Fluoride is essential to your dental health. It is used in almost all toothpastes and mouthwashes and serves as a primary agent in the fight against dental decay. The CDC says that for every tax dollar spent on community water fluoridation, $20 is saved in future dental procedures (CDC). Despite its widespread and natural function, fluoride has recently come under intense scrutiny and skepticism. We at Westtown Dental Care have noticed a decline in the acceptance of fluoride treatments. We wanted to address these persisting concerns, and communicate our practice stance that community and medical fluoridation practices are overwhelmingly beneficial.
The adoption of water fluoridation is regarded as one of the top ten public health achievements made in the 20th century. Despite its lauded adoption in the scientific world, fluoridation has faced consistent and enthused opposition. 1945 in Grand Rapids, MI marks the US’ first major township fluoridation project. The immense success of this fluoridation trial in decreasing dental caries inspired a gradual, national expansion, all the way through today where 77.1% of people living in the US consume fluoridated water. Resistance to this expansion occurred throughout the 81-year fluoridation process; early opponents to the project were reported to have hallucinated symptoms, experiencing asymptomatic dishware staining and stomach issues before the fluoride had even been added to their water. Right-wing and libertarian political leaders further opposed the measure between the 40’s-60’s, calling it a harmful, communist mode of chemical warfare, subtly weakening the US population. Contemporary culture has seen a surge of anti-fluoridation sentiments, showcased particularly well in US Secretary of Health Robert F. Kennedy, who recently suggested the elimination of all fluoridated water projects (Schoenbaum and Stobbe).
The basis of the fear surrounding fluoride stems from its proven toxicity in high percentages. Certain composites of fluoride, such as sodium fluoroacetate, are toxic to mammals and have been used as rodenticide since at least 1896. The fluoride used in water and dental treatments is entirely unlike those used in rat poisons, but the linkage served as an early deterrent towards fluoride’s acceptance. With fluoride, safety is a matter of concentration and scale. Like everything, high percentages of non-toxic fluoride become toxic, with extreme cases causing a condition called skeletal fluorosis. Skeletal fluorosis is a bone disease caused by fluoride overconsumption and accumulation, resulting in a variety of chronic symptoms, including: brittle bones, arthritis, pain in the joints, calcification of ligaments, muscle atrophy, hyperthyroidism, ruptures in the stomach lining, congenital deformities, and infertility. Skeletal fluorosis was named an epidemic issue by UNICEF in the 25 countries within which it is present. The conservative count of afflicted people comes in within the tens of millions. Skeletal fluoroisis is not an epidemic in the US.
Dental fluorosis is a much milder and more common side effect of increased exposure to fluoride. A Colorado community beset by an intense case of dental fluorosis was a major factor in the discovery of fluoride’s dental strengthening properties. Scores of residents in the town of Colorado Springs were observed to have irreversible, “grotesque” brown stains on their teeth (Unde, et al.). Called the Colorado Brown stain, this was discovered to be an intense case of dental fluorosis caused by the high concentration of natural fluoride in their water. While investigating the cause of the “mottled enamel,” the researchers discovered that the brown teeth were stronger and more resistant to decay than their pearly counterparts (Unde, et al.). After years of research, this brown stain was eventually categorized as dental fluorosis: defined as a hypocalcification of the dental enamel and characterized by scattered areas of internal discoloration, ranging from lacy white to the aforementioned dark brown. Severe dental fluorosis is extremely rare in the US, with fluoride concentration in most municipal water supplies being well below what would cause that intensity of staining (Naizi and Pepper). This concentration also falls well beneath the 1.65-4.4 ppm known to cause skeletal fluorosis in its varying intensities (Choubisa, 3). The international recommendation for fluoride concentration is between 0.5 and 1.0 mg/L* depending upon climate relative to water consumed (WHO). The US has their own guideline set within that range, at 0.7 mg/L. In the US, the rare major cases of dental or skeletal fluorosis come from communities dependent on natural, unregulated water sources (like wells or springs) living in areas with naturally high water fluoridation. Milder versions of dental fluorosis are statistically on the rise in America, with the percentage of affected adolescents doubling since 1987 and currently sitting at 41%, but fluorosis of this intensity is minimally noticeable and generally considered aesthetically negligible (Naizi and Pepper).
The dental benefits vastly outweigh the potential aesthetics costs. As mentioned in its discovery, teeth exposed to higher percentages of fluoride become much stronger, both in physical durability and decay resistance. The effect of water fluoridation on the decline of dental caries is demonstrable, with 90% of adolescents aged 12–17 having at least one cavity in 1960 and only 60% having a cavity from 1999-2004. Fluoridated water best prevents cavities through fluoride’s inhibition of cariogenic (cavity-causing) bacteria’s activity. Fluoridated water is particularly important for preventing cavities and improving dentition in underserved communities. For people without access to regular dental cleanings, fluoridated water is a simple, cheap way to keep dental caries to a minimum. But fluoridated water on its own does not provide perfect prevention against caries. For the best results, patients with developing or fragile dentition should also receive concentrated, topical fluoride treatments during their biannual cleanings. Topical fluoride is particularly well suited to fluoride’s other major mode of caries prevention: remineralization. Fluoride’s remineralization repairs the present decay in teeth, keeping bacteria and infection out, while also strengthening already stable dentition to continually combat decay.
As mentioned earlier, lambasts against fluoride have often cited a deteriorating mental effect on those exposed. This idea has persisted from the early days of its widespread usage, and has found new traction today in right-wing medical spheres and social media health trends. The data supporting these ideas is inconclusive at best. It is true that at extremely high percentages (8ppm) of fluoride can act as a neurotoxin and effect development, but it is extremely unlikely that the average American citizen could be exposed to that concentration of fluoridation. Studies that claim fluoride’s degenerative effect at the lower and current standard concentrations are indefinite and undefined. Studies will find significant IQ differences in children with variable fluoride consumption, but also find an equally statistically significant difference between the IQs of the sexes (Green, et al.). In most cases, these studies falsely attribute a lower IQ to fluoride, when it is more likely indicative of a child’s particular situation: their educational access, systemic sources of support, and genetics.
Given all this information, Westtown Dental Care’s recommendation is to maximize fluoride exposure within the healthy limits. Drinking fluoridated water and receiving biannual fluoride treatments as a child greatly increases tooth strength and serves to vastly reduce the frequency and severity of dental caries. If the mild aesthetic blips caused by the uncommon dental fluorosis is a major concern for you, you should carefully consider your water supply’s fluoridation levels in conjunction with your toothpaste, mouthwash, and biannual fluoride treatments to keep your consumption to a level you find comfortable. As mentioned prior, the US limit on fluoridation sits at 0.7 mg/L. In West Chester, the Chester Water Authority (CWA) and Aqua provide water to the majority of the West Chester borough and surrounding areas. Respectively, these institutions have fluoridation levels of 0.69-0.7ppm and 0.0-0.62 ppm (CWA, “fluoridation and Chlorine;” Aqua, “2022 Water Quality Report”, 2). This concentration, in conjunction with fluoride treatments, is extremely unlikely to cause any discoloration.
If your water is private or deregulated, determining your own supply’s fluoridation level is advised. The West Chester area sits at the intersection of the Chester Creek, Brandywine Creek East Branch, and Brandywine Creek Main Stem watersheds. Naturally fluoridated water is common in the US, so concerned patients should consider where their groundwater stems from, based on location and physical source, and research fluoridation levels accordingly. Statistically speaking, the US has levels of natural fluoridation that sit well below the government limit (McMahon). The western side of the US is also more likely to have higher fluoride levels in the groundwater; as Pennsylvania is on the eastern side of the country, the chance for fluoride over-concentration is further diminished. In either case, the worst case scenario for fluoride treatment in the US is mild, painless discoloration. Patients and their parents should carefully weigh the benefits of the increased strength and cavity resistance of the teeth if deciding to opt out of fluoride treatments. But of course, as with any procedure or treatment, the choice is entirely yours.
If you have further questions or concerns, please bring them up to our doctors at your appointment. They are happy to discuss and assuage any lingering fears.
Give our practice a call at 484-887-0777 to schedule any cleanings or fluoride treatments, to keep your teeth healthy, happy, and stable!
*mg/L and ppm are functionally equivalent when discussing dissolved water concentrations, with one ppm equaling 0.998 mg/L.
Works Cited
Green, Rivka, et al. “Association Between Maternal Fluoride Exposure During Pregnancy and IQ Scores in Offspring in Canada.” JAMA Pediatrics, vol. 173, no. 10, 19 August 2019, pp. 940-948.
McMahon, Peter B., et al. “Fluoride in Groundwater: Too much or too little of a good thing?.” United States Geological Survey, 19 May 2020. https://www.usgs.gov/news/comprehensive-assessment-fluoride-groundwater
Niazi, Fatima C. and Tom Pepper. “Dental Fluorosis.” National Library of Medicine, 1 June 2023. https://www.ncbi.nlm.nih.gov/books/NBK585039/
“Return on Investment: Optimally Fluoridated Water.” Center for Disease Control, 15 May 2024. https://www.cdc.gov/oral-health/php/infographics/roi-fluoridated-water.html
Schoenbaum, Hannah and Mike Stobbe. “RFK Jr. will tell CDC to stop recommending fluoride in drinking water.” PBS News, 8 April 2025. https://www.pbs.org/newshour/health/rfk-jr-will-tell-cdc-to-stop-recommending-fluoride-in-drinking-water
Unde, Maitreyee P., et al. “The Untold Story of Fluoridation: Revisiting the Changing Perspectives” Indian Journal of Occupational & Enviromental Medicine, vol. 22, no. 3, September-December 2018, pp. 121-127.