The Dentist’s Role Amidst the Waning Public Trust in Water Fluoridation

By Genni Burkhart, Incisor Editor

Fluoride, long regarded as a cornerstone of public oral health, has increasingly become a focus of intense debate. In August, a report from the Department of Health and Human Services' National Toxicology Program linked high levels of fluoride exposure (notably in Canada, India, Iran, China, Mexico, and Pakistan) to reduced IQ in children, fueling further confusion and concern around this contentious issue.

Understanding this discussion is crucial for dental professionals, not only because of the implications it may have on public perception but also because of the potential impact on patient care.

Water Fluoridation Across America

Water fluoridation, the process of adding fluoride to public water supplies, began in the United States in Grand Rapids, MI, on January 25, 1945. The Centers for Disease Control and Prevention (CDC) has since named water fluoridation one of the top ten public health achievements of the 20th century due to its role in reducing cavities by 25% in children and adults.

The Fluoride Action Network has compiled a list that ranks the states, including the District of Columbia, based on the percentage of people served by community water systems that provide fluoridated water using CDC data. For context, the list also includes the density of dentists per 100,000 people (as of 2013) and the percentage of people who visited a dentist or dental clinic within the past year (as of 2014).

Cognitive Development Concerns

Despite its known benefits, recent studies, along with public mistrust and misleading claims, have brought the safety of fluoride under increased scrutiny, specifically regarding its impact on cognitive development.

Moreover, a growing body of research suggests that excessive fluoride exposure may be linked to lower IQ levels in children. This issue gained substantial attention in 2019 when a study published in JAMA Pediatrics reported that higher levels of fluoride exposure in utero were associated with reduced IQ scores in children ages 3 to 4.

In May of this year, another JAMA study on fluoride exposure during pregnancy and its potential link to neurobehavioral issues in children found that women with higher fluoride levels during pregnancy later reported their children experienced headaches, stomachaches, temper tantrums, and other neurobehavioral issues by age 3.

The potential neurotoxic effects of fluoride have led to an increase in legal battles and public debates. For instance, a federal court case in the United States is examining whether the Environmental Protection Agency (EPA) should regulate fluoride levels in drinking water more strictly. Proponents of stricter regulation argue that the current fluoride levels may not adequately protect children from potential neurodevelopmental harm.

The Scientific Consensus

However, the scientific community remains divided on the issue. While some studies suggest a link between fluoride exposure and reduced IQ, others have found no significant association, even a decline in pediatric oral health due to lack of fluoridation.

A critical review published in Nature in July highlights this ongoing controversy. The authors note that many studies suffer from methodological flaws, such as small sample sizes or failure to account for confounding factors. They argue that more rigorous research is needed before definitive conclusions can be drawn about the safety of fluoride in drinking water.

Furthermore, many public health organizations, including the CDC, the World Health Organization (WHO), and the American Dental Association (ADA), continue to support water fluoridation as a safe and effective measure to prevent dental caries. They emphasize that the levels of fluoride used in public water supplies in the U.S. are well below the threshold that could cause harm. These organizations argue that the benefits of preventing tooth decay, which can lead to severe health problems if untreated, far outweigh the potential risks.

Providing Context

For context, The U.S. Public Health Service (PHS) recommends a fluoride concentration of 0.7 milligrams per liter in public water systems. In comparison, WHO advises a maximum limit of 1.5-2 milligrams per liter for fluoride in drinking water.

In an August USA Today article by Ken Alltucker, Howard Pollick, a professor at the University of California, San Francisco, and a fluoride expert with the ADA, states, "For the average person, there is no concern based on the recent federal report." However, Pollick explains that a small percentage of "excessively fluoridated" public water systems in the U.S. could pose a risk to children.

Under EPA guidelines, water providers are required to notify the public when fluoride levels exceed the threshold.

Implications for Dental Professionals

The debate has several important implications for dental professionals. Primarily, it underscores the need for clear, evidence-based communication with patients. As public awareness of the fluoride debate grows, patients are more likely to voice their concerns over the safety of fluoride, both in drinking water and in dental products, with you.

Dental professionals should be prepared to address these concerns by discussing the current evidence, emphasizing the proven benefits of fluoride for oral health, and clarifying the differences between fluoride exposure from water and that from dental products. It's also essential to stay informed about the latest research and developments in this area, as new findings could influence public health recommendations and patients' habits.

Discussion and even discourse often promote advancements in modern healthcare. If nothing else, the fluoride debate highlights the importance of personalized dental care. When recommending fluoride use, dentists should consider patients' risk factors for dental caries, such as their overall fluoride exposure, diet, and oral hygiene habits.

For instance, fluoride toothpaste and professional fluoride treatments may be even more critical in communities where water is not fluoridated or patients have limited access to dental care. However, in areas where the water fluoridization is higher than 0.7 milligrams per liter, pregnant and breastfeeding women or young children might be advised to drink filtered water.

As experts are divided and conflict remains, over 1,500 towns and communities across North America have voted to exclude fluoride from their public water supplies. As a dentist, you may be treating patients affected by these decisions. Consider the patient’s oral health and readiness to engage in discussions to address this topic effectively. Promoting patient education and science-based health literacy could be the first step for some patients.

In Conclusion

The ongoing debate over fluoride in drinking water presents challenges and opportunities for dentists and hygienists.

While the potential risks associated with fluoride exposure are under increased scrutiny, fluoride use also has established benefits. By staying engaged in transparent, evidence-based communication with patients, dental professionals can continue to promote oral health while addressing the evolving concerns surrounding fluoride use.

This balanced approach will ensure patients receive the best possible care, grounded in the latest scientific-based knowledge while maintaining public trust in dental practices and preventive measures.

To learn more about what’s lurking in our water supplies, check out The Incisor's recent feature on PFAS, or "forever chemicals." These persistent pollutants, now found in the blood of nearly every American, are at the center of growing concern and numerous class action lawsuits against corporations for contaminating public drinking water.

UPDATE: On September 24th, a federal judge in California ordered the U.S. Environmental Protection Agency (EPA) to strengthen fluoride regulations in drinking water under the amended Toxic Substances Control Act (TSCA). The judge cited potential risks to children's brain development at the current level of 0.7 mg/L. Learn more here.

Author: With 14 years as a published journalist, editor, and writer, Genni Burkhart's career has spanned politics, healthcare, law, business finance, technology, and news. She resides in Northern Colorado, where she works as the editor-in-chief of the Incisor at DOCS Education.

References:

1. Green R, Lanphear B, Hornung R, et al. Association Between Maternal Fluoride Exposure During Pregnancy and IQ Scores in Offspring in Canada. JAMA Pediatr. 2019;173(10):940–948. doi:10.1001/jamapediatrics.2019.1729
2. Malin AJ, Eckel SP, Hu H, et al. Maternal Urinary Fluoride and Child Neurobehavior at Age 36 Months. JAMA Netw Open. 2024;7(5):e2411987. doi:10.1001/jamanetworkopen.2024.11987
3. Ramasubbu, D., Lewney, J. & Duane, B. Investigating the effectiveness of water fluoridation. Evid Based Dent (2024). https://doi.org/10.1038/s41432-024-01032-4
4. Science. (2023). "Does Fluoride in Drinking Water Lower IQ? The Question Looms Large in Court Battle." [Science Article](https://www.science.org/content/article/does-fluoride-drinking-water-lo…)
5. Undark. (2024). "Fluoride in Drinking Water: Balancing Public Health Benefits and Potential Risks." [Undark Article](https://undark.org/2024/03/06/fluoride-drinking-water/)