Intended for healthcare professionals

Rapid response to:

Clinical Review ABC of oral health

Dental damage, sequelae, and prevention

BMJ 2000; 320 doi: (Published 24 June 2000) Cite this as: BMJ 2000;320:1717

Rapid Response:

Fluoride Not The Answer

Holt et al give commendable diet and lifestyle recommendations to
prevent tooth decay(1). However, their fluoride recommendations may do
more harm than good.

Fluoride overdose is widespread in both fluoridated and non-
fluoridated communities(2)at the same time the United States Surgeon
General dubbed oral disease a silent epidemic in his recent Oral Health

In the world’s most fluoridated country, where fluoride toothpastes
are 95% of the market and where dental fluorosis rates are growing, the US
youngest and poorest children (ages 2-5 and living below the poverty
level) have almost 5 times as much tooth decay as children of higher
income families (>300% poverty) according to the National Institute of
Dental Research. (4)

In fact, after over 50 years of water fluoridation, many children in
Newburgh, New York, have more cavities and more dental fluorosis than
children in never-fluoridated Kingston, NY(5). Newburgh and Kingston are
the experimental cities that helped launch fluoride into the water systems
that 62% of Americans now drink. Today, researchers recommend children cut
back on fluoride.(6)

The poorest oral health in the US is found among non-Hispanic blacks,
Hispanics, and American Indians and Alaska Natives(3). However, many of
these populations already live in fluoridated communities according to the
US census and US fluoridation census.

“Bleeding gums, impacted teeth and rotting teeth are routine matters
for the children I have interviewed in the South Bronx (one of the US
poorest areas),” writes Jonathan Kozol in 'Savage Inequalities.' Children
get used to feeling constant pain...I have seen children in New York
(City) with teeth that look like brownish, broken sticks. I have also seen
teen-agers who were missing half their teeth. But to me, most shocking is
to see a child with an abscess that has been inflamed for weeks and that
he has simply lived with and accepts as part of the routine of life.”

New York City has been fluoridated since the late 1960s. Kozol’s book
was published in 1991.

It’s not unusual for dentists to recommend more fluoride when the
literature suggests less. Connersville, Indiana, children were studied and
found to already ingest more than sufficient fluoride through their food,
beverages and dental products(6). Nonetheless, dentists still successfully
lobbied the town legislators to fluoridate it’s water supply increasing
children’s dental fluorosis risk unnecessarily. (“Indiana Vote Focuses on
Fluoridation, “Associated Press 10-31-1999 & “Indiana Town OKs
Fluoridated Water,” AP, 2-28-00). This happens often all over the US while
80 percent of the poorest youngsters do not receive dental care because
few dentists will take Medicaid patients (3)

The World Health Organization ranks the US 24th in healthy life
expectancy because of the “miserable standards among the US poor” (NY
Newsday, 6/5/2000). Over 11% of US poor children go hungry most days (7).
The most cavity prone populations are also the least healthiest.
Malnutrition has been associated with Early Childhood Caries (ECC)(8) or
severely decayed primary dentition. ECC is currently at epidemic
proportions in some US minority populations (9).

It’s time to stop throwing more fluoride at children - especially
since the silicofluorides mostly used for fluoridation have never been
safety tested (sodium fluoride was used in experiments). Recent research
by Masters, et al,(10) show that children who live in silicofluoridated
communities have higher blood lead levels than children who live in non-
or sodium fluoridated communities. Other studies show that high blood lead
levels are associated with more tooth decay.

Ingested fluoride supplements aren’t the answer either since
fluoride’s beneficial properties are mostly topical (11) and since optimal
fluoride intake was never proved scientifically (12).

Instead of spending millions of dollars funding researchers to
determine just how much fluoride is too much and what kind should or
should not be in the water, that money should go to feed the hungry and
treat the dental disease of poor children.

Tooth decay appears to be, not a disease of the fluoride deficient,
but a disease of the poor, undernourished and dentally undertreated



1) Holt, Roberts, Scully, Clinical review, ABC of oral health, Dental
damage, sequelae, and prevention, BMJ 2000;320:1717-1719

2) Clark DC, Trends in prevalence of dental fluorosis in North America,
Community Den Oral Epidemiol, 1994, 22, 148-52

3) Oral Health in America: A Report of the Surgeon General, Department of
Health and Human Services, released May 2000

4) (Factoid #2)

5) Kumar, Green, Recommendations for Fluoride Use in Children,” NYS
Dental Journal, February 1998 See Chart (Figure 1) page 41

6) Rojas-Sanchez F, Kelly SA, Drake KM, Eckert GJ, Stookey GK, Dunipace
AJ, Fluoride intake from foods, beverages and dentifrice by young children
in communities with negligibly and optimally fluoridated water: a pilot
Community Dent Oral Epidemiol. 1999 Aug;27(4):288-97

7) America’s Children: Key National Indicators of Well-Being, Federal
Interagency Forum on Child and Family Statistics 1999

8) Ismail AI, The role of early dietary habits in dental caries
development, Spec Care Dentist 1998, Jan-Feb

9) Tinanoff N. Introduction to the Early Childhood Caries Conference:
initial description and current understanding, Community Dent Oral
Epidemiol 1998;26(1 suppl)

10) Masters, Coplan, Hone, International Journal of Environmental Studies,
August 1999,

11) Burt, The case for eliminating the use of dietary fluoride supplements
for young children, J Public Health Dent 1999 Fall

12) Levy SM, Kohout FJ, Kiritsy MC, Heilman JR, Wefel JS Infants' fluoride
ingestion from water, supplements and dentifrice, J Am Dent Assoc 1995 Dec

Competing interests: No competing interests

26 June 2000
Carol S Kopf
Freelance Health Writer