to a point recommendation of 0.7 ppm. 


The letter writers wrote: “The same guidance also reaffirmed that community water fluoridation remains an effective public health strategy for delivering fluoride to prevent tooth decay, and is the most feasible and cost-effective strategy for reaching entire communities.” 


Though he was not familiar with the controversial article, Dr. Steven Spitz, DMD, an alumnus of the Harvard School of Dental Medicine who has also been a leader in the Boston dental community, has been a clinical professor of Prosthodontics in the Department of Post-Graduate Prosthodontics at Harvard University School of Dental Medicine, is a big believer in fluoride and CWF.


In Boston, the water is fluoridated at .7 ppm, but there are outlying communities such as Worcester and Springfield with no CWF, and that is where he sees a higher incidence of tooth decay in his patients. One of the biggest proponents of the merits of fluoride interviewed, Spitz said all his patients, many from a wealthier income bracket, receive fluoride varnish treatments as a routine part of their dental checkups. The varnish makes adult teeth less prone to cavities, minimizes the bacterial population around their gums and offers three months of protection. Spitz cautions that taking fluoride supplements – whether that be in a pill form or one’s water, is only effective for the younger population to help their growing and developing tooth buds. 


“Ninety percent of our patients completely understand the value of fluoride,” Spitz said. “We know there is a huge positive effect on the dental health of children from a scientific and epidemiological standpoint.  In Boston, we know that patients living in towns that do not fluoridate their water can be four times as susceptible to caries as those who put fluoride in the water. Why would a community not fluoridate their water when we have so much research? I am sure the reasons can be financial, and sometimes they are political. But if you have a water supply to a lower income, it does not make any sense not to fluoridate the water.” 


When it comes to news of eliminating optimized fluoride in waters of European countries, Spitz said this is something they will soon come to regret. 


“I think they’re making a big mistake, and a lot of their kids are going to see a major epidemic of cavities,” he said.


In May 2024, the Journal of the American Medical Association (JAMA) released a study entitled Maternal Urinary Fluoride and Child Neurobehavior at Age 36 Months. It looked at whether prenatal fluoride exposure is associated with neurobehavior in children based on studying the prenatal urine sample records from 2017 to 2020 from 229 predominantly Hispanic women living in Los Angeles when they were pregnant and then observed around 32 of these children from birth through three years. Researchers concluded that prenatal fluoride exposure may increase the risk of neurobehavioral problems among children living in an optimally fluoridated area of the United States.


Written by public health, medical and dental researchers from the University of Florida, Gainesville, University of Southern California, Los Angeles, and Indiana University, the study concluded that prenatal fluoride exposure was associated with increased neurobehavioral problems. These findings suggest that there may be a need to establish recommendations for limiting fluoride exposure during the prenatal period.


In response, the American Dental Association (ADA) released a statement that disparaged the findings and unnecessary alarm bells about having fluoride in drinking water. The ADA stated: “The study is not nationally representative and has several limitations including a small sample size from one population group in one U.S. city. Also, the study did not measure the actual consumption of fluoridated water.”


The ADA said the JAMA study should be considered exploratory and decisions to change a public health precedent that has stood for decades should not be swayed by one single study. The ADA maintained that it has not seen any peer-reviewed research that would change its long-standing recommendation to the public to brush twice a day with fluoride toothpaste and drink optimally fluoridated water.


Gathering up consensus opinion against the study is Dr. Hector Chapa, MD, FACOG, clinical assistant professor at Texas A&M University and staff ob-gyn for Texas A&M University Student Health Services. In a recent episode on his Clinical Pearls podcast released on May 21, “Fluoride in Drinking Water Harmful in Pregnancy? Fake News of Real Foe?” Chapa unpacked the findings of the study and gathered opinions of research leaders as to why leaders from the American Dental Association, American Academy of Pediatrics, the CDC, the EPA and major independent think groups viewed this study as “much ado about nothing.”


He said a much wider 2023 study from Australia, where 90 percent of water is fluoridated, followed a much larger population of children (2,682) from birth to age five, and it showed no effect on neurocognitive development.


While there are lots of contaminants in our water supply, from forever chemicals to excessive pharmaceuticals, Chapa said naturally occurring and highly regulated added levels of fluoride is­ not one of them.


“High doses of fluoride can damage teeth and be associated with other negative health outcomes, but you would have to drink a ton of water for it to be dangerous,” Chapa pointed out. “In utero, the amount of fluoride that passes from the mother to the fetus through the placenta and embeds in the child is about 0.01%.”


Like most researchers, Chapa said that this is just one study and rash decisions to cease CWF nationwide would do more harm than good. He concluded that the study did not consider “multifactorial” elements that could also be attributed to neurodevelopmental issues such as nutritional, environmental, infectious, family history, and epigenetic changes that would offer a full spectrum for a study.


“To say that issues in neurodevelopment are completely, absolutely, the fault of fluoride is false. Coming to a conclusion against fluoride based on this one study cannot be done,”


Chapa continued. “These findings merely suggest that more research needs to be conducted to establish recommendations for limiting fluoride exposure during the prenatal period. You can try to limit fluoride during pregnancy, but to say we should remove it from all drinking water would be a disaster.”


But toxicologist Linda Birnbaum, a retired scientist and former director of the National Institute of Environmental Health Sciences (NIEHS) and the National Toxicology Program, reviewed the study and said it is a valid one.


“I believe the study focused on a large enough sampling of the population of the United States, and it’s coming up with the same kind of results that have been seen in multiple other studies from Canada, Mexico, and China,” Birnbaum said. “The study indicates that fluoride can be hazardous to the developing brain. Fluoride can be applied topically at a dentist’s office, and that is how it works to prevent cavities. One should not have to ingest it (in water).”


Birnbaum continued: “Yes, putting fluoride in water does ensure that everyone in a population has fluoride exposure, but it also affects the developing fetus and an infant. And we are learning that this fluoride is not just going to our teeth, it is impacting brain development.”


Birnbaum believes that more research needs to be conducted in addition to the JAMA study, and public health and dental professionals should be promoting the use of fluoridated toothpaste, which has fluoride levels between 1000-1500 ppm, and fluoride rinses/swishes instead of relying on fluoridated drinking water, implement fluoride rinse/swish programs for children in daycares and schools instead of fluoridating all drinking water.


While the United States is largely guided by the pro-fluoride opinions of public health and dentistry experts, other places in the world, especially Europe, are trending away from the practice.


According to a 2002 report from the Fluoride Action Network, an anti-fluoride advocacy group, 98 percent of Western Europe had rejected engineered fluoridation. As of 2020, countries that do not add fluoride to their water include Austria, Belgium, Denmark, Finland, France, Germany, Iceland, Italy, Luxembourg, Netherlands, Norway, Sweden, the majority of Switzerland (97 percent) and the majority of the United Kingdom (90 percent).


The reasons to opt out vary. The opinion in Germany and Belgium is that unnaturally fluoridating the water is akin to “compulsory medication.”


Some water systems in Europe are too antiquated and populations are spread too thinly to accommodate fluoridation mechanics, and some areas already have fluoride in their waters suitable for protecting teeth.


Some of these countries prescribe fluoride salt or special milk supplements to infants and children.


Still, countries continue to fluoridate their water including Britain, Spain and Ireland.

And let’s not forget that for most Europeans, dental care is free and widely available. From a nutrition perspective, Europeans consume less processed sugary snacks and beverages than Americans.


U of M’s Fontana described, for example, approaches to pediatric dental care in northern Europe. “There are free, intensive programs where children are assigned to nurses and other medical professionals who closely care for them from birth through their childhood,” Fontana said. “They care not only for their general health but for their oral health as well.”


According to CDC statistics from 2020, Michigan ranks 16th in the nation in terms of the percentage of residents receiving optimally fluoridated water. The Michigan Department of Health and Human Services (MDHHS) states that Michigan is not mandated to fluoridate all its water, but 90 percent of the state’s population is served by CWF. Each municipality considering the practice has cast it to a vote or it is the decision of the local government.


Areas that do not fluoridate their water supply include Cadillac, Gladwin, Three Rivers, Iron Mountain and Saugatuck. According to information from the CDC’s Community Water Fluoridation website, most mobile home communities in Michigan do not fluoridate their water. 


According to the MDHHS, those drawing water from private wells should test them annually with a partial water chemistry test they can obtain from the local health department to check for fluoride levels. Mineral tests cost between $18-124. The sample is mailed to a State of Michigan lab and results are sent back to the individual.


In Oakland County, Waterford Township’s population of about 6,500 receives non-fluoridated water from municipal wells. The township in its latest consumer confidence report has listed fluoride as a contaminant and stated:“Some people who drink water containing fluoride more than the maximum contaminant level over many years could get bone disease, including pain and tenderness of the bones. Children may get mottled teeth. The Department of Public Works treatment process does not add fluoride to its finished water. However, fluoride occurs naturally in groundwater.”


Referring residents to its 2023 fluoride levels, the report said that the wells tested contain between .39 - .56 ppm of fluoride, which is below the optimal minimum of .7 ppm to protect teeth. Waterford water officials in their report advised residents to consult with their healthcare provider for fluoride supplement recommendations.


Downtown reached out to several Waterford dentists about how they advise their patients, but none responded to requests to comment.


MDHHS runs several programs to promote dental health. It provides fluoridation incentive programs to children and offers grants to municipalities to pay for fluoridation equipment. MDHHS runs “Varnish Michigan!” – a program intended to train more oral health providers and technicians who can work with underprivileged children to monitor their oral health with the intent of reducing caries in children ages 0-5.


In 2020, “Varnish Michigan!” reported that from October 2019 - September 2020, in children ages 0-5, 6,015 children were screened with 5,326 requiring a varnish application; 196 children had been previously treated for tooth decay; 359 had active and untreated tooth decay; 397 had some white spotting which could be evidence of fluorosis; and 1,660 were referred for further dental care.


Compare those numbers to pre-pandemic 2019, when 12,983 were screened; 11,822 required a fluoride varnish treatment; 475 children had been previously treated for tooth decay; 782 had active and untreated tooth decay; 1,513 had some white spotting which could be evidence of fluorosis and 3,573 were referred for further dental care.


The report did not indicate the percentage of children who lived in areas with CWF.


For 25 years, April Stopczynski of the Michigan Dental Association (MDA) has advanced dental health access and knowledge for patients and providers in the state.


“Community water fluoridation is the most equitable way to distribute fluoride, as not everyone has dental coverage or access to a dental office,” Stopczynski said. “Dentists in non-fluoridated communities will evaluate the circumstance of the patient’s exposure to other fluoride sources, and then make a recommendation about fluoride supplements, which can be beneficial for everyone from children and especially seniors.”


Stopczynski said other options would be topical applications during regular checkups or prescribing toothpaste or rinses with higher doses of fluoride.


Stopczynski said the following states mandate that all its public water systems are regulated to contain optimum levels of fluoride for tooth decay prevention: Illinois, California, Delaware, Georgia, Kentucky, Louisiana, Minnesota, Mississippi, Nebraska, Nevada, Ohio and South Dakota.


Stopczynski said the MDA works to dispel misconceptions about fluoride in communities, sharing data from recognized health organizations such as the World Health Organization, American Medical Association, American Academy of Pediatric Dentistry, American Academy of Pediatrics and the American Dental Association. 


“Sometimes, a decision to fluoridate water comes down to a measure on a ballot,” Stopczynski said. “There is a lot of misinformation out there when it comes to fluoride, and we want to make sure the public has an educated voice when the time comes to vote on it. The MDA connects vulnerable populations to local dentists so they can have conversations with trusted professionals. They can tell people firsthand the difference they see in their patient’s dental health when they live in areas that are fluorinated versus non-fluoridated.” 


For example, in 2014, the Boyne City Council de-fluorinated its water.  A group of citizens and health professionals from the area mobilized to get the issue on the ballot and voters approved the re-instatement of fluoridation. Stopczynski said over the past 10 years, about six other municipalities in Michigan put fluoride on the ballot and voters supported fluoridating by over two-thirds or more. 


The MDA as well as Lynn Sutfin, spokeswoman for the Michigan Department of Health and Human Services, state that contrary to the misconception, many Europeans are still drinking fluoridated water. 


“Europe has not moved on from fluoridation,” Sutfin said. “Ireland, the UK, parts of Spain, Poland, Serbia and others use community water fluoridation reaching 13 million people. Many other countries such as Austria, France, Germany and other countries use fluoridated salt reaching over 70 million people. Bulgaria, England, Hungary, Russia and Scotland also use fluoridated milk. Many of these countries have wells and do not have the water system infrastructure that the United States has.” 

 

Dr. Mark Birnholtz, DMD, served his patients in West Bloomfield for over 30 years. He places skepticism towards fluoride in the same bucket as conspiracy theorists who do not believe in vaccines. When it comes to widespread, accessible and preventative dental health practices, nothing holds a candle to fluoride, he affirmed. 


“There is enough data that shows that when you compare two communities that have no (added) fluoride in their water to those that had high levels of fluoride in their water, the rate of tooth decay in the areas with no fluoride was incredibly high. And when people had high levels of fluoride, at four parts per million, fluorosis showed up cosmetically, as tiny white spots on teeth,” he said.


Birnholtz said that eventually, health experts found that levels between .7 and 1 parts per million were ideal levels of fluoridation. And for the patients he had who did not have water at those levels, he observed a noticeable difference. 


“Patients who came to me who lived on wells that had low or no naturally occurring fluoride visibly had a more significant decay issue than by other patients who were drinking municipal fluoridated water,” he noted.


For patients on well water, especially toddlers and children aged up to 18, Birnholtz followed ADA recommendations to prescribe fluoride supplements in droplet form for infants and chewable tablets in varying doses to children up to ages 16 or 18, depending on the extent of their vulnerability. Often, his patients would already have a prescription from their pediatricians.


On very rare occasions, he would give a fluoride treatment to an adult patient, but fluoride treatments were not a regular part of his practice. 


“That fluoride (in water) is especially important in a child’s formative years, when the baby teeth and then eventually the adult teeth, from the crown to the roots, are forming,” explained Birnholtz. “There is no need to provide teens with fluoride treatments after age 16 or 18 because the real benefit of that fluoride is in the formation of the teeth. There is a frivolous notion that by drinking fluoridated water (as an adult) you are bathing your teeth in it, but that (one part per million) is not going to have any effect as far as the surface of their teeth is concerned. I believe that when a person gets that fluoride in their drinking water, from age zero to 16 years old, it benefits the person’s dental health for the remainder of their life.” 




Dr. Paul Darmon, DDS, has been a dentist for 39 years and currently has a practice in Beverly Hills. His attitude towards extra fluoride treatments or supplements for his patients has been changing, as in the last decade or so he has seen evidence of fluorosis manifesting in tiny white spots on their teeth. 


He is not sure of the reason for the increase in this mainly cosmetic condition. Darmon, who has decreased his practice of offering fluoride treatments or prescribing fluoride supplements, said it could be from ingesting too much toothpaste as a child or receiving high levels of fluoride in one’s drinking water, or a combination of both. 


Still, the benefits of fluoride must be weighed against the risks, especially for patients with more advanced decay,he said. 


“One must always weigh the risks versus benefits, and I would imagine that overdosing on fluoride would certainly have a negative effect, but there are a million things we do not know. As dental professionals, what we do know is that fluoride makes tooth enamel harder and more resistant to decay,” Darmon said. “For patients who are averse to fluoride or do not have fluoridated water, I just advise them that they are at higher risk for decay. Let’s also remember that some people are more genetically susceptible to tooth decay, have a diet of sugary or processed foods, or are taking medication which puts them more at risk.” 


Darmon said that fluoridated water is not a catchall to preventing cavities. In some instances he has seen children patients who had a cavity developing, the tooth mineralized over the cavity, perhaps due to the fluoridated water, making the cavity more difficult to detect. 


“In cases of hidden decay that are not even detected with an x-ray, we have developed advanced techniques such as infrared laser imaging and AI assistance to help us if we suspect hidden decay,” he said.


Darmon said fluoridated water is not completely foolproof if kids are not drinking tap water but opting for bottled water, sugary beverages or sports drinks. Moreover, Darmon said there is a trend across the country that is looking to reverse fluoridation mandates and stop the practice of optimizing levels altogether. 


For example, in March of 2024, the nonprofit nonpartisan newsroom Stateline reported that lawmakers in Georgia, Kentucky and Nebraska filed bills that would reverse their states’ mandates and leave the choice up to a local voter referendum or to the governing body of local water systems. Maine, New Hampshire and Utah each require a public vote for fluoridation by municipalities and their public water systems. Hawaii has banned the practice altogether. The report said health experts scoffed at the reversal, blaming it on increased skepticism toward science and public health measures – exacerbated by the mask and vaccine mandates during the pandemic.


“I think this may be a trend or an attitude that is coming on the horizon,” Darmon said  “But I would think it would need to be backed up with the right amount of research that would prove that there are detrimental (health effects) happening because of fluoride. But then again, if we eliminate community fluoridation, down the road, we may be looking at rampant dental disease.”

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