My Personal Harm

Unpacking Truth

…..from fluoride.

I write this newsletter in an effort to inform, not to alarm. My intention is not to stir controversy but to bring awareness. I serve a broad patient population, with many desiring to minimize their exposure to the growing burden of toxins in our environment. There is no magic bullet to our health.  It is a complex interplay of how we eat, sleep, think and live our lives.   My goal is to offer information that will help you achieve your wellness goals. I am honored for the experience to be a voice in the dental community and I welcome your inquiries in the comments below.

Water Fluoridation

Water fluoridation is claimed to be one of the top 10 health interventions of the 20th century. Until about three years ago, I believed this with all my heart even after personally experiencing harm from an overconsumption of fluoride as a child. All of my anterior teeth (the ones you see when you smile) came in with a hideous white and brown stain that made me embarrassed and afraid to smile. My father, now a retired dentist, explained to me that this was a result of the fluoride tablets I had consumed as a child. We lived rurally and drank well water. Dad was a recent graduate of dental school and he was passionate about the benefits of fluoride to protect his daughter's teeth from cavities. It would only be years later, as my permanent teeth erupted, that he recognized the amount of fluoride recommended damaged his daughter’s teeth.

Instead of seeing fluoride as a potential toxin that could damage my teeth, I just thought I had too much of a good thing. My logic was, if fluoride was dangerous, why would the ADA and all of my dental school professors continue to recommend the substance in water, in toothpastes, in mouthwash and in fluoride treatments with little to no guidance on overexposure? Plus, anyone who saw fluoride as anything other than the savior of teeth was considered tin foil hat wearing. It became quite clear to me, at an early age, there is certain ‘science’ you don’t question.

Exposure to fluoride from water consumption has been demonstrated to reduce tooth decay by about 25% . This is a relative risk reduction potential, the actual risk reduction is closer to 1%. The original studies that demonstrated evidence that water fluoridation was beneficial for reducing tooth decay were not blinded and therefore prone to bias (side note: all studies are prone to bias and this can be reduced by a double-blinded study). You may be asking, isn’t a cavity a cavity, how could there be bias? Believe it or not, diagnosing tooth decay is somewhat subjective! I often joke that you could visit 10 different dentists, receive 9 different treatment plans and 8 of those plans would be valid based on your finances and your dental goals. But when determining a public health intervention an unblinded study could introduce bias into the dentists’ judgement of what is and is not tooth decay. This understanding makes it a lot easier to comprehend why the decrease in decay seen around the world runs parallel between countries that do and don’t fluoridate their water.

Fluorosis

Back to my ugly smile… I was diagnosed with the condition known as dental fluorosis (seen in the photos below). Dental fluorosis is a condition that causes brown or white staining of teeth due to an overexposure of fluoride. It can only occur in teeth that are developing, usually affecting children eight years and younger but the damage will not be recognized until all permanent teeth have erupted. Some will wave this condition off as purely cosmetic and not harmful to the individual’s health. There is  disagreement amongst qualified researchers about  (here, here, here and here) the toxicity of cumulative fluoride exposure. I wish my profession was demanding the high powered (expensive) studies to determine these risks. Unfortunately, ad hominem attacks are how most of dentistry approaches anyone who questions the efficacy and safety of fluoride.  With a growing number of Americans questioning fluoride, I fear my profession may suffer a decrease in trust from the public if we don't open respectful scientific conversations.

In 2015, the surgeon general lowered the amount of fluoride in our public water by nearly 40% over what had been practiced since the 1960s. One of the reasons for the change in this guidance was the increasing presentation of dental fluorosis amongst children and teens in America.

It is well known that a beautiful smile not only affects our personal self image but it also impacts what others thinks of us. Research has demonstrated that children affected by fluorosis are more likely to suffer from poor self esteem. These children are also more likely to be viewed by their peers as less attractive, less intelligent, less happy and less social. Fluorosis may seem like just a minor amount of tooth discoloration but the social impact on these teenagers may have a deleterious effect on their overall wellbeing. Most children are not fortunate enough to have a father that can fix their embarrassing smile. Additionally, the repair to an unattractive smile caused by an overexposure to fluoride is expensive and cost prohibitive for many families. 

The above photo is of mild to moderate fluorosis. Something that is more common than I would like to see in my patient population.

The above photo is moderate to severe fluorosis. Less commonly seen, thankfully!

Latest Research

A new research study was published by USC and it points to an entirely different aspect of potential harm…neurotoxicity. The neurotoxic effects of fluoride have been long understood and as we all know, the dose makes the poison. In fact, the 2024 fluoride lawsuit that took place in California was presenting this point. Some wish to dismiss the results of the NTP Monograph because the studies included were done in other countries…Mexico, Canada and China. The USC study is the first study completed in America.

Researchers at Keck School of Medicine at USC analyzed 229 mother-child pairs by collecting fluoride samples during pregnancy and an assessment of child behavior at age 3. What the researchers discovered is that a very small increase in urine fluoride levels (0.68mg/L) was associated with a nearly double the chance that the child demonstrated neurobehavioral problems.

These population-level findings add to existing evidence from animal studies showing that fluoride can harm neurodevelopment, as well as data from studies conducted in Canada, Mexico and other countries showing that prenatal exposure to fluoride is linked with a lower IQ in early childhood.

The researchers hope the new findings help convey the risks of fluoride consumption during pregnancy to policymakers, health care providers and the public.

"This is the first U.S.-based study to examine this association. Our findings are noteworthy, given that the women in this study were exposed to pretty low levels of fluoride—levels that are typical of those living in fluoridated regions within North America," said Ashley Malin, Ph.D., an assistant professor of epidemiology at the University of Florida's College of Public Health and Health Professions and College of Medicine and lead author of the present study.

The are certainly limitations to this study and many in the business of supporting fluoride doubled down on their position.

“There is nothing about this study that alarms me or would make me recommend that pregnant women stop drinking tap water.” said Dr. Patricia Braun, a professor of pediatrics at the University of Colorado and a spokesperson for the American Academy of Pediatrics.

A Question of Ethics

Fluoride is not a vitamin. It is not necessary for any bodily function. There are no known conditions caused by a lack of fluoride in one’s diet. Fluoride is a medical/dental intervention and with this, there should be guidelines for daily exposure from water, from toothpaste, from foods and from prescription meds. When any patient starts on a medication, age and weight are considered for dosing. We have no medicine that is a one size fits all, no drug that we prescribe without specific guidance and there is NO MEDICATION that is safe for EVERYONE.

The precautionary principle is obfuscated when fluoride is added to drinking water.  Since we are unable to we control how much water people drink, we cannot control the level of fluoride people are exposed to.  Is it OK for office employees to consume just 1 liter of water/day but employees in construction drink 3-5x that per day because of working in the summer heat? What about child athletes vs those who don’t compete? Is it OK that some children consume 2-4x as much water as their peers?

One of the compelling arguments used in Europe against adding fluoride to water comes from the Nuremberg Trials after WWII. These trials led to the Nuremberg Code that established the individual’s right to refuse medical intervention. Most reading this can afford to buy bottled watered or install expensive reverse osmosis water filtration systems. But those who are most harmed are the poor, the ones fluoride proponents argue stand to benefit.

What Do I Recommend

I believe there needs to be a broader discussion by dentists about actions patients can take to promote dental health. Since oral health is tightly tied to overall health, there are opportunities to encourage conversations that may reduce the burden of metabolic disease being seen in this country. The dental profession has a front row seat in the battle of illness in America and we should be advocating for more consistent conversations with patients about eating a diet of organic, whole foods. Patient should also be reminded to avoid foods that promote decay (aka processed foods), they should be informed that mouth breathing and sleep apnea establishes an oral environment prone to decay and patients should be discouraged from sipping sodas, coffee and flavored waters that lead to the acidic dissolution of enamel. A hurdle to these discussions for most dentists is that insurance companies do not reimburse for nutritional counseling. But, insurance companies do reimburse for fluoride treatments. The convenience and ease of this has been our default and sadly I think this has been at the expense of the overall health of our patients.

My prior view of tooth decay was to see an opportunity to recommend fluoride as a treatment to a condition.  My evolving view is that decay is a symptom of a much more serious systemic problem that should be addressed with education and encouragement.  Treating with fluoride as a means to an end is ignoring the broader health issues and negating efforts to improve patient health.

My recommendations (for dental fluoride exposure):

1. Pregnant mothers: if you’re able to avoid municipal water, do so. Drink water that is bottled at the source or investigate home treatment systems that remove unwanted toxins.

2. Newborns: breastfeed whenever possible. If using formula be sure to use distilled or filtered water.

3. Toddlers: be sure to use a toothpaste that is FLUORIDE free because of the risk of your child swallowing. Again, considered bottled/filtered water for consumption.

4. Children: depending on your comfort level of fluoride exposure you could use a pea sized amount of traditional toothpaste. If you’re avoiding fluoride consider the more natural remineralizing agent calcium phosphate/hydroxyapatite. We have these products available at my office.  There are many other products that can be found in grocery stores and online. Consider bottled/filtered water for consumption. Fluoride treatments at the dental office should be considered on the basis of the individual patient need. In the absence of clinical disease, I would recommend declining fluoride treatments.

5. Teens/Adults: if using a fluoridated toothpaste, you only need a pea sized amount and you want to be sure to rinse well with water when finished to minimize swallowing excess. If you select a natural toothpaste, consider one with calcium phosphate/hydroxyapatite as your remineralizing agent.