When folks share their concern about ending fluoridation, it’s often accompanied by the direst of predictions about what it would mean. A recent paper in JAMA Health Forum, for instance, states that we’d see 25 million more kids with cavities, almost $10 billion in extra treatment costs over five years, and overwhelmed dental offices that would struggle to meet demand.
Of course, that assumes that fluoride removal would happen in a vacuum. No increase in preventive education. No adoption of safer remineralizing agents such as hydroxyapatite or products containing cavity-preventers such as xylitol, erythritol, or arginine. No other changes at all.
And that’s just not how health systems work.
Instead of asking what would happen if we just subtracted fluoride, perhaps we’d do better to ask which combination of nontoxic strategies might best prevent decay.
Of course, we understand the concern that the authors of the Health Forum paper express about the impact of a fluoride-free world on children from low-income homes, who tend to be disproportionately affected by dental disease. Yet framing fluoridation as the main solution sidesteps a more important matter: the structural barriers that keep many families from getting the dental care they need.
Even that ignores an uncomfortable tension in the debate: Universal water fluoridation means that poorer communities may be less able to avoid exposure and the neurodevelopmental risks that recent research suggests it presents. Good water filters, fluoride-free hygiene products, and other alternatives can get expensive, after all.
Any concerns about neurotoxicity, though, are blown off by the authors as “misinformation” based on “poor scientific practices.” The authors claim that studies linking fluoride to lower IQ scores are “irrelevant” here in the US since they tend to focus on exposure levels above US standards.
Could they have really missed the systematic review and meta-analysis published earlier this year in JAMA Pediatrics? That review found inverse associations between fluoride exposure and children’s IQ scores across 74 studies – associations that showed as exposure went up, IQ went down.
When researchers looked at urinary fluoride levels (which reflect exposure from all sources, not just fluoridated water), those associations remained statistically significant even at levels similar to those we see in fluoridated communities in North America.
Sure, we could – and should – debate what these findings mean for public health policy, but simply dismissing them as “misinformation” does nothing to deepen conversations about it. It’s a move meant to silence those with differing views when we should all be thinking and talking more broadly about solutions to prevent decay.
And there are solutions to decay other than fluoride, many of which we’ve blogged about right here. Hydroxyapatite toothpaste, for one, has proven at least as effective as fluoride pastes, and it’s made from the actual mineral your teeth are made of. Eight-percent arginine toothpaste has proven to be more effective. Nutritional approaches that address the metabolic roots of decay can keep cavities from forming in the first place.
All these are evidence-based approaches that work with the body’s natural processes rather than relying on a single systemic universal intervention like water fluoridation.
The choice between fluoridation and decay is ultimately a false one, although we do face a choice about whether prevention should be universal and singular or personal and multifaceted; whether we rely on mid-20th century practices or incorporate newer evidence about alternatives.
These are legitimate questions worth debating, but that debate should be based on a realistic understanding of all the potential alternatives, not dire predictions that assume that if we stopped fluoridating, we’d do nothing else.
