Do We Have an Over-Fluoridation Problem or Not?

By Emma Yasinski


The most recent data from the National Health and Nutrition Examination Survey (NHANES) suggests that prevalence of fluorosis – markings  on the teeth caused by long-term exposure to excess fluoride – increased in children from the period 1999-2004 to 2011-2016. Anti-fluoridation advocates contend the data prove that U.S. water is over-fluoridated.

But many dentists were left scratching their heads over the findings.

Johnny Johnson, Jr., DMD, a pediatric dentist in Florida who heads a group that advocates for community water fluoridation, told Incisor he received a flurry of phone calls from dentists disputing the NHANES findings, saying that they have not observed any such increases in their practices.

Dr. Johnny Johnson, Jr.
Dr. Johnny Johnson, Jr.

Shortly after, the CDC published an analysis explaining the flaws in the NHANES survey methodology that led the work to suggest a dramatic increase in fluorosis, which, the CDS said, is not only unlikely but doesn’t make sense biologically.


Once fluorosis is present, it doesn’t progress; it doesn’t get better, nor does it get worse.


Severe dental fluorosis, which can damage enamel and put patients at risk for further tooth decay, is very rare in the U.S. The survey looked for signs of mild-to-moderate fluorosis which Howard Pollick, BDS, MPH, a dental professor of the University of California, San Francisco, and American Dental Association spokesperson, explained to Incisor, does not adversely impact health, but can be visible on the teeth.

Fluorosis happens when patients under the age of eight consistently consume too much fluoride, which can be found in tap water, toothpaste, mouthwash, and supplements. “It's not going to happen because you swallow a lot of fluoride one time,” said Dr. Pollick. Additionally, once fluorosis is present, it doesn’t progress; it doesn’t get better, nor does it get worse.

Dentists recognize fluorosis by identifying whitened spots on an individual’s teeth. Generally, these spots will show up on the same teeth on each side of the mouth, suggesting that the exposure occurred while those teeth were developing.

Dr. Howard Pollick
Dr. Howard Pollick

The NHANES survey is conducted every two years to assess various aspects of health, including fluorosis levels. It asks dentists to evaluate the teeth of patients in different age groups meant to be a representative sample of the overall U.S. population. 

In the most recent survey, NHANES reported notable increases in the prevalence of fluorosis.

However, there can be other reasons for the discoloration. Dr. Johnson explained that many conditions, including dehydration and celiac disease, can cause marks on teeth that look like fluorosis. Plus, the identification of mild-to-moderate fluorosis can be highly subjective.

The analysis by the CDC studied the data showing examinations from different dentists on the same patient’s teeth. The level of agreement ranged from “moderate” to “almost perfect.” But the scores that were shown for individual teeth showed greater variability.

“The difference in DFI [Dean’s Fluorosis Index] values for the same teeth assessed in the same way days apart, however, indicates the subjective nature of the DFI scoring method,” the study authors wrote.


“It's not biologically plausible to see that major of a shift in moderate to severe fluorosis as the data is showing from the NHANES” – Dr. Johnny Johnson”


Then, the researchers conducted a cohort analysis on the data from NHANES 2001–2004 and 2011–2014. The CDC found that 9.5 percent of 6-9 year-olds in 2001-2004 showed fluorosis, but when that same group was 16-19 years old in 2011-2014, the prevalence had increased to 46.9 percent. The CDC explained that the difference in fluorosis between age groups was not logical. Since fluorosis occurs in childhood and does not change in adulthood, the prevalence of fluorosis in the sample of children from the earlier survey should match the sample of adults in the later ones.

“It's not biologically plausible to see that major of a shift in moderate to severe fluorosis as the data is showing from the NHANES,” said Dr. Johnson.

There are some areas, mostly outside of the U.S. or where people drink well water, where rates of moderate to severe fluorosis are higher. Dr. Johnson explained these areas have fluoride levels of four to 16 milligrams per liter (mg/L) as opposed to the national U.S. average of one to three mg/L.

New methods may improve surveys going forward, but in the meantime, “I don't think dentists have to be concerned,” said Dr. Pollick. “If they see a child with dental fluorosis, then they should inquire, ‘where do you live? where are you drinking water?’” and adjust their recommendations accordingly.

Author: Contributing writer Emma Yasinski received her Master of Science (MS) in science and medical journalism from Boston University. Her articles have also appeared at, Kaiser Health News, NPR Shots, and Genetic Engineering and Biotechnology News.

Other Recent Incisor Articles by Emma Yasinski:

The information contained in this, or any case study post in Incisor, should never be considered a proper replacement for necessary training and/or education regarding adult oral conscious sedation. Regulations regarding sedation vary by state. This is an educational and informational piece. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 3250 Airport Way S, Suite 701 | Seattle, WA 98134. Please print a copy of this posting and include it with your question or request.
DOCS Membership

Upcoming Events
May 17- 18, 2024
Atlanta, GA skyline
August 23- 24, 2024
October 04- 05, 2024

More Articles