What is Fluoride Manufacturers and Why Do We Use Them?

What is fluoride?

Fluoride is a naturally occurring mineral found in many foods and water. In dentistry, healthcare providers use fluoride to strengthen teeth and reduce the risk of cavities.

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What does fluoride do?

Every day, your enamel (the protective outer layer of your tooth) gains and loses minerals. You lose minerals when acids — formed from bacteria, plaque and sugars in your mouth — attack your enamel. (This process is demineralization.) You gain minerals — like fluoride, calcium and phosphate — when you consume food and water that contain these minerals. (This process is remineralization.)

Tooth decay is a result of too much demineralization without enough remineralization.

Dental fluoride helps prevent tooth decay by making your enamel more resistant to acid attacks. It also reverses early decay.

Types of fluoride used in dentistry

Many foods and water contain fluoride. You can also purchase fluoride toothpaste and mouthwash. You can buy low-strength fluoride mouthwash over the counter. Stronger concentrations in liquid or tablet form need a healthcare provider’s prescription.

A dentist can also apply fluoride to your teeth in the form of:

• Foam, which they’ll dispense into a custom tray, then place over your teeth.
• Varnish, which they’ll paint directly on your teeth.
• Gel, which they’ll either paint on your teeth or dispense in a custom tray.

At what age is fluoride intake most important?

Infants and children between the ages of 6 months and 16 years need an appropriate amount of fluoride. Developing teeth benefit from fluoride just as much as teeth that have already erupted (grown in).

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The American Dental Association (ADA) recommends watching the intake of too much fluoride in infants and young children. The ADA specifically recommends avoiding reconstituted liquid formulas, such as liquid concentrate or powdered baby formulas that require mixing with fluoridated water.

Instead, the ADA recommends breast milk, ready-to-feed formula or prepared formula mixed with fluoride-free water. These recommendations are to guard against enamel fluorosis — faint white streaks that can appear on tooth enamel during a child’s developmental years, even before the teeth erupt through the gums.

For young children, the ADA also recommends:

• Using a pea-sized amount of fluoride toothpaste at each brushing.
• Spitting out rather than swallowing the toothpaste.
• Not allowing children under age 6 to use fluoride mouth rinses unless recommended by a dentist or other healthcare provider.
• Not giving fluoride-containing dietary supplements to children under 6 months of age.

Do adults benefit from fluoride?

Yes, adults can benefit from fluoride, too. You might especially benefit from fluoride if you have:

• Dry mouth (xerostomia), a common side effect of some healthcare conditions (like Sjögren’s syndrome) and certain medications (such as allergy medications and antihistamines). Saliva (spit) helps wash away food particles and bacteria. Slow saliva production makes you more prone to oral health issues like gum disease and cavities.
• Gum disease, which exposes your teeth and gums to bacteria and increases your risk of tooth decay.
• A history of tooth decay, which usually means that you’d benefit from additional fluoride.
• Crowns, bridges, braces or removable partial dentures, which may increase your risk of cavities, especially around orthodontic brackets or where your crown meets your tooth.

What are the benefits of fluoride?

Fluoride strengthens teeth and reduces your risk of cavities by approximately 25%.

Specifically, fluoride:

• Remineralizes your tooth enamel.
• Reverses early tooth decay.
• Slows down the process of demineralization.
• Prevents the growth of cavity-causing bacteria.

Is fluoride toxic?

When used properly, fluoride is safe and effective. But it can be hazardous at high doses. (The “toxic” dosage level varies based on a person’s weight).

If you’re a parent, it’s important to supervise your child’s use of fluoride. Here are some helpful tips:

• Avoid flavored toothpaste. (Children are more likely to swallow flavored toothpaste.)
• Use only a pea-sized amount of fluoridated toothpaste on your child’s toothbrush.
• Be cautious about using fluoridated toothpaste in children under age 6. (Children under 6 years of age are more likely to swallow toothpaste instead of spitting it out.)

It’s very difficult to reach dangerous fluoride levels due to the low levels of fluoride in over-the-counter products. But if you have concerns, talk to your dentist, pediatrician or primary care provider (PCP).

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Are there risks or side effects of fluoride?

The most common side effect of fluoride is fluorosis (fluoride-induced tooth discoloration). People with fluorosis develop spots on their teeth that can range from light white to dark brown. These spots typically occur during tooth development, usually in children under the age of 6.

Fluorosis most often results from consuming naturally occurring fluoride, like that found in well water. If you have well water, testing a sample can help determine how much fluoride is in your water.

You can’t brush fluorosis away, but a dentist might be able to use special bleaching methods to address the issue. If professional whitening doesn’t work, you can opt for dental bonding or porcelain veneers.

How much fluoride is the right amount?

The optimal level of fluoride is 0.7 parts per million. This is the amount in public water supplies in the communities that have fluoridated water.

Where can I find out how much fluoride is in my tap water?

Get in touch with your local health department or water supplier. They can tell you how much fluoride is in your water. In the United States, about 74% of people with public water supplies have adequate levels of fluoride in their water.

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What does fluoride do to your body?

When you consume fluoride, your gut absorbs it, and your bones and teeth store the rest. Any unabsorbed fluoride leaves your body when you pee.

What are the pros and cons of fluoride?

The benefits of using dental fluoride include stronger enamel and better protection against tooth decay. But large amounts of fluoride can be toxic. It can also result in fluoride-induced tooth discoloration (fluorosis). Ask your dentist how to get the right amount of fluoride.

Is fluoride good for your teeth?

Yes. When used properly, fluoride is one of the best ways to strengthen your enamel and reduce your risk of cavities. Ask your dentist for product recommendations and how often you should get fluoride treatments.

Why is there fluoride in the U.S. water supply? What are the benefits?

In the first part of the 20th century, dental caries [dental decay and cavities] were very prevalent, costly conditions that caused a lot of suffering, and impacted the entire population. There was a lot of tooth loss in children, and there were toothaches and abscesses related to extensive dental decay. The problems left many Americans with no teeth at all.

Around the s, researchers were looking at why there were some individuals in certain parts of our country that didn't have as much dental decay, and who also had some mottling or staining to their teeth. Ultimately, they found that in some parts of the country, like Colorado, fluoride was naturally present in the drinking water. 

At very high levels of fluoride intake, you can get some erosion of tooth enamel, which predisposes them to staining from things like drinking coffee. That is what these researchers were seeing. But they noticed at slightly lower levels of fluoride, you saw primarily caries prevention. That was a transformative revelation to the oral health of our country, because based on that research, they looked at other cities around the U.S. with fluoride naturally present in the water. Those concentrations varied from zero to more than four parts per million. Our current recommended amount of fluoride in community water fluoridation is 0.7 parts per million.

There were people already benefiting from fluoride in the water even before we had community water fluoridation, and researchers said, where is that sweet spot where we can optimize dental decay prevention but not cause side effects? 

The reason why we know that fluoride is effective is because it's naturally present in the water around our globe, and there are more than 50 million people who are already drinking water that is one part per million, because that's naturally present in their water. This is not something that is added or a pollutant. 

Does fluoridated water have side effects?

The biggest side effect that people were concerned about in the past was dental fluorosis, which is dose dependent. At low doses, it may just cause little white specks on the teeth, but those teeth are also more resistant to dental decay. As you get to higher doses, then you can start to have more adverse effects. And in some parts of the world where there are very high levels of fluoride in the environment, you actually have a chronic condition that develops called skeletal fluorosis, which is essentially very brittle bones. We don't see that sort of fluorosis in the U.S.

What do you think about the suggestion that we should remove fluoride from our water? 

Trying to connect fluoride in the water to health risks has been going on for decades. Those potential connections, for example, hip fractures or bone cancer, have all been disproven through robust research. 

The more recent concerns that have arisen, are about the impact on neurocognitive development based on fetal and early childhood exposure to fluoride. We don't know what the exact dose is that would cause those problems. We know that in environments, such as India, China, and Iran, where there's very high concentrations of fluoride naturally present in the soil, that there can be an increased risk of a neurocognitive effect of very high exposure [to] fluoride—but the quality of the studies is poor. Based on that, concerns then spread to lower levels of fluoride exposure, including what we use for community water fluoridation. 

When did these concerns start to become more widespread?

There was an article published late in the s by Rivka Green, who conducted some epidemiologic analysis based on some cities in Canada, and concluded that a fluoride exposure early in development could decrease IQ in boys. That paper was published in a prominent pediatric journal and got a lot of press. 

However, there are a lot of problems with that particular study, and subsequent studies have not shown that same effect, and in fact, have shown an opposite effect. There have also been population-based studies, which do a much better job at establishing cause and effect, that have shown absolutely no effect on neurocognitive development or IQ scores, and have shown that in an economic analysis, if you have fewer cavities, you're more likely to be successful in life and to attain higher earnings in adulthood. There's even been some work showing that it's quite beneficial to have exposure to fluoride in the levels that we see in community water fluoridation. But those haven't gotten the same attention. 

Unfortunately, what did get a lot of attention was a report by the [federal] National Toxicology Program, which is also a problematic document. Two attempts underwent peer review by the National Academies of Sciences, Engineering, and Medicine (NASEM) and were rejected as bad science that relied on studies of poor quality, and drew conclusions that were not supported by the research. On their third attempt, they did not take it to NASEM, and instead it went to a judge in San Francisco. Even though the report explicitly said that it was not meant to apply to community water fluoridation, or to apply to levels below 1.5 parts per million, the judge drew conclusions from it that fluoride in the water is risky to health. That is not a valid conclusion from the work. 

Since we have access to fluoridated toothpaste and dental care, do we need fluoride in the water anymore?

There's a number of advantages to community water fluoridation, including that it's a relatively passive public health intervention. By adding it to the water supply, it's available to everyone, regardless of their access to dental care or their ability to routinely participate in home oral hygiene practices. That’s why we've seen it be so effective, particularly in eradicating some disparities in oral health, which are pronounced in the U.S. 

If you don't consider the historical perspective, you may be led to believe that these things are no longer problems. However, you'd be ignoring the fact that we already have a very robust system in place to try to keep those issues as low as possible. Two-thirds of the population is supplied by a public water supply that has fluoride in it. Many manufacturing plants produce beverages—like juices and soda—using community water that has fluoride in it. These things are now unlabeled sources of community water fluoridation, and have diffused from centers where there's community water fluoridation into areas where it's unfluoridated. 

Because of that, we've seen a smaller difference between communities with and without community water fluoridation in terms of cavity levels. In the initial studies done in the s, there was a 60% drop over a period of a few years in terms of the amount of cavities in children. That's still very valid and important research, because during those studies, there were no other sources of fluoride—no supplementation. It wasn't diffusing into other communities and fluoridated toothpaste wasn't commercially available till the early s. Those studies show the dramatic effect of fluoride in the water and the drop in cavities was an incredible achievement. 

It may seem like we don't need fluoride anymore, but in reality, it's everywhere. Removing it from the water will cause a lot of vulnerable populations to suffer—it's not a good thing for us to be contemplating, and we've seen that in some studies. Calgary discontinued their fluoridation program in and over a relatively short period of time, saw dramatic increases in cavities in kids. The number of kids who are requiring IV antibiotics or needing operative dental care under general anesthesia, increased quickly with removal of fluoride from the water. 

I believe ongoing use of community water fluoridation is safe because it's at a low enough level that we know that it's advantageous to be drinking it based on the research that we have.
 

This interview was edited for length and clarity by Morgan Coulson, an editorial associate in the Office of External Affairs at the Johns Hopkins Bloomberg School of Public Health.

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