The scientific consensus that fluoridation is a safe and effective public health measure is based on the relevant research from over seven decades of studies evaluated by relevant science and health experts. 

Some Published Studies Related to Fluoridation (additional information here):

The National Library of Medicine makes medical and scientific journal abstracts and some entire articles available to the general public.  Most journals represented publish peer-reviewed studies for much of the medical and scientific research world wide.  Below are over 200 examples of research papers from the 1950s into 2018 on fluoride and fluoridation to counter the argument that there is NO recent evidence that water fluoridation is beneficial or safe.

Other important resources:
Excellent discussion of anti-F "evidence" and arguments
   ADA Fluoridation Facts

   Why voters and elected officials should support CWF
   Over 30 recent reviews and studies that support fluoridation
   Scientific Consensus on Fluoridation
   Tactics of Anti-Science Activists Anti-F Associations

I encourage you to evaluate for yourself the evidence for and against community drinking water fluoridation (CWF) with an open mind.  If you are not a scientist, and/or if you have strong existing beliefs one way or another, that is an extremely daunting task.  Fluoridation, like other scientific topics, is very complex, the studies are not easy to understand, and you can find studies that apparently support either side.  Compare the content and conclusions of these recent reviews and studies (and those cited below) that accurately highlight the benefits and risks of CWF with the way studies are presented by fluoridation opponents who frequently exaggerate and.or misrepresent study conclusions and cite studies that have nothing to do with drinking optimally fluoridated water.

Search the National Library of Medicine and  Search for terms related to water fluoridation.  A search on general topics like, fluoridation will return a large number of results (6,491 in October 2018), or community water fluoridation, (1,100 results), but it is a good way to find other words to include that limit the search.  For example you can reduce the number of results to a more manageable size by using more restrictive search terms like: b>water fluoridation caries (3,344 results); water fluoridation safety (129 results); water fluoridation benefits (214 results); water fluoridation risks (559 results); drinking water fluoridation (914 results);  fluoridation health (2,667 results); water fluoridation cancer (164 results - note that virtually none of the papers actually study the link between fluoridation and cancer); water fluoridation brain (11 results - note the paper on fluoride-induced oxidative stress in the rat brain used concentrations of fluoride in the water 100-200 times greater than found in fluoridated water); water fluoridation IQ (1 result); water fluoridation fractures (89 results); fluoridation ethical (51 results); fluoridation cost (415 results).  If you take time to look through the medical literature on any aspect of fluoridation, I am confident you will discover that papers which support the effectiveness and safety of fluoridation outnumber those which report risks of fluoridation (at recommended levels) by many times.  If you understand how scientific studies are designed and conducted - and the results analyzed and reported - you will also see the limitations of most studies that report harm from or ineffectiveness of community water fluoridation.

Fluoridation opponents list on their websites many papers which document claims that fluoridation is harmful and not effective.  Many of these papers are not archived at the National Library of Medicine.  This typically means the papers have not been published in recognized peer-reviewed journals.  The reason usually given is that the traditional dental, medical and scientific communities are so committed to community water fluoridation that they actively block funding and publication of any research that might uncover health risks of fluoridation.  There is, of course another explanation: The majority of research that shows other health risks at optimal fluoridation besides the risks of dental fluorosis, is simply not of high enough quality to be published in a peer reviewed journal. 

Below is a sample of about 220 research papers and reviews that should, without any question, dispel the myth propagated by some fluoridation opponents that there is no current evidence to support the safety and effectiveness of drinking water fluoridation.  This evidence (updated 10/3/2018) provides specific citations and conclusions from over 60 years of research (1950 - 2018).

National Toxicity Program fluoride study, An Evaluation of Neurotoxicity Following Fluoride Exposure from Gestational Through Adult Ages in Long-Evans Hooded Rats: At these exposure levels, we observed no exposure-related differences in motor, sensory, or learning and memory performance on running wheel, open-field activity, light/dark place preference, elevated plus maze, pre-pulse startle inhibition, passive avoidance, hot-plate latency, Morris water maze acquisition, probe test, reversal learning, and Y-maze. T3, T4, and TSH levels were not altered as a function of 10 or 20 ppm F- in the drinking water. No exposure-related pathology was observed in the heart, liver, kidney, testes, seminal vesicles, or epididymides. Mild inflammation in the prostate gland was observed at 20 ppm F-. No evidence of neuronal death or glial activation was observed in the hippocampus at 20 ppm F-. (McPherson, et al., Neurotox Res. 2018)
The Role of Fluoride in the Prevention of Tooth Decay: Although there are recommendations to prevent tooth decay by other means, this nonsystematic review finds that fluoride is the key to prevention and control of tooth decay. There are multiple fluoride modalities with effectiveness and safety of fluoride depending on dose and concentration. Prevention of tooth decay occurs at the individual level by fluoride use at home and with professional application and at the community level through fluoridation of water or salt. (Pollick H, Pediatr Clin North Am. 2018)>
Science, Politics, and Communication: The Case of Community Water Fluoridation in the US: Community water fluoridation (CWF) and its effect in reducing the burden of dental caries (tooth decay) is considered one of the 10 public health achievements in the 20th century. In the U.S., three-quarters (74.4%) of people on community water supplies have optimally fluoridated water, and each year approximately 90 communities actively consider starting or discontinuing CWF. ... The continued involvement of epidemiologists as part of multidisciplinary teams is needed in research, surveillance, peer review of studies, assessment of systematic review findings, and in the translation and communication of science findings to audiences with limited science/health literacy. (Allukian M Jr, et al., Ann Epidemiol. 2018)
A multi-variable analysis of four factors affecting caries levels among five-year-old children; deprivation, ethnicity, exposure to fluoridated water and geographic region: CONCLUSIONS: Five-year-old children who were from the most deprived areas, not exposed to fluoridated water, of an Eastern European ethnic group and living in the North West demonstrated the highest prevalence and severity of caries in the survey under scrutiny. This is of public health importance, providing evidence for population groups to target with health improvement activities. (Weston-Price, et al., Community Dent Health. 2018)
Fluoridation and county-level secondary bone cancer among cancer patients 18 years or older in New York State:
We found no evidence of an association between community water fluoridation category and secondary bone cancer from 2008 to 2010 at the county level in New York State. (Crnosija, et al., Environ Geochem Health. 2018)
Water Fluoridation and Dental Caries in U.S. Children and Adolescents: These findings confirm a substantial caries-preventive benefit of CWF for U.S. children and that the benefit is most pronounced in primary teeth. (Slade, et al., J Dent Res. 2018) Interview with Dr. Slade.
Contemporary evidence on the effectiveness of water fluoridation in the prevention of childhood caries: CONCLUSION: Analysis of contemporary data representative of the Australian child population found consistent associations between %LEFW and childhood caries, which persisted when socioeconomic differences were adjusted across exposure groups, supporting the continued effectiveness of water fluoridation. (Spencer, et al., Community Dent Oral Epidemiol. 2018)
Caries and fluoridated water in two Brazilian municipalities with low prevalence of the disease: CONCLUSIONS: Exposure to fluoridated water implied lower mean values for the DMFT and SiC indexes, even in the presence of the concomitant exposure to fluoridated toothpaste, in a scenario of low prevalence of the disease, and with a similar pattern of caries distribution in the populations analyzed. (Cruz & Narvai, Rev Saude Publica. 2018)
Fluoridation and attention deficit hyperactivity disorder - a critique of Malin and Till (2015): A recent ecological study found a statistically significant association of attention deficit hyperactivity disorder (ADHD) prevalence in youth with exposure to fluoride in fluoridated water. However, it included only household income as a possible covariate. In contrast another study found a significant association of ADHD prevalence with residential altitude. A multiple regression analysis including water fluoridation extent, mean US state elevation and a number of possibly important social factors as covariates showed statistically significant associations of ADHD prevalence in 2011 with altitude and per capita personal income in 2009. There was no statistically significant association of ADHD with the exposure to fluoride when these covariates were included. The ADHD-fluoridation study suffers from insufficient consideration of possible risk-modifying factors but has been widely cited because its reported findings appear advantageous to political campaigns against community water fluoridation. (Perrott, K, Br Dent J. 2018)   Full Article
The costs and benefits of water fluoridation in NZ: RESULTS: Over 20 years, the net discounted saving from adding fluoride to reticulated water supplies supplying populations over 500 would be NZ$1401 million, a nine times pay-off. Between 8800 and 13,700 quality-adjusted life years would be gained. While fluoridating reticulated water supplies for large communities is cost-effective, it is unlikely to be so with populations smaller than 500.  CONCLUSIONS: Community water fluoridation remains highly cost-effective for all but very small communities. The health benefits-while (on average) small per person-add up to a substantial reduction in the national disease burden across all ethnic and socioeconomic groups. (Moore, et al., BMC Oral Health. 2017)
Caries prevention with fluoridated and iodinated salt in school-aged children living in areas with fluoride and iodine deficiency: The aim of the study was to evaluate the efficacy of dental caries prevention program with 3 years follow-up in children living in areas with fluoride and iodine deficiency. The study involved 625 school-aged children aged 6, 12 and 15 years receiving endogenous prevention with fluoridated and iodinated salt (300±50 mgF/kg and 40±10 mgI/kg). Obtained reduction of DMFT growth, positive changes of mineral composition and dental hard tissues microhardness prove high clinical efficacy of applied prevention program. (Ahmedbeyli RM, Stomatologiia (Mosk). 2017)
Does water fluoridation affect the prevalence of enamel fluorosis differently among racial and ethnic groups? CONCLUSIONS: Enamel fluorosis was not associated with race/ethnicity. Our analysis suggests that exposure to similar levels of fluoride in the water does not appear to place certain race/ethnic groups at a higher risk for developing enamel fluorosis, and lowering the optimal range of drinking water fluoride to a single value of 0.7 ppm will provide a level of protection against enamel fluorosis that will benefit all race/ethnicity groups. (Arora, et al., J Public Health Dent. 2018)
Fluoride exposure and reported learning disability diagnosis among Canadian children: Implications for community water fluoridation: CONCLUSION: Overall, there did not appear to be a robust association between fluoride exposure and parental- or self-reported diagnosis of a learning disability among Canadian children. (Barberio, et al., Can J Public Health. 2017)  Full Article
Fluoride exposure and indicators of thyroid functioning in the Canadian population: implications for community water fluoridation: RESULTS: There was no evidence of a relationship between fluoride exposure (from urine and tap water) and the diagnosis of a thyroid condition. There was no statistically significant association between fluoride exposure and abnormal (low or high) TSH levels relative to normal TSH levels. CONCLUSION: These analyses suggest that, at the population level, fluoride exposure is not associated with impaired thyroid functioning in a time and place where multiple sources of fluoride exposure, including CWF, exist. (Barberio, et al., J Epidemiol Community Health. 2017)  Full Article
Fluoride Depletes Acidogenic Taxa in Oral but Not Gut Microbial Communities in Mice: [F]luoride treatment did not induce a significant shift in gut microbial community composition or function in our mouse model, possibly due to absorption in the upper gastrointestinal tract. Fluoride-associated perturbations thus appeared to have a selective effect on the composition of the oral but not gut microbial community in mice. (Yasuda, et al., mSystems. 2017)
Salt fluoridation and dental caries: state of the question: RESULTS: After a literature search, 22 references were selected reporting data on the preventive effect of salt fluoridation programmes in Europe (Hungary, Switzerland, France, Germany) and South and Central America (Colombia, Mexico, Jamaica...). Data were mainly obtained from descriptive or retrospective epidemiological studies. The results indicate that, in the absence of topical fluoride support, salt fluoridation leads to a significant reduction in caries indexes among treated children compared to a control group. (Vautey, et al., Sante Publique. 2017)
CONCLUSIONS: Exploring the short-term impact of community water fluoridation cessation on children's dental caries: a natural experiment in Alberta, Canada: Our results suggest an increase in dental caries in primary teeth during a time period when community fluoridation was ceased. That we did not observe a worsening for permanent teeth in the comparative analysis could reflect the limited time since cessation. It is imperative that efforts to monitor these trends continue. (McLaren, et al., Public Health. 2017)  Full Article
Communicating about risk: strategies for situations where public concern is high but the risk is low: In this article, we summarise research that identifies best practice for communicating about hazards where the risk is low but public concern is high. We apply Peter Sandman's 'risk = hazard + outrage' formulation to these risks, and review factors associated with the amplification of risk signals. We discuss these features of successful risk communication in relation to a range of specific examples, particularly opposition to community water fluoridation, Ebola, and routine childhood immunisation. (Hooker, et al., Public Health Res Pract. 2017)
Effectiveness of water fluoridation in the prevention of dental caries across adult age groups: CONCLUSION: Access to FW was associated with caries experience in Australian adults. The magnitude of associations varied between age groups, dependent on the natural history of caries and its measurement by DMFS. (Do, et al., Community Dent Oral Epidemiol. 2017)
Costs And Savings Associated With Community Water Fluoridation In The United States: Based on 2013 estimated costs ($324 million), net savings (savings minus costs) from fluoridation systems were estimated to be $6,469 million and the estimated return on investment, 20.0. While communities should assess their specific costs for continuing or implementing a fluoridation program, these updated findings indicate that program savings are likely to exceed costs. (O'Connell, Health Aff (Millwood). 2016)
Associations of Community Water Fluoridation with Caries Prevalence and Oral Health Inequality in Children: These results suggest that CWF programmes are effective in the prevention of caries on permanent teeth and can reduce oral health inequalities among children. The implementation of CWF programmes should be sustained to overcome oral health inequalities due to socio-economic factors and improve children's overall oral health. (Kim, et al., Int J Environ Res Public Health. 2017)
The differences in healthcare utilization for dental caries based on the implementation of water fluoridation in South Korea:   RESULTS: Individuals with water fluoridation had a lower risk of dental care visits (HR = 0.949, 95 % CI = 0.928-0.971). Among the individuals who experienced a dental care visit, those with water fluoridation program had a lower number of dental care visits (β = -0.029), and the period of water fluoridation had an inverse association with the dental care expenditures. CONCLUSION: The implementation of water fluoridation programs and these periods are associated with reducing the utilization of dental health care. Considering these positive impacts, healthcare professionals must consider preventive strategies for activating water fluoridation programs, such as changes in public perception and relations, for the effective management of dental care in South Korea. (Cho MS, et al. – BMC Oral Health. 2016 Nov 8;16(1):119)
Independent and Additive Effects of Different Sources of Fluoride and Dental Fluorosis:   CONCLUSION: In a community with water fluoridation, the factors associated with dental fluorosis are intentional toothpaste ingestion and tooth-paste applied on the whole toothbrush. (Celeste RK & Luz PB – Pediatr Dent. 2016;38(3):233-8)
ECONOMIC IMPORTANCE OF THE PREVENTIVE MEASURES IN DENTISTRY:   CONCLUSION: The importance of continuing education and local fluoridation is clearly reflected in the different values DMF-index, which was the subject of research. In the first group, in which is carried out continuous education and local fluoridation value of DMF index was 2.7, in the second group with local fluorination this value was 3.56, while in the third group, in which is not implemented preventive measures, the value DMF- index was 5.93. From an economic point the preventive measures are the cheapest, most effective and the best solution in order to maintain oral health. (Deljo E, et al., & Mater Sociomed. 2016 Oct;28(5):397-401)
Fluoridation may not be linked with adverse health outcomes:   CONCLUSION: There was no evidence for associations between fluoridation and nondental health outcomes such as hip fracture, Down syndrome, osteosarcoma, all-cancer, or all-cause mortality.  The authors concluded that their study provides reassurance that fluoridation programs are a safe and highly effective way to provide a population with the protective dental health property of fluoride. The study found lower rates of nondental outcomes in areas of artificial fluoridation. However, the authors stated that the ecological study design did not allow any conclusions to be drawn with regard to the potential protective effect of fluoridation for nondental outcomes. (Blakey K & McNally RJ – J Evid Based Dent Pract. 2016 Sep;16(3):209-212)
Measuring the short-term impact of fluoridation cessation on dental caries in Grade 2 children using tooth surface indices:   CONCLUSIONS: Trends observed for primary teeth were consistent with an adverse effect of fluoridation cessation on children's tooth decay, 2.5-3 years post-cessation. Trends for permanent teeth hinted at early indication of an adverse effect. It is important that future data collection efforts in the two cities be undertaken, to permit continued monitoring of these trends. (McLaren L, et al. – Community Dent Oral Epidemiol. 2016 Jun;44(3):274-82)
Water fluoridation and hypothyroidism:   Commentary on the 2015 Peckham et al hypothyroidism study.
The biggest problem with this paper, however, is in the interpretation which puts far too much weight on such weak evidence. The approach used is notoriously unreliable as a way of identifying independent associations and the lack of a clearly established prior hypothesis make it very unconvincing as evidence of a causal relationship. Given the other problems we have identified, this loose interpretation is a very serious concern. Such speculation is likely to result in unfounded public anxiety about a public health intervention which currently protects the health of children's teeth in many parts of the world. (John N Newton, et al. – J Epidemiol Community Health. 2015 Jul; 69(7): 617–618)
Access to Fluoridated Water and Adult Dental Caries - A Natural Experiment:   Participants who accessed fluoridate water <50% of their lifetime presented a higher mean rate ratio of DMFT (1.39; 95% CI, 1.05-1.84) compared with those living >75% of their lifetime with residential access to fluoridated water. Participants living between 50% and 75% and <50% of their lives in fluoridated areas presented a decayed and filled teeth mean ratio of 1.34 (95% CI, 1.02-1.75) and 1.47 (95% CI, 1.05-2.04) higher than those with residential access to fluoridated water >75% of their lifetime, respectively. Longer residential lifetime access to fluoridated water was associated with less dental caries even in a context of multiple exposures to fluoride. (Peres MA, et al. – J Dent Res. 2016 Jul;95(8):868-74)
Does cessation of community water fluoridation lead to an increase in tooth decay? A systematic review of published studies:   CONCLUSIONS: Overall, the published research points more to an increase in dental caries post-CWF cessation than otherwise. However, the literature is highly diverse and variable in methodological quality. (McLaren L & Singhal S – J Epidemiol Community Health. 2016 Sep;70(9):934-40)
Comparative effectiveness of water and salt community-based fluoridation methods in preventing dental caries among schoolchildren:   CONCLUSION: Fluoridated water appears to provide a better protective effect against dental caries than fluoridated household salt among schoolchildren from developing countries. (Fabruccini A, et al. – Community Dent Oral Epidemiol. 2016 Jul 28)
Dental caries, fluorosis, oral health determinants, and quality of life in adolescents:   CONCLUSION: Increased impact on oral health-related quality of life (OHRQoL) was related to the severity of cavitated dentine lesions, but fluorosis resulting from combined fluoride exposure from early ages was not of concern for the adolescents. CLINICAL RELEVANCE: Combined fluoride exposure from fluoridated drinking water, consumption of food prepared with fluoridated water, and daily twice brushing with conventional fluoride toothpaste from early ages may be recommended to control caries progression at population level without impact on OHRQoL. This information is particularly relevant for supporting oral health police for disadvantaged populations. (Aimée NR, et al. – Clin Oral Investig. 2016 Sep 27)
Evaluation of optimal water fluoridation on the incidence and skeletal distribution of naturally arising osteosarcoma in pet dogs:   Taken together, these analyses do not support the hypothesis that optimal fluoridation of drinking water contributes to naturally occurring osteosarcoma in dogs. (Rebhun RB, et al. – Vet Comp Oncol. 2016 Jan 14)
Economic Evaluation of Community Water Fluoridation: A Community Guide Systematic Review:   EVIDENCE SYNTHESIS: The analysis was conducted in 2014. The benefit-only studies used regression analysis, showing that different measures of dental costs were always lower in communities with water fluoridation. For the six cost-benefit studies, per capita annual intervention cost ranged from $0.11 to $4.92 for communities with at least 1,000 population, and per capita annual benefit ranged from $5.49 to $93.19. Benefit-cost ratios ranged from 1.12:1 to 135:1, and these ratios were positively associated with community population size. CONCLUSIONS: Recent evidence continues to indicate that the economic benefit of community water fluoridation exceeds the intervention cost. Further, the benefit-cost ratio increases with the community population size. (Ran T, et al. – Am J Prev Med. 2016 Jun;50(6):790-6)
Cost-effectiveness of preventing dental caries and full mouth dental reconstructions among Alaska Native children in the Yukon–Kuskokwim delta region of Alaska:
Water Fluoridation: Adjusting the level of fluoride in the community water systems results in a 26-35 percent reduction in tooth decay among children receiving lifelong exposure to fluoridated water. Other estimates based earlier YK dental reviews suggests 18-40 percent reduction in tooth decay among children receiving community fluoridated water. (Charisma Y. Atkins, et al. – J Public Health Dent. 2016 Jun; 76(3): 228–240)
Public perceptions and scientific evidence for perceived harms/risks of community water fluoridation: An examination of online comments pertaining to fluoridation cessation in Calgary in 2011:   OBJECTIVES: To examine the perceived harms/risks of fluoridation as expressed in online forums relating to cessation and aftermath in Calgary, specifically, 1) which harms/risks are mentioned, 2) for those harms/risks, what kinds of evidence are cited, 3) to what extent is scientific literature cited, and what is its quality, and 4) for a subset of harms/risks, what is known from the broader scientific literature?
METHODS: Relevant online comments were identified through free-text Internet searches, and those explicitly discussing the harms/risks of water fluoridation were extracted. Types of evidence mentioned were identified, and the scientific papers cited were reviewed. Finally, the broader scientific literature on two of the harms/risks was reviewed and synthesized.
SYNTHESIS: We identified 17 distinct groups of harms/risks, which spanned human body systems, the environment and non-human organisms. Most often, no evidence was cited. When evidence was cited, types included individuals viewed as authorities and personal experiences. Reference to scientific articles was rare, and those papers (n = 9) had significant methodological concerns. Our review of scientific literature on fluoride and 1) thyroid functioning and 2) phytoplankton revealed some negative effects of fluoride at concentrations exceeding maximum recommended levels (>1.5 ppm).
CONCLUSION: The findings have implications for communication with the public about fluoridation. First, to the extent that the public consults the scientific literature, it is essential that the methodological limitations of a study, as well as its relevance to community water fluoridation, be widely and promptly communicated. Second, scientific evidence is only one component of why some people support or do not support fluoridation, and communication strategies must accommodate that reality. (Podgorny PC & McLaren L. – Can J Public Health. 2015 Jun 19;106(6):e413-25)
Long-term evaluation of the clinical effectiveness of community milk fluoridation in Bulgaria:   CONCLUSIONS: Fluoridated milk delivered daily in schools in Bulgaria resulted in substantially lower caries development compared with children in schools receiving milk without added fluoride. The nation-wide experiences from milk fluoridation indicate that such a public health scheme can be effective to the global fight against dental caries of children. (Petersen PE, et al. – Community Dent Health. 2015 Dec;32(4):199-203)
Association between estimated fluoride intake and dental caries prevalence among 5-year-old children in Korea:   CONCLUSION: The inverse association between dietary fluoride intake levels and prevalence of dental caries implies that the introduction of community caries prevention programmes may be beneficial. Such programmes would include water fluoridation and a fluoride supplementation programme. (Kim MJ, et al. – BMC Oral Health. 2015 Dec 30;15:169)
Factors attributable for the prevalence of dental caries in Queensland children:   In the full models, children in the nonfluoridated areas had significantly higher prevalence of dental caries [PR for the primary: 1.29 (1.11-1.50); PR for the permanent 1.49 (1.01-2.21)] compared with children in fluoridated areas, controlling for other factors. PAF estimates indicated that lack of water fluoridation attributed to 21% and 31% of primary and permanent dental caries, respectively in this child population. (Do LG., et al. – Community Dent Oral Epidemiol. 2015 Oct;43(5):397-405)  (full review)
Water fluoridation for the prevention of dental caries - Cochrane Review:  
The results from the caries severity data indicate that the initiation of water fluoridation results in reductions in dmft of 1.81 (95% CI 1.31 to 2.31; 9 studies at high risk of bias, 44,268 participants) and in DMFT of 1.16 (95% CI 0.72 to 1.61; 10 studies at high risk of bias, 78,764 participants). This translates to a 35% reduction in dmft and a 26% reduction in DMFT compared to the median control group mean values. There were also increases in the percentage of caries free children of 15% (95% CI 11% to 19%; 10 studies, 39,966 participants) in deciduous dentition and 14% (95% CI 5% to 23%; 8 studies, 53,538 participants) in permanent dentition. The majority of studies (71%) were conducted prior to 1975 and the widespread introduction of the use of fluoride toothpaste.There is insufficient information to determine whether initiation of a water fluoridation programme results in a change in disparities in caries across socioeconomic status (SES) levels.There is insufficient information to determine the effect of stopping water fluoridation programmes on caries levels.No studies that aimed to determine the effectiveness of water fluoridation for preventing caries in adults met the review's inclusion criteria.With regard to dental fluorosis, we estimated that for a fluoride level of 0.7 ppm the percentage of participants with fluorosis of aesthetic concern was approximately 12% (95% CI 8% to 17%; 40 studies, 59,630 participants). This increases to 40% (95% CI 35% to 44%) when considering fluorosis of any level (detected under highly controlled, clinical conditions; 90 studies, 180,530 participants). Over 97% of the studies were at high risk of bias and there was substantial between-study variation. (Cochrane Database Syst Rev. 2015 Jun 18;6) (a response to feedback)

There was significant resulting commentary (#1, #2, #3, #4, #5, #6, #7) that clearly illustrates the complexity of the fluoridation discussion, the way a published paper can be misused by fluoridation opponents and the impact of personal biases (for and against fluoridation) on the interpretation of study results.  Contrast the 2015 Cochrane review with a 2000 literature review of fluoridation, Systematic review of water fluoridation, published in the British Medical Journal that concluded, "The evidence of a beneficial reduction in caries should be considered together with the increased prevalence of dental fluorosis. There was no clear evidence of other potential adverse effects."
Community water fluoridation and health outcomes in England: a cross-sectional study: 
BACKGROUND: Six million people in England live in areas where the level of fluoride in water is adjusted to reduce the significant public health burden of dental caries. The dental effects of fluoride are well established, but evidence for suggested adverse health effects is limited, with a lack of rigorous small area population studies that control for confounding. This study aims to test the association between water fluoridation schemes and selected health outcomes using the best available routine data sources.
METHODS: Ecological level exposure to fluoridated water was estimated for standard small areas and administrative districts in England using Geographical Information Systems and digitized boundaries based on known patterns of water supply. The association between fluoridation and dental and nondental health indicators was tested using multivariable regression models including ecological level confounding variables. Health indicator data were obtained from routine sources.
RESULTS: There was strong evidence of lower prevalence of dental caries (P< 0.001) among children living in fluoridated areas, they also had fewer teeth affected on average (P < 0.001), and lower admission rates for tooth extraction (55% lower; 95% CI-73%, -27%; P = 0.001). There was no strong evidence of an association between fluoridation and hip fracture, Down syndrome, all-cancer, all-cause mortality or osteosarcoma. Fluoridation was negatively associated with the incidence of renal stones (7.9% lower; 95% CI-9.6%,-6.2%; P < 0.001) and bladder cancer (8.0% lower; 95% CI-9.9%,-6.0%; P < 0.001).
CONCLUSION: This study uses the comprehensive data sets available in England to provide reassurance that fluoridation is a safe and highly effective public health measure to reduce dental decay. Although lower rates of certain nondental outcomes were found in fluoridated areas, the ecological, observational design prohibits any conclusions being drawn regarding a protective role of fluoridation. (Young N, et al. – Community Dent Oral Epidemiol. 2015 Dec;43(6):550-9)

Community Water Fluoridation in New Zealand
A cost effectiveness analysis of community water fluoridation in New Zealand: 
This cost effectiveness analysis supports an earlier economic analysis of community water fluoridation in New Zealand by Wright et. al. (2001) 3 . CWF remained a cost effective public health intervention in New Zealand despite an overall reduction in dental caries. This finding also agrees with a number of economic analyses of CWF conducted in countries similar to New Zealand, 7, 9-11 . It should be noted however, that for smaller communities cost effectiveness was more marginal. Wright et. al. (2001) identified a ‘break even’ community size for CWF of 700-900 people 3 . In smaller communities cost effectiveness was more dependent on the risk profile of the population. CWF would be more cost effective in communities with a higher risk of dental caries. (Fyfe C, et al. – New Zealand Medical Journal 12/2015, 128(1427))
Public perceptions and scientific evidence for perceived harms/risks of community water fluoridation: An examination of online comments pertaining to fluoridation cessation in Calgary in 2011: 
OBJECTIVES: To examine the perceived harms/risks of fluoridation as expressed in online forums relating to cessation and aftermath in Calgary, specifically, 1) which harms/risks are mentioned, for those harms/risks, what kinds of evidence are cited, to what extent is scientific literature cited, and what is its quality, and for a subset of harms/risks, what is known from the broader scientific literature?
METHODS: Relevant online comments were identified through free-text Internet searches, and those explicitly discussing the harms/risks of water fluoridation were extracted. Types of evidence mentioned were identified, and the scientific papers cited were reviewed. Finally, the broader scientific literature on two of the harms/risks was reviewed and synthesized.
SYNTHESIS: We identified 17 distinct groups of harms/risks, which spanned human body systems, the environment and non-human organisms. Most often, no evidence was cited. When evidence was cited, types included individuals viewed as authorities and personal experiences. Reference to scientific articles was rare, and those papers (n = 9) had significant methodological concerns. Our review of scientific literature on fluoride and thyroid functioning and phytoplankton revealed some negative effects of fluoride at concentrations exceeding maximum recommended levels (>1.5 ppm).
CONCLUSION: The findings have implications for communication with the public about fluoridation. First, to the extent that the public consults the scientific literature, it is essential that the methodological limitations of a study, as well as its relevance to community water fluoridation, be widely and promptly communicated. Second, scientific evidence is only one component of why some people support or do not support fluoridation, and communication strategies must accommodate that reality. (Podgorny PC, McLaren L. – Can J Public Health. 2015 Jun 19;106(6))
Water Fluoridation: Safety, Effectiveness and Value in Oral Health: A Symposium at the 2014 Annual Meeting of the American and Canadian Associations for Dental Research: 
The objective of this symposium was to review the scientific evidence supporting CWF and consider the implications for optimizing the use of fluoride in public health and clinical practice. The following presentations were held at the symposium:
1. Effectiveness of fluorides - Findings of evidence-based reviews:  The use of fluoride has been associated with a substantial reduction in caries in children and adolescents. The presentation also highlighted evidence gaps for effectiveness of certain fluoride modalities, as well as the relationship among effectiveness, dose, and safety for the products. With the exception of enamel fluorosis, no other adverse effects are associated with community water fluoridation.
2. The health assessment of fluoride in drinking water: Conclusions from the National Research Council and subsequent scientific assessments by EPA: 
a) EPA estimates of RfD and the recommended benchmarks are conservative.
b) More recent studies of osteosarcoma and bone fractures confirm that water fluoridation has no impact on these outcomes.
c) Lowering fluoride exposure may lead to reduction in dental fluorosis but the question remains about its impact on caries.
3. Gaps in scientific knowledge regarding water fluoridation and other fluoride modalities: Fluoridated water reduces tooth decay in adults, even if they start drinking it after childhood. Communities that implement fluoridation can expect benefits to accrue for both future and current generations. More people in the population benefit from water fluoridation than previously was thought. The greater benefit has a significant impact on calculations of population cost-effectiveness. Recent findings from Australia add to six decades of evidence showing that community water fluoridation prevents dental caries in adults. The evidence should be considered when formulating health policies and public health programs.
4. Community water fluoridation: Translating evidence into public health practice: The translation of scientific evidence into public health practice demands ongoing efforts to update estimates of effectiveness and costs of the intervention, assure safety, identify and address gaps in knowledge, and apply data-driven approaches to monitor implementation and communicate with stakeholders.
(Presenters, Dr. Martinez-Mier, Dr. Kumar, Dr. Slade, Dr. Gooch – J Can Dent Assoc 2015;81:f16)
Does fluoride in the water close the dental caries gap between Indigenous and non-Indigenous children? 
RESULTS: Dental caries prevalence and severity for Indigenous and non-Indigenous children, in both dentitions, was lower in fluoridated areas compared to non-fluoridated areas. Among non-Indigenous children, there was a 50.9% difference in mean dmft scores in fluoridated (1.70) compared to non-fluoridated (2.86) areas. The difference between Indigenous children in fluoridated (3.29) compared to non-fluoridated (4.16) areas was 23.4%. Among non-Indigenous children there was a 79.7% difference in the mean DMFT scores in fluoridated (0.68) compared to non-fluoridated (1.58) areas. The difference between Indigenous children in fluoridated (1.59) and non-fluoridated (2.23) areas was 33.5%.
CONCLUSIONS: Water fluoridation is effective in reducing dental caries, but does not appear to close the gap between non-Indigenous children and Indigenous children. (Lalloo R, et al. – Aust Dent J. 2015 Sep;60(3):390-6)
U.S. Public Health Service Recommendation for Fluoride Concentration in Drinking Water for the Prevention of Dental Caries:   Through this final recommendation, the U.S. Public Health Service (PHS) updates and replaces its 1962 Drinking Water Standards related to community water fluoridation—the controlled addition of a fluoride compound to a community water supply to achieve a concentration optimal for dental caries prevention.1 For these community water systems that add fluoride, PHS now recommends an optimal fluoride concentration of 0.7 milligrams/liter (mg/L). In this guidance, the optimal concentration of fluoride in drinking water is the concentration that provides the best balance of protection from dental caries while limiting the risk of dental fluorosis. The earlier PHS recommendation for fluoride concentrations was based on outdoor air temperature of geographic areas and ranged from 0.7–1.2 mg/L.
Systematic reviews of the scientific evidence related to fluoride have concluded that community water fluoridation is effective in decreasing dental caries prevalence and severity. Effects included significant increases in the proportion of children who were caries-free and significant reductions in the number of teeth or tooth surfaces with caries in both children and adults. When analyses were limited to studies conducted after the introduction of other sources of fluoride, especially fluoride toothpaste, beneficial effects across the lifespan from community water fluoridation were still apparent.
Fluoride in saliva and dental plaque works to prevent dental caries primarily through topical -remineralization of tooth surfaces. Consuming fluoridated water and beverages, and foods prepared or processed with fluoridated water, throughout the day maintains a low concentration of fluoride in saliva and plaque that enhances remineralization. Although other fluoride-containing products are available and contribute to the prevention and control of dental caries, community water fluoridation has been identified as the most cost-effective method of delivering fluoride to all members of the community regardless of age, educational attainment, or income level.9,30 Studies continue to find that community water fluoridation is cost saving. (Public Health Rep. 2015 Jul-Aug; 130(4): 318–331)
Water Intake by Outdoor Temperature Among Children Aged 1-10 Years: Implications for Community Water Fluoridation in the U.S.
RESULTS: We found that total water intake was not associated with temperature. Plain water intake was weakly associated with temperature in unadjusted (coefficient 5 0.2, p=0.015) and adjusted (coefficient 5 0.2, p=0.013) linear regression models. However, these models explained little of the individual variation in plain water intake (unadjusted: R(2)=0.005; adjusted: R(2)=0.023).
CONCLUSION: Optimal fluoride concentration in drinking water to prevent caries need not be based on outdoor temperature, given the lack of association between total water intake and outdoor temperature, the weak association between plain water intake and outdoor temperature, and the minimal amount of individual variance in plain water intake explained by outdoor temperature. These findings support the change in the U.S. Public Health Service recommendation for fluoride concentration in drinking water for the prevention of dental caries from temperature-related concentrations to a single concentration that is not related to outdoor temperature. (Beltrán-Aguilar ED, et al. – Public Health Rep. 2015 Jul-Aug;130(4):362-71)
Risk perception, psychological heuristics and the water fluoridation controversy: 
OBJECTIVES: Increasingly, support for water fluoridation has come under attack. We seek an explanation, focusing on the case of Waterloo, Ontario, where a 2010 referendum overturned its water fluoridation program. In particular, we test whether individuals perceive the risks of water fluoridation based not on 'hard' scientific evidence but on heuristics and cultural norms.
METHODS: A sample of 376 residents in Waterloo were surveyed in June 2012 using random digit dialing. We use factor analysis, OLS regression, as well as t-tests to evaluate a survey experiment to test the credibility hypothesis.
RESULTS: Perceptions of fluoride as a risk are lower among those who perceive fluoride's benefits (B = .473, p < 0.001) and those whose cultural view is 'egalitarian' (B = .156, p < 0.05). The experiment shows a lower level of perception of fluoride's benefits among respondents who are told that water fluoridation is opposed by a national advocacy group (Group A) compared to those who are told that the government and the World Health Organization support fluoridation (Group B) (t = 1.6547, p < 0.05), as well as compared to the control group (t = 1.8913, p < 0.05). There is no difference between Group B and the control, possibly because people's already general support for fluoridation is less prone to change when told that other public organizations also support fluoridation.
CONCLUSION: Public health officials should take into account cultural norms and perceptions when individuals in a community appear to rise up against water fluoridation, with implications for other public health controversies.
(Perrella AM, Kiss SJ – Can J Public Health. 2015 Apr 29;106-10)
New international review supports community water fluoridation as an effective and safe dental health promotion measure:  Strong evidence supports the safety and efficacy of CWF. The benefits are most pronounced for low SES groups. However, opponents of fluoridation through dissemination of misinformation pose an ongoing threat to CWF’s continuation. Public health professionals have a responsibility to counter such misinformation and to support water fluoridation. (Howat P, et al. – Health Promotion Journal of Australia, 2015, 26, 1–3)
A 4-year assessment of a new water-fluoridation scheme in New South Wales, Australia: 
OBJECTIVE: To monitor the changes in dental caries prevalence of 5- to 7-year-old children living in a fluoridated area, a newly fluoridated area and in an area without water fluoridation, in NSW, Australia.
RESULTS: The caries prevalence changed over time. In 2008, the mean dmft index was 1.40 for the fluoridated area, 2.02 for the area about to fluoridate and 2.09 for the unfluoridated control. By 2012, these mean dmft scores were 0.69, 0.72 and 1.21, respectively. In the two areas where children received fluoridated water, the significant caries index was 2.30 for the fluoridated area and 2.40 for the newly fluoridated area. The significant caries score for children in the unfluoridated location was 3.93. Multivariate analysis showed that over time the differences in dental caries prevalence between the established fluoride area and the newly fluoridated area diminished. However, children in the unfluoridated control area continued to demonstrate significant differences in the mean number of decayed teeth compared with children in the fluoridated comparator sites, and the proportions of children free from decay were significantly higher in the fluoridated areas than in the unfluoridated area.
CONCLUSION: Fluoridation of public water supplies in Gosford and Wyong offers young children better dental health than those children who do not have access to this public health measure. (Blinkhorn AS, et al. – Int Dent J. 2015 Jun;65(3):156-63)
Does lower lifetime fluoridation exposure explain why people outside capital cities have poor clinical oral health? 
BACKGROUND: Australians outside state capital cities have greater caries experience than their counterparts in capital cities. We hypothesized that differing water fluoridation exposures was associated with this disparity.
METHODS: Data were the 2004-06 Australian National Survey of Adult Oral Health. Examiners measured participant decayed, missing and filled teeth and DMFT Index and lifetime fluoridation exposure was quantified. Multivariable linear regression models estimated differences in caries experience between capital city residents and others, with and without adjustment for fluoridation exposure.
RESULTS: There was greater mean lifetime fluoridation exposure in state capital cities (59.1%, 95% confidence interval=56.9,61.4) than outside capital cities (42.3, confidence interval=36.9,47.6). People located outside capital city areas had differing socio-demographic characteristics and dental visiting patterns, and a higher mean DMFT (Capital cities=12.9, Non-capital cities=14.3, p=0.02), than people from capital cities. After adjustment for socio-demographic characteristics and dental visits, DMFT of people living in capital cities was less than non-capital city residents (Regression coefficient=0.8, p=0.01). The disparity was no longer statistically significant (Regression coefficient=0.6, p=0.09) after additional adjustment for fluoridation exposure. (Crocombe LA, et al. – Aust Dent J. 2015 Mar 26)

Fluoridation and hypothyroidism – a commentary on Peckham et al. -  
Peckham et al. fail to understand the limitations of a poorly conducted ecological trial, and the paper contains serious biases and flaws. Literature reviews have been highly selective and critical analysis of that literature has been poor. The authors show a disturbing tendency to focus on a small number of poor quality studies that reinforce their own views, while ignoring contradictory evidence from much stronger studies and reviews. Peckham et al. should have heeded the adage ‘correlation is not causation’ before coming to a conclusion at odds with a large body of reputable evidence from around the world. In my opinion, the paper’s conclusions can and should be dismissed. (M. Foley – British Dental Journal, Vol. 219,9, 11/13/2015)
Exposure to fluoride in drinking water and hip fracture risk: a meta-analysis of observational studies: 
CONCLUSION: The present meta-analysis suggests that chronic fluoride exposure from drinking water does not significantly increase the risk of hip fracture. Given the potential confounding factors and exposure misclassification, further large-scale, high-quality studies are needed to evaluate the association between exposure to fluoride in drinking water and hip fracture risk. (Yin XH, et al. – PLoS One. 2015 May 28)
Water fluoridation, dentition status and bone health of older people in Ireland:  
RESULTS: It was found that the greater the percentage of households with a fluoridated water supply in an area, the higher the probability that respondents had all their own teeth. There was no significant relationship between the proportion of households with a fluoridated water supply in an area and bone health.
CONCLUSION: This study suggests that water fluoridation provides a net health gain for older Irish adults, though the effects of fluoridation warrant further investigation. (O Sullivan V, O Connell BC. – Community Dent Oral Epidemiol. 2015 Feb;43(1):58-67)  A description of the study can be read here/a>.
Effects of water fluoridation on caries experience in the primary dentition in a high caries risk community in Queensland, Australia:  CONCLUSIONS: After only 36 months of water fluoridation there was a significant drop in caries prevalence from 87 to 75% and a 19% reduction in caries experience in a community with one of the highest caries rates in Australia. (Koh R, et al. – Caries Res. 2015;49(2):184-91)
Perceived safety and benefit of community water fluoridation: 2009 HealthStyles survey: CONCLUSIONS: Although only a minority of the US population perceived CWF as unsafe or providing no benefit to health, perceptions regarding CWF varied by knowledge of CWF and socio-demographic factors. Oral health promotion activities should consider these differing perceptions of CWF among groups to tailor oral health messaging appropriately. (Mork N, Griffin S. – J Public Health Dent. 2015 Sep;75(4):327-36)
Hospitalizations for dental infections: Optimally versus nonoptimally fluoridated areas in Israel:  CONCLUSIONS: These results clearly indicate that there is an association between adequacy of water fluoridation and hospitalization due to dental infections among children and adolescents. This effect is more prominent in populations of lower socioeconomic status. (Klivitsky A, et al. – J Am Dent Assoc. 2015 Mar; 146(3):179-83)   Full Article
Community Water Fluoridation and Intelligence: Prospective Study in New Zealand:  
. This study aimed to clarify the relationship between Community Water Fluoridation (CWF) and IQ.
Methods. We conducted a prospective study of a general population sample of those born in Dunedin, New Zealand, between April 1, 1972, and March 30, 1973 (95.4% retention of cohort after 38 years of prospective follow-up). Residence in a CWF area, use of fluoride dentifrice and intake of 0.5-milligram fluoride tablets were assessed in early life (prior to age 5 years); we assessed IQ repeatedly between ages 7 to 13 years and at age 38 years.
Results. No clear differences in IQ because of fluoride exposure were noted. These findings held after adjusting for potential confounding variables, including sex, socioeconomic status, breastfeeding, and birth weight (as well as educational attainment for adult IQ outcomes).
These findings do not support the assertion that fluoride in the context of CWF programs is neurotoxic. Associations between very high fluoride exposure and low IQ reported in previous studies may have been affected by confounding, particularly by urban or rural status. (Broadbent JM, et al. – Am J Public Health. 2015 Jan;105(1):72-76)
The Dental Health of primary school children living in fluoridated, pre-fluoridated and non-fluoridated communities in New South Wales, Australia:   CONCLUSION: The children living in the well-established fluoridated area had less dental caries and a higher proportion free from disease when compared with the other two areas which were not fluoridated. Fluoridation demonstrated a clear benefit in terms of better oral health for young children. (Blinkhorn AS, et al. – BMC Oral Health. 2015 Jan 21;15(1):9)

Setting the Record Straight on Fluoride:  In a letter to JAMA Internal Medicine published earlier this year, two political scientists from the University of Chicago reported that 12% of Americans agree with this statement: “Public water fluoridation is really just a secret way for chemical companies to dump the dangerous byproducts of phosphate mines into the environment.” Perhaps more disturbing, fewer than half of respondents disagreed with the statement, which means there is an urgent need to steer people toward reliable sources of accurate information so they can play an informed role in decision-making around this crucial aspect of the public health infrastructure. (Valachovic R. – J Mich Dent Assoc. 2015 Apr;97(4):38-40)
Contemporary multilevel analysis of the effectiveness of water fluoridation in Australia:   RESULTS: Data from 2,214 5-8 year-olds and 3,186 9-14 year-olds from 207 schools in 16 areas were analysed. Queensland's average dmfs was 4.23 and DMFS 1.47. The lowest levels of dental caries were observed in long-term fluoridated Townsville. In the full models, Townsville children had significantly lower caries experience (RR for dmfs: 0.61 (95%CI: 0.44-0.82); RR for DMFS 0.60 (95%CI: 0.42-0.88)) compared with children in non-fluoridated areas. (Do L, Spencer AJ. – Aust N Z J Public Health. 2015 Feb;39(1):44-50)
Dental fluorosis in the Blue Mountains and Hawkesbury, New South Wales, Australia: policy implications:   CONCLUSIONS: For the group as a whole, we concluded that: (a) fluorosis prevalence (0.39) in both regions was similar; and (b) the higher-than-expected prevalence and severity of fluorosis was due mainly to two factors: (a) the higher-than-optimal fluoride level in drinking water; and (b) swallowing of fluoride toothpaste in early childhood. (Bal IS, et al. – J Investig Clin Dent. 2015 Feb;6(1):45-52)  A related letter to the BDJ

From the American Academy of Pediatrics
Fluoride Use in Caries Prevention in the Primary Care Setting:   Dental caries remains the most common chronic disease of childhood in the United States. Caries is a largely preventable condition, and fluoride has proven effectiveness in the prevention of caries. The goals of this clinical report are to clarify the use of available fluoride modalities for caries prevention in the primary care setting and to assist pediatricians in using fluoride to achieve maximum protection against dental caries while minimizing the likelihood of enamel fluorosis. (Clark M, et al. – Pediatrics Vol. 134 No. 3 September 1, 2014 pp. 626 -633)

North Carolina Medical Journall
Preventing Dental Caries Through Community Water Fluoridation:   The weight of the scientific evidence in peer-reviewed literature does not support an association between community water fluoridation and any adverse health effects or systemic disorders, including an increased risk for cancer, Down syndrome, heart disease, osteoporosis, bone fractures, immune disorders, low intelligence, renal disorders, Alzheimer disease, or allergic reactions.  Not only is community water fluoridation safe and effective, it is also cost saving, and it is the least expensive way to deliver the benefits of fluoride to all residents of a community. (White BA & Gordon SM – N C Med J. 2014;75(6):430-431) {A summary of benefits from a review of other papers} - Free Full Text
Dental Fluorosis and Dental Caries Prevalence among 12 and 15-Year-Old School Children in Nalgonda District, Andhra Pradesh, India:
BACKGROUND: Fluoride is a double edged sword. The assessment of dental caries and fluorosis in endemic fluoride areas will facilitate in assessing the relation between fluoride concentrations in water with dental caries, dental fluorosis simultaneously.
RESULTS: The caries prevalence was less among 12-year-old children (39.9%]) compared with 15-years-old children (46.7%). The prevalence was more among females (50.4% than males (35.8%. The prevalence was more in low fluoride area (60.5%) followed by very high fluoride area (54.8%), high fluoride area (32.4%]) and medium fluoride area (17.6%) in the descending order. The fluorosis prevalence increased with increasing fluoride concentration with no difference in gender and age distribution.
CONCLUSION: Low fluoride areas require fluoridation or alternate sources of fluoride, whereas high fluoride areas require defluoridation. Defluoridation of water is an immediate requirement in areas with fluoride concentration of 4 parts per million and above as dental fluorosis is a public health problem in these areas with 100% prevalence. (Sukhabogi Jr, et al. – Ann Med Health Sci Res. 2014 Sep;4(Suppl 3))
The effect of lifetime fluoridation exposure on dental caries experience of younger rural adults:   CONCLUSIONS: The higher level of lifetime fluoridation exposure was associated with substantially lower caries experience in younger rural adults, largely due to a lower number of filled teeth. (Crocombe L, et al. – Aust Dent J. 2014 Oct 20.)
Variation in fluorosis and caries experience among Lithuanian 12 year olds exposed to more than 1 ppm F in tap water: AIM: The aim of the present study was to analyze caries experience in relation to the occurrence of fluorosis in 12 year olds in a natural fluoride area. CONCLUSION: The presence of fluorosis associates with lesser caries experience in 12-year-old lifetime residents of an area with moderately-elevated natural fluoride. (Narbutaitė J, et al. – J Investig Clin Dent. 2014 Dec 1)
Fluoride retention in saliva and in dental biofilm after different home-use fluoride treatments:   In this study, we evaluated whether fluoride concentrations in saliva and dental biofilm remained significantly elevated at 8 h after four different oral hygiene procedures in volunteers living in an area with fluoridated water supply. The fluoride concentrations in saliva and in dental biofilm were not significantly different among the treatments. The frequency of brushing with a fluoride dentifrice and additional use of fluoride mouthrinse followed by brushing with a fluoride dentifrice did not affect the fluoride concentrations in biofilm and saliva at 8 h after the last procedure. The results of this study are in agreement with the findings of most of the studies conducted in areas with a fluoridated water supply.13,20,21,22 These studies also did not show a long-term effect on the fluoride concentration in saliva and in dental biofilm compared to baseline values. A possible explanation for these is that plaque-binding sites for long-term fluoride retention are occupied by fluoride ions largely in communities with fluoridated water, but not where the water contains only traces of this ion. (Souza DC & Maltz M. – Braz Oral Res. 2014 Jan-Feb;28)

British Dental Journal
Concern over limited access to water fluoridation:   The British Dental Association (BDA) and the British Society of Paediatric Dentistry (BSPD) have expressed concern that limited access to water fluoridation - only 10% of the UK's population - means we are failing children who live in communities with high levels of tooth decay. Concern over limited access to water fluoridation In its latest report on fluoridation, the BSPD highlights that 60,683 children and adolescents in England were admitted to hospital in 2012/13 to have multiple decayed teeth removed under general anaesthetic, costing the NHS at least '27.6 million. By contrast, evidence suggests that children living in fluoridated areas, such as the West Midlands, have around half the rate of tooth decay of those living in non-fluoridated areas, and thousands have been spared from traumatic and distressing operations. Research indicates that adults also benefit. (British Dental Journal 217, 616 (2014))
An alternative marker for the effectiveness of water fluoridation: hospital extraction rates for dental decay, a two-region study:  CONCLUSIONS: After ranking by IMD, DSRs of hospital admissions for the extraction of decayed or pulpally/periapically involved teeth is lower in areas with a fluoridated water supply. The analysis of routinely collected HES data may help identify the impact of water fluoridation schemes. (Elmer TB, et al. – Br Dent J. 2014 Mar;216(5))
Community water fluoridation on the Internet and social media:
In the United States, 95 percent of teens and 85 percent of adults use the Internet. Two social media outlets, Facebook and Twitter, reach more than 150 billion users. This study describes anti-fluoridation activity and dominance on the Internet and social media, both of which are community water fluoridation (CWF) information sources.
METHODS: Monthly website traffic to major fluoridation websites was determined from June 2011 to May 2012. Facebook, Twitter, and YouTube fluoridation activity was categorized as "proCWF" or "anti-CWF." Twitter's anti-CWF tweets were further subcategorized by the argument used against CWF.
RESULTS: Anti-CWF website traffic was found to exceed proCWF activity five- to sixty-fold. Searching "fluoride" and "fluoridation" on Facebook resulted in 88 to 100 percent anti-CWF groups and pages; "fluoridation" on Twitter and YouTube resulted in 64 percent anti-CWF tweets and 99 percent anti-CWF videos, respectively. "Cancer, " "useless, " and "poisonous" were the three major arguments used against fluoridation.
CONCLUSIONS: Anti-fluoridation information significantly dominates the Internet and social media. Thousands of people are being misinformed daily about the safety, health, and economic benefits of fluoridation. (Mertz A, Allukian M. – J Mass Dent Soc. 2014 Summer;63(2):32-6)
Does fluoride in drinking water delay tooth eruption?  RESULTS: By age 7, almost all permanent first molars had erupted. The adjusted mean number of erupted permanent first molars per child were 3.81, 3.67, and 3.92 in areas with <0.3, 0.3-<0.7, and 0.7-1.2 ppm of fluoride, respectively. The adjusted caries attack rate in the first permanent molars among 5- to 17-year-old children was 93, 81, and 78 per 1,000 surfaces in fluoride deficient, suboptimal, and optimally fluoridated areas, respectively (P < 0.0001). This pattern of higher first molar attack rate among children in the fluoride-deficient communities was also observed in all erupted teeth.
CONCLUSION: Exposure to fluoride in drinking water did not delay the eruption of permanent teeth. The observed difference in dental caries experience among children exposed to different fluoride levels could not be explained by the timing of eruption of permanent teeth. (Jolaoso IA, et al. – J Public Health Dent. 2014 Summer;74(3):241-7)
Is fluoride a risk factor for bone cancer? Small area analysis of osteosarcoma and Ewing sarcoma diagnosed among 0-49-year-olds in Great Britain, 1980-2005:  CONCLUSIONS: The findings from this study provide no evidence that higher levels of fluoride (whether natural or artificial) in drinking water in GB lead to greater risk of either osteosarcoma or Ewing sarcoma. (Blakey K1, et al. – Int J Epidemiol. 2014 Feb;43(1):224-34)
Eye cancer incidence in U.S. states and access to fluoridated water: Environmental risk factors for uveal melanomas (cancer of the iris, ciliary body, and choroid) have not been identified. To search for these, we examined the correlation of age-adjusted eye cancer incidence rates, a surrogate for uveal melanoma rates, in U.S. states with group level geographic and demographic factors using multivariate linear regression. Incidence rates for eye cancer were inversely correlated with the percentage of the population receiving fluoridated water; that is, higher rates were found in states with lower prevalences of fluoridation (P = 0.01). Fluoride is known to inhibit the growth of microbial agents that cause choroiditis and choroidal lesions in animals. We speculate that fluoridation protects against choroidal melanoma by inhibiting microbial agents that cause choroiditis and/or choroidal lesions in humans. (Schwartz GG – Cancer Epidemiol Biomarkers Prev. 2014 Sep;23(9):1707-11)
Effects of Life-long Fluoride Intake on Bone Measures of Adolescents: A Prospective Cohort Study:  The findings suggest that fluoride exposures at the typical levels for most US adolescents in fluoridated areas do not have significant effects on bone mineral measures. (Levy SM, et al. – J Dent Res. 2014 Apr;93(4):353-9)
Association of dental caries with socioeconomic status in relation to different water fluoridation levels:   CONCLUSIONS: This study supported that water fluoridation could not only lead to a lower prevalence of dental caries, but also help to reduce the effect of SES inequalities on oral health. (Cho HJ, et al. – Community Dent Oral Epidemiol. 2014 Dec;42(6):536-42)
Effectiveness of water fluoridation in caries reduction in a remote Indigenous community in Far North Queensland:   BACKGROUND: Children in remote Indigenous communities in Australia have levels of dental caries much greater than the national average. One such, the Northern Peninsula Area of Far North Queensland (NPA), had an oral health survey conducted in 2004, shortly before the introduction of fluoridated, reticular water. Children were again surveyed in 2012, following five years exposure. CONCLUSIONS: There has been considerable improvement in child dental health in the NPA over the past 6-7 years. In light of continued poor diet and oral hygiene, water fluoridation is the most likely explanation. The cost-effectiveness for this small community remains an issue which, in the current climate of political antagonism to water fluoridation in many quarters, requires continued study. (Johnson NW, et al. – Aust Dent J. 2014 Sep;59(3):366-71)
An alternative marker for the effectiveness of water fluoridation: hospital extraction rates for dental decay, a two-region study:   OBJECTIVES: To examine inpatient hospital episodes statistics for dental extractions as an alternative population marker for the effectiveness of water fluoridation by comparing hospital admissions between two major strategic health authority (SHA) areas, the West Midlands SHA-largely fluoridated--and the North West SHA--largely unfluoridated. METHOD: Hospital episodes statistics (HES) were interrogated to provide data on admissions for simple and surgical dental extractions, which had a primary diagnostic code of either dental caries or diseases of pulp and periapical tissues for financial years 2006/7, 2007/8 and 2008/9. Data was aggregated by SHA area and quinary age group. Directly standardised rates (DSR) of admissions purchased for each primary care trust (PCT) were calculated and ranked by index of multiple deprivation (IMD). RESULTS: A significant difference in DSRs of admission between PCTs in the West Midlands and North West was observed (Mann-Whitney U test [p <0.0001]) irrespective of IMD ranking. The difference in rates between the two most deprived PCTs was 27-fold. CONCLUSIONS: After ranking by IMD, DSRs of hospital admissions for the extraction of decayed or pulpally/periapically involved teeth is lower in areas with a fluoridated water supply. (Elmer TB, et al. – Br Dent J. 2014 Mar;216(5):E10)
Systemic effect of water fluoridation on dental caries prevalence:   CONCLUSIONS: While 6-year-old children who had not ingested fluoridated water showed higher dft in the WF-ceased area than in the non-WF area, 11-year-old children in the WF-ceased area who had ingested fluoridated water for approximately 4 years after birth showed significantly lower DMFT than those in the non-WF area. This suggests that the systemic effect of fluoride intake through water fluoridation could be important for the prevention of dental caries. (Cho HJ, et al. – Community Dent Oral Epidemiol. 2014 Jan 16)
Milk fluoridation for the prevention of dental caries:  CONCLUSION: These evaluations showed clearly that the optimal daily intake of fluoride in milk is effective in preventing dental caries. The amount of fluoride added to milk depends on background fluoride exposure and age of the children: commonly in the range 0.5 to 1.0 mg per day. An advantage of the method is that a precise amount of fluoride can be delivered under controlled conditions. The cost of milk fluoridation programmes is low, about - 2 to 3 per child per year. Fluoridation of milk can be recommended as a caries preventive measure where the fluoride concentration in drinking water is suboptimal, caries experience in children is significant, and there is an existing school milk programme. (Beneczy J et al. – Acta Med Acad. 2013 Nov;42(2):156-67)
Factors associated with surface-level caries incidence in children aged 9 to 13: the Iowa Fluoride Study:  CONCLUSION: More frequent tooth brushing was protective of sound surfaces, and fluoride in home tap water was also protective, but significantly more so for adolescents in low-income families. (Broffitt B, et al. – J Public Health Dent. 2013 Fall;73(4):304-10
Reduced adhesion of oral bacteria on hydroxyapatite by fluoride treatment:  The mechanisms of action of fluoride have been discussed controversially for decades. The cavity-preventive effect for teeth is often traced back to effects on demineralization. However, an effect on bacterial adhesion was indicated by indirect macroscopic studies. To characterize adhesion on fluoridated samples on a single bacterial level, we used force spectroscopy with bacterial probes to measure adhesion forces directly. We tested the adhesion of Streptococcus mutans , Streptococcus oralis , and Staphylococcus carnosus on smooth, high-density hydroxyapatite surfaces, pristine and after treatment with fluoride solution. All bacteria species exhibit lower adhesion forces after fluoride treatment of the surfaces. These findings suggest that the decrease of adhesion properties is a further key factor for the cariostatic effect of fluoride besides the decrease of demineralization. (Loskill P, et al. –  Langmuir. 2013 May 7;29(18):5528-33
Water fluoridation and oral health:  CONCLUSION: Water fluoridation is an effective safe means of preventing dental caries, reaching all populations, irrespective of the presence of other dental services. Regular monitoring of dental caries and fluorosis is essential particularly with the lifelong challenge which dental caries presents. (Harding MA, O'Mullane DM – Acta Med Acad. 2013 Nov;42(2):131-9)
The economic value of Quebec's water fluoridation program:  RESULTS: The analyses showed the water fluoridation program was cost-effective even with a conservatively estimated 1 % reduction in dental caries. The benefit-cost ratio indicated that, at an expected average effectiveness of 30 % caries reduction, one dollar invested in the program saved $71.05-$82.83 per Quebec's inhabitant in dental costs (in 2010) or more than $560 million for the State and taxpayers. CONCLUSION: The results showed that the drinking-water fluoridation program produced substantial savings. Public health decision-makers could develop economic arguments to support wide deployment of this population-based intervention whose efficacy and safety have been demonstrated and acknowledged. (Tchouaket E, et al. – Z Gesundh Wiss. 2013;21:523-533)
The economic value of Quebec's water fluoridation program:  Aim: Dental caries is a major public health problem worldwide, with very significant deleterious consequences for many people. The available data are alarming in Canada and the province of Quebec. The water fluoridation program has been shown to be the most effective means of preventing caries and reducing oral health inequalities. This article analyzes the cost-effectiveness of Quebec's water fluoridation program to provide decision-makers with economic information for assessing its usefulness. Conclusion: The results showed that the drinking-water fluoridation program produced substantial savings. Public health decision-makers could develop economic arguments to support wide deployment of this population-based intervention whose efficacy and safety have been demonstrated and acknowledged. (Eric Tchouaket, et al. – Z Gesundh Wiss. 2013; 21(6): 523-533)
Dental caries in 14- and 15-year-olds in New South Wales, Australia:  Teenagers living in fluoridated areas of NSW had lower mean DMFT rates (DMFT 1.1 versus 1.7, Table 5) and a higher percentage of children who had never experienced decay (56.0% versus 45.0%) than children in un-fluoridated areas. (John Skinner, et al. – BMC Public Health. 2013; 13: 1060)
Estimated Drinking Water Fluoride Exposure and Risk of Hip Fracture.  A Cohort Study:  Overall, we found no association between chronic fluoride exposure and the occurrence of hip fracture. The risk estimates did not change in analyses restricted to only low-trauma osteoporotic hip fractures. Chronic fluoride exposure from drinking water does not seem to have any important effects on the risk of hip fracture, in the investigated exposure range. (Nesman P, et al. – J Dent Res. 2013 Oct 1) - Free Article
Understanding Public Decision-Making on Community Water Fluoridation (CWF):  Understanding public concern and building from common ground when engaging the public can effectively build trust. 'Trust is difficult to build once a CWF campaign is already underway,' adds Dr. Swan. The report found that although public trust in scientific and medical organizations cannot be relied on, people's trust in their own practitioners remained high. 'So, discussing CWF with your patients may help build public support for CWF.' (J Can Dent Assoc. 2013 May;79:d77)
Related: Effectiveness of Population-Based Interventions to Promote Oral Health
Effects of Fluoridated Drinking Water on Dental Caries in Australian Adults: The study shows that Australian adults with more than 75% lifetime exposure to water fluoridation have significantly reduced caries experience when compared with those with less than a 25% lifetime exposure. This reduction has occurred in adult Australians born in both the pre- and post-fluoridation generation. The significance of this is that the introduction of water fluoridation to a community will benefit all residents, not only those who grow up drinking fluoridated water. (Slade GD, et al. – J Dent Res. 2013 Mar 1)
Fluoridation and dental caries severity in young children treated under general anaesthesia: an analysis of treatment records in a 10-year case series:  CONCLUSIONS: Children with severe dental caries had statistically significantly lower numbers of lesions if they lived in a fluoridated area. The lower treatment need in such high-risk children has important implications for publicly-funded dental care.. (Kamel MS, et al. – Community Dent Health. 2013 Mar;30(1):15-8)
Water fluoridation and the association of sugar-sweetened beverage consumption and dental caries in Australian children: Consumption of sugar-sweetened beverages should be considered a major risk factor for dental caries. However, increased exposure to fluoridated public water helped ameliorate the association between SSB consumption and dental decay. These results reconfirm the benefits of community water fluoridation for oral health. (Mullen J, et al. – Am J Public Health. 2013 Mar;103(3):494-500)
Caries status in 16 year-olds with varying exposure to water fluoridation in Ireland: RESULTS: With both systems of measurement, significantly lower caries levels were found in those children with the greatest exposure to fluoridated water when compared to those with the least exposure.
CONCLUSIONS: The survey provides further evidence of the effectiveness in reducing dental caries experience up to 16 years of age. The extra intricacies involved in using the Percentage Lifetime Exposure method did not provide much more information when compared to the simpler Estimated Fluoridation Status method. . (Armfield JM, et al. – Community Dent Health. 2012 Dec;29(4):293-6) - Free Article
Prevalence of dental caries and dental fluorosis among 12 and 15 years old school children in relation to fluoride concentration in drinking water in an endemic fluoride belt of Andhra Pradesh: CONCLUSION: There was a negative correlation between dental caries and fluoride concentration for the entire study population. However, in high fluoride areas, there was a positive correlation between fluoride concentration and dental caries. Water defluoridation on an urgent basis is a priority here than water fluoridation, because the prevalence and severity of dental flurorosis is very high.
According to our study, an optimum range of fluoride concentration in this area that offered maximum protection against dental caries with minimal risk for esthetically significant fluorosis, was 0.6 - 1.3 PPM. This is very close to the optimal fluoride concentration of 0.6 - 1.2 PPM, suggested by Bureau of Indian standards. (Shekar C, et al. – Indian J Public Health. 2012 Apr-Jun;56(2):122-8) - Free Article
The association between social deprivation and the prevalence and severity of dental caries and fluorosis in populations with and without water fluoridation: CONCLUSIONS: Water fluoridation appears to reduce the social class gradient between deprivation and caries experience when considering caries into dentine. However, this was associated with an increased risk of developing mild fluorosis. The use of intra-oral cameras and remote scoring of photographs for caries demonstrated good potential for blinded scoring. (McGrady MG, et al. – BMC Public Health. 2012 Dec 28;12:1122)
Decline in dental caries among 12-year-old children in Brazil, 1980-2005: CONCLUSIONS: Data showed a significant decrease in dental caries across the entire country, with an average reduction of 25% occurring every 5 years. General trends indicated that a reduction in DMFT index values occurred over time, that a further reduction in DMFT index values occurred when a municipality fluoridated its water supply, and mean DMFT index values were lower in larger than in smaller municipalities. (Lauris JR, et al. – Int Dent J. 2012 Dec;62(6):308-14) - Free Article
Fluorides - mode of action and recommendations for use: Various authors have shown that the caries decline in the industrialized countries during recent decades is based on the use of fluorides, of which local fluoride application in the form of fluoridated toothpastes is of primary importance. The caries-protective potential of fluorapatite is quite low; in contrast, dissolved fluorides in the vicinity of enamel are effective both in promoting remineralization and inhibiting demineralization. Considering the fact that the caries decline occurred at the same time that local fluoridation measures became widely used, the conclusion seems justified that regular application of F⁻ can inhibit caries. (Lussi A, et al. – Schweiz Monatsschr Zahnmed. 2012;122(11):1030-42)
Effectiveness of water fluoridation in caries prevention: CONCLUSIONS: Fewer studies have been published recently. More of these have investigated effect at the multi-community, state or even national level. The dmf/DMF index remains the most widely used measure of effect. % CR were lower in recent studies, and the 'halo' effect was discussed frequently. Nevertheless, reductions were still substantial. Statistical control for confounding factors is now routine, although the effect on per cent reductions tended to be small. Further thought is needed about the purpose of evaluation and whether measures of effect and study design are appropriate for that purpose. (Rugg-Gunn AJ & Do L. – Community Dent Oral Epidemiol. 2012 Oct;40 Suppl 2:55-64)
A model to determine the economic viability of water fluoridation: CONCLUSIONS: This model confirmed that water fluoridation is an economically viable option to prevent dental caries in South African communities, as well as conclusions over the last 10 years that water fluoridation leads to significant cost savings and remains a cost-effective measure for reducing dental caries, even when the caries-preventive effectiveness is modest. (Kroon J & van Wyk PJ. – J Public Health Dent. 2012 Fall;72(4):327-33)
Battle renewed over value of fluoridation: Linking the decision made by the United States Department of Health and Human Services to lower the recommended level of fluoride added to drinking water to the effectiveness of water fluoridation is inaccurate. This decision was based on studies showing that the levels previously accepted in the US presented a risk of dental fluorosis that was deemed unacceptable for infant formula reconstituted with tap water. The change was a dosage adjustment, not a retreat from water fluoridation. The reference to the balance of protection and risk confirms that the decision had nothing to do with 'bone effects' and everything to do with fluorosis. There is no evidence that exposure to fluoride from water fluoridation leads to bone abnormalities of any kind. (MacGregor, R. – CMAJ. 2011 July 12; 183(10): 1173. )
Fluoride in drinking water and osteosarcoma incidence rates in the continental United States among children and adolescents: CONCLUSION: Our ecological analysis suggests that the water fluoridation status in the continental U.S. has no influence on osteosarcoma incidence rates during childhood and adolescence. (Levy M, Leclerc BS. – Cancer Epidemiol. 2012 Apr;36(2):e83-8)

Drinking water fluoridation in Canada
Review and synthesis of published literature, April 2011.   Main findings may be summarized as follows:
  • Evidence for the effectiveness of drinking water fluoridation in the prevention of dental caries in Canada exists. The strongest evidence is from the original trials (e.g., Brantford-Sarnia-Stratford) in the 1940s through 1960s. These original trials were impressive for their adherence to a rigorous research protocol.
  • Since the 1970s, research on drinking water fluoridation has been complicated by the widespread availability of other sources of fluoride, most notably fluoride toothpaste. As such, more recent evidence on fluoridation is weaker than the earliest findings, though on balance it supports more than it refutes the effectiveness of the intervention.
  • Existing research consistently shows an association between exposure to drinking water fluoridation and increased risk of dental fluorosis. Case studies of fluorosis in communities with high levels of fluoride in drinking water illustrate the critical importance of monitoring fluoride concentrations, particularly in rural areas with weaker infrastructure.
  • Although there is some indication that exposure to fluoridation may have some benefit for bone density, on balance there is no clear evidence for an association between drinking water fluoridation and health outcomes other than dental outcomes.
  • To conduct research on the health impact of drinking water fluoridation, it is essential to have accurate information on exposure, including a) length of residence in the community; and b) use of other sources of fluoride. This has implications for oral health surveillance across multiple Canadian jurisdictions.
  • Although resistance to fluoridation is sometimes thought to be a recent phenomenon, well-defined opposition to fluoridation has in fact existed as long as fluoridation itself.
  • Many arguments have been put forth by those opposed to fluoridation, ranging from the relatively innocuous 'it's not effective' to the more apocryphal 'communist plot' and 'aluminum company conspiracy'. Part of the power of the anti-fluoride movement is that some of the arguments - e.g., potential harm to the environment and aquatic life - cross ideological lines and have proponents in both the political right and left.
  • We identified a large amount of material on local circumstances surrounding plebiscites or referenda. While this information may be helpful for communities undergoing a vote, it is important to recognize that fluoridation plebiscites are more likely to fail than to pass, which reflects characteristics of fluoridation and characteristics of plebiscites.
  • Contrasting with the failure of most fluoridation plebiscites is the observation, from public opinion polls, that a majority of Canadians are in favour of, or at least not opposed to, fluoridation. This suggests that anti-fluoridationists are over-represented among voters at plebiscites, and it speaks to the success of the anti-fluoridationists in persuading otherwise undecided or non-voters to vote no.
  • From an ethical point of view, drawing on principles of beneficence, autonomy, and truthfulness, the controversy over fluoridation may be un-resolvable. (McLaren L. & McIntyre L., )
    Calgary's City Council voted 10-3 to remove fluoride from the city's drinking water on Feb. 8, 2011.   Dr. McLaren has initiated a study to follow results of this decision on the city's youth - results are expected (from one source) in spring, 2015.
Drinking water fluoridation and osteosarcoma incidence on the island of Ireland: The results of this study do not support the hypothesis that osteosarcoma incidence in the island of Ireland is significantly related to public water fluoridation. However, this conclusion must be qualified, in view of the relative rarity of the cancer and the correspondingly wide confidence intervals of the relative risk estimates. (Comber H, et al. – Cancer Causes Control. 2011 Jun;22(6):919-24)
Fluoride supplements (tablets, drops, lozenges or chewing gums) for preventing dental caries in children: BACKGROUND: Dietary fluoride supplements were first introduced to provide systemic fluoride in areas where water fluoridation is not available. Since 1990, the use of fluoride supplements in caries prevention has been re-evaluated in several countries.  MAIN RESULTS: We included 11 studies in the review involving 7196 children.In permanent teeth, when fluoride supplements were compared with no fluoride supplement (three studies), the use of fluoride supplements was associated with a 24% (95% confidence interval (CI) 16 to 33%) reduction in decayed, missing and filled surfaces (D(M)FS). AUTHORS' CONCLUSIONS: This review suggests that the use of fluoride supplements is associated with a reduction in caries increment when compared with no fluoride supplement in permanent teeth. The effect of fluoride supplements was unclear on deciduous teeth. When compared with the administration of topical fluorides, no differential effect was observed. We rated 10 trials as being at unclear risk of bias and one at high risk of bias, and therefore the trials provide weak evidence about the efficacy of fluoride supplements. (Tubert-Jeannin S, et al. – Cochrane Database Syst Rev. 2011 Dec 7;12:CD007592.) (copy of the paper)
An Assessment of Bone Fluoride and Osteosarcoma: No significant association between bone fluoride levels and osteosarcoma risk was detected in our case-control study, based on controls with other tumor diagnoses.
(Kim FM, et al. – J Dent Res. 2011 Oct;90(10):1171-1176. Epub 2011 Jul 28) - Free Article 
Validation of a multifactorial risk factor model used for predicting future caries risk with Nevada adolescents: {logistic regression analysis indicated that youth living in non-fluoridated areas of Nevada had greater odds of developing tooth decay than those who lived in the county with fluoridated water - RJ}
(Ditmyer MM, et al. – BMC Oral Health. 2011; 11: 18. Published online 2011 May 20)
Related article: - Free Article
Inequalities of caries experience in Nevada youth expressed by DMFT index vs. Significant Caries Index (SiC) over time:
At the community level, action should focus on retaining and expanding the community fluoridation program as an effective preventive measure.  (Ditmyer MM, et al. – BMC Oral Health. 2011 Apr 5;11:12)
Dental caries in children: a comparison of one non-fluoridated and two fluoridated communities in NSW: The caries prevalence in the permanent dentition of Lithgow {non-fluoridated} children was significantly higher than that in children living in the fluoridated towns of Bathurst and Orange {fluoridated}. No significant differences were observed in the estimates for primary teeth.
CONCLUSION: Although the mean levels of dental caries in schoolchildren in Lithgow were low, oral health inequalities exist between children residing in non-fluoridated Lithgow and the fluoridated locations of Orange and Bathurst. The local council decided that Lithgow will have fluoridated water by December 2010. (Arora A & Evans RW – N S W Public Health Bull. 2010 Nov-Dec;21(11-12):257-62) - Free Article 
Fluoride: its role in dentistry: In spite of decades of research on fluoride and the recognition of its role as the cornerstone of dental caries reduction in the last fifty years, questions still arise on its use at community, self-applied and professional application levels. Which method of fluoride delivery should be used? How and when should it be used? How can its benefits be maximized and still reduce the risks associated with its use? These are only some of the challenging questions facing us daily. The aim of this paper is to present scientific background to understand the importance of each method of fluoride use considering the current caries epidemiological scenario, and to discuss how individual or combined methods can be used based on the best evidence available.
(Tenuta LM, Cury JA – Braz Oral Res. 2010;24 Suppl 1:9-17) {a very good summary of the role of the fluoride ion, saliva, and oral ecology on the process of tooth decay - RJ}  (requires subscription)
Geographic Variation in Medicaid Claims for Dental Procedures in New York State: Role of Fluoridation Under Contemporary Conditions: Results. Compared with the predominantly fluoridated counties, the mean number of restorative, endodontic, and extraction procedures per recipient was 33.4% higher in less fluoridated counties.  Conclusions. We found that the mean number of claims for caries related services for children in the NYS Medicaid program was correlated with the extent of fluoridation in a county. These annual decreases in claims per recipient, when applied to lifetime exposure of the whole population, have large societal benefits. These findings, when added to the already existing weight of evidence, have implications for promoting policies at the federal and state levels to strengthen the fluoridation program. (Kumar, JV, et al. – Public Health Reports, September - October 2010, Volume 125 p647)
Community Effectiveness of Public Water Fluoridation in Reducing Children's Dental Disease:
Results. Children from every age group had greater caries prevalence and more caries experience in areas with negligible fluoride concentrations in the water (<0.3 parts per million [ppm]) than in optimally fluoridated areas (>0.7 ppm).  Conclusions. This study demonstrates the continued community effectiveness of water fluoridation and provides support for the extension of this important oral health intervention to populations currently without access to fluoridated water. (Armfield, JM – Public Health Reports, September - October 2010, Volume 125 p655-664)
What we know and do not know about fluoride: Summary: There is much that we know about fluoride as it relates to human health in general and dental health in particular. Some of the information that is known concerning water fluoridation and dental fluorosis is listed. What we do not know about fluoride is discussed in more detail, namely the efficacy of lower levels of fluoride in drinking water, the effect of discontinuing fluoride in drinking water in the absence of additional preventive measures, the prevalence of fluorosis and whether or not this presents a cosmetic problem. Other issues discussed include the actual amount of fluoride ingested from all sources, whether low-fluoride dentifrices are as efficacious as conventional dentifrices in caries protection and reducing enamel fluorosis, the role of socioeconomic factors in determining caries prevalence, and the effects of bottled water use on caries prevalence in fluoridated communities. (Newbrun E. – J Public Health Dent. 2010 Jun 2. [Epub ahead of print])
The impact of changing dental needs on cost savings from fluoridation: CONCLUSION: Community water fluoridation remains a cost-effective preventive measure in Australia. (Campain AC, et al. – Aust Dent J. 2010 Mar;55(1):37-44)
Drinking water fluoridation in South East Queensland: a cost-effectiveness evaluation: CONCLUSION: Fluoridation remains still a very cost-effective measure for reducing dental decay. (Ciketic S, et al. – Health Promot J Austr. 2010 Apr;21(1):51-6)
Water fluoridation in the Blue Mountains reduces risk of tooth decay: CONCLUSIONS: Tooth decay reduction observed in the Blue Mountains corresponds to high rates reported elsewhere and demonstrates the substantial benefits of water fluoridation. (Evans RW, et al. – Aust Dent J. 2009 Dec;54(4):368-73)
The long-term effects of water fluoridation on the human skeleton: Municipal water fluoridation has notably reduced the incidence of dental caries and is widely considered a public health success. However, ingested fluoride is sequestered into bone, as well as teeth, and data on the long-term effect of exposure to these very low doses of fluoride remain inconclusive. Epidemiological studies suggest that effects of fluoride on bone are minimal. We hypothesized that the direct measurement of bone tissue from individuals residing in municipalities with and without fluoridated water would reveal a relationship between fluoride content and structural or mechanical properties of bone. However, consonant with the epidemiological data, only a weak relationship among fluoride exposure, accumulated fluoride, and the physical characteristics of bone was observed. Analysis of our data suggests that the variability in heterogenous urban populations may be too high for the effects, if any, of low-level fluoride administration on skeletal tissue to be discerned. (Chachra D, et al. – J Dent Res. 2010 Nov;89(11):1219-23) - Free Article
Epidemiology of fluorosis and dental caries according to different types of water supplies: Conclusions: Only the schoolchildren in the WTS {fluoridated water} group presented a DMFT index {the total number of teeth with caries experience, including decayed teeth} below 3, probably because of the better water fluoridation, demonstrating the efficacy of this method; thus, this preventive measure should be recommended for our population. (Franzolin Sde O, et al. – Cien Saude Colet. 2010 Jun;15 Suppl 1:1841-7)
The long-term effects of water fluoridation on the human skeleton: Abstract - Municipal water fluoridation has notably reduced the incidence of dental caries and is widely considered a public health success. However, ingested fluoride is sequestered into bone, as well as teeth, and data on the long-term effect of exposure to these very low doses of fluoride remain inconclusive. Epidemiological studies suggest that effects of fluoride on bone are minimal. We hypothesized that the direct measurement of bone tissue from individuals residing in municipalities with and without fluoridated water would reveal a relationship between fluoride content and structural or mechanical properties of bone. However, consonant with the epidemiological data, only a weak relationship among fluoride exposure, accumulated fluoride, and the physical characteristics of bone was observed. Analysis of our data suggests that the variability in heterogenous urban populations may be too high for the effects, if any, of low-level fluoride administration on skeletal tissue to be discerned. (Chachra D, Limeback H, Willett TL, Grynpas MD – J Dent Res. 2010 Nov;89(11):1219-23)
The association between community water fluoridation (CWF) and adult tooth loss: CONCLUSIONS: This study suggests that the benefits of CWF may be larger than previously believed and that CWF has a lasting improvement in racial/ethnic and economic disparities in oral health. (Neidell M, et al. – Am J Public Health. 2010 Oct;100(10):1980-5) - Free Article
A case-control study of determinants for high and low dental caries prevalence in Nevada youth: Community water fluoridation has been documented as the most cost-effective, equitable, and safe community-based approach to improving oral health. Participants living in areas without community water fluoridation in Nevada were almost 2 times more likely to present with higher DMFT indices. The benefits of water fluoridation are proportionally higher for people who do not have regular access to other sources of fluoride. Therefore, dental professionals should counsel patients living in non-fluoridated geographic areas on the importance of using other sources of fluoride. It is of special significance that several futile attempts have been made in Nevada to introduce community water fluoridation to other counties, such as Washoe County, which comprises around 15% of the population. (Ditmyer M, et al. – BMC Oral Health. 2010 Nov 11;10:24) (Full Article)
Water fluoridation: AIM: This was to present a summary of the evidence from systematic reviews of the effectiveness and safety of water fluoridation
RESULTS: Of the 59 publications identified, 3 systematic reviews and 3 guidelines were included in this review. While the reviews themselves were of good methodological quality, the studies included in the reviews were generally of moderate to low quality. The results of the three reviews showed that water fluoridation is effective at reducing caries in children and adults. With the exception of dental fluorosis, no association between adverse effects and water fluoridation has been established. Water fluoridation reduces caries for all social classes, and there is some evidence that it may reduce the oral health gap between social classes.
CONCLUSION: Water fluoridation, where technically feasible and culturally acceptable, remains a relevant and valid choice as a population measure for the prevention of dental caries. (Parnell C, et al. – Eur Arch Paediatr Dent. 2009 Sep;10(3):141-8)  Related Article Community Water Fluoridation: An Evidence Review, 2012, Campos-Outcalt, et al.
The Association Between Enamel Fluorosis and Dental Caries in U.S. Schoolchildren: Conclusion. This study's findings suggest that molars with fluorosis are more resistant to caries than are molars without fluorosis.
Clinical Implications. The results highlight the need for those considering policies regarding reduction in fluoride exposure to take into consideration the caries-preventive benefits associated with milder forms of enamel fluorosis. (Hiroko, I, et al. – J Am Dent Assoc, Vol 140, No 7, 855-862, 2009)
Appetitive-based learning in rats: lack of effect of chronic exposure to fluoride: CONCLUSION: Chronic ingestion of fluoride {by rats} at levels up to 230 times more than that experienced by humans whose main source of fluoride is fluoridated water had no significant effect on appetitive-based learning.(Whitford, GM, et al. – Neurotoxicol Teratol. 2009 Jul-Aug;31(4):210-5)
Risk perception and water fluoridation support and opposition in Australia: Objectives: A considerable body of evidence confirms that water fluoridation effectively reduces the community incidence of dental caries with minimal side effects. However, proposals to introduce this widely endorsed public-health measure are often perceived as controversial, and public opinion frequently plays a role in the outcome. Despite this, the public's perception of risk associated with water fluoridation has not been well researched and remains poorly understood. Our objectives were to determine whether risk perceptions reflecting various "outrage" factors are associated with water fluoridation support and opposition. Conclusion: Outrage factors are important aspects of the public's perception of risk in relation to water fluoridation. Given that water fluoridation appears to be a low-risk, high-outrage controversy, efforts to mitigate the level of public outrage, rather than continuing to deny possible hazards, may offer a worthwhile strategy in gaining public acceptance for the extension of water fluoridation. (Armfield, JM and Akers, HF – J Public Health Dent. 2009 Aug 20)
Assessing a potential risk factor for enamel fluorosis: a preliminary evaluation of fluoride content in infant formulas: Some infants aged between birth and 6 months who consume powdered and liquid concentrate formulas reconstituted with water containing 1.0 part per million fluoride likely will exceed the upper tolerable limit of fluoride. CONCLUSIONS: When powdered or liquid concentrate infant formulas are the primary source of nutrition, some infants are likely to exceed the recommended fluoride upper limit if the formula is reconstituted with water containing 1.0 ppm fluoride. On the other hand, when the fluoride concentration in water used to reconstitute infant formulas is below 0.4 ppm, it is likely that infants between 6 and 12 months of age will be exposed to fluoride at levels below IOM's recommended adequate intake level. (Siew, C et al. – J Am Dent Assoc. 2009 Oct;140(10):1228-36)
A controlled study of risk factors for enamel hypoplasia in the permanent dentition: PURPOSE: The purpose of this study was to investigate risk factors for enamel hypoplasia (EH) and enamel opacity (EO) in the permanent teeth of healthy schoolchildren from a nonfluoridated community in Australia.  CONCLUSIONS: Children with low socioeconomic status, histories of respiratory or chickenpox infections, exposure to cigarette-smoking, urinary tract infections, otitis, and use of adult toothpaste are predisposed to enamel hypoplasia. By contrast, drinking optimally fluoridated water at 0 to 3 years old reduces the risk for enamel opacities. (Ford, D et al. – Pediatr Dent. 2009 Sep-Oct;31(5):382-8)
Evidence that fluoride in the infant formula causes enamel fluorosis weak: CONCLUSIONS: Infant formula consumption may be associated with an increased risk of developing at least some detectable level of enamel fluorosis, but this depends on the level of fluoride in the water supply. The evidence that the fluoride in the infant formula caused enamel fluorosis was weak, as other mechanisms could explain the observed association. (Edwards, M – Evid Based Dent. 2009;10(3):73)
Association of natural fluoride in community water supplies with dental health of children in remote indigenous communities - implications for policy:  OBJECTIVE: To map the geographic distribution of fluoride in water supplies and child dental caries in remote Indigenous communities of the Northern Territory (NT). To examine the association between fluoride levels, household and community factors, access to services and child dental caries in these communities and to model the impact on the caries experience of children of introducing water fluoridation.  CONCLUSIONS AND IMPLICATIONS: Introduction of fluoridation of water supplies into communities with inadequate natural fluoride is a vital measure for improving the dental health of children living in remote NT communities. (Bailie, RS, et al. – Aust N Z J Public Health. 2009 Jun;33(3):205-11)
 Water fluoridation in Canada: past and present: Water fluoridation remains a contentious issue in Canada and many communities choose not to fluoridate their water supply. As of 2007, 45.1% of the Canadian population had access to fluoridated water supplies. The main arguments for and against fluoridation have changed very little over the years, with supporters (including the World Health Organization and Health Canada) citing evidence that shows fluoridation as a safe and effective method of caries prevention, while detractors cite high costs and potential health risks. This article provides an historical overview and a current snapshot of water fluoridation in Canada. It concludes that the ultimate advantage of fluoridation is that it helps everyone in a community, regardless of socioeconomic status. (Rabb-Waytowich D – J Can Dent Assoc. 2009 Jul;75(6):451-4)
Effects of long-term fluoride in drinking water on risks of hip fracture of the elderly: an ecologic study based on database of hospitalization episodes, OBJECTIVES: Fluoridation of drinking water is known to decrease dental caries, particularly in children. However, the effects of fluoridated water on bone over several decades are still in controversy. To assess the risk of hip fracture related to water fluoridation, we evaluated the hip fracture-related hospitalizations of the elderly between a fluoridated city and non-fluoridated cities in Korea.
CONCLUSIONS: We cannot conclude that fluoridation of drinking water increases the risk of hip fracture in the elderly. (Park EY, et al. – J Prev Med Public Health. 2008 May;41(3):147-52)
Prevalence and extent of dental caries, dental fluorosis, and developmental enamel defects in Lithuanian teenage populations with different fluoride exposures: The aim of this study was to describe the pattern of dental caries, dental fluorosis, and developmental defects of non-fluoride origin in Lithuanian children born and raised in regions with 1.1 ppm (1.1 mg/l F) and 0.3 ppm (0.3 mg/l F) water fluoride levels, respectively. All permanent surfaces/teeth of 300 teenagers were examined for dental caries, dental fluorosis, and non-fluoride developmental defects. The caries prevalence of the study population was 100%. The mean number of decayed surfaces (DS) differed only slightly and statistically insignificantly between the '1.1 ppm fluoride' and '0.3 ppm fluoride' groups (19.6 and 18.1, respectively). However, a greater number of inactive lesions and fewer fillings were found in the '1.1 ppm fluoride' group than in the '0.3 ppm fluoride' group (mean difference 1.18 and -2.80, respectively). The prevalence of dental fluorosis was 45% and 21%, respectively; the prevalence of non-fluoride opacities was 8% and 19%, respectively; and the prevalence of hypoplasia was 12% and 16%, respectively, in the '1.1 ppm fluoride' and '0.3 ppm fluoride' groups. Higher caries levels were noted in children with no fluorosis compared to those with fluorosis recorded (mean DS difference, 3.43). The results lend support to the hypothesis that the presence of fluoride in the oral environment promotes lesion arrest rather than inhibiting the initiation of new lesions. (Machiulskiene V, et al. – Eur J Oral Sci. 2009 Apr;117(2):154-60)
Public opinions on community water fluoridation: BACKGROUND: Community water fluoridation (CWF) is currently experiencing social resistance in Canada. Petitions have been publicly registered, municipal plebiscites have occurred, and media attention is growing...  RESULTS: Approximately 1 in 2 Canadian adults surveyed knew about CWF. Of these, 80% understood its intended use, approximately 60% believed that it was both safe and effective, and 62% supported the idea of having fluoride added to their local drinking water. Those with greater incomes [OR=1.4; p<0.001] and education [OR=1.6; p<0.001] were more likely to know about CWF. Those with greater incomes [OR=1.3; p<0.03] and those who visited the dentist more frequently [OR=1.8; p<0.002] were more likely to support CWF, and those with children [OR=0.5; p<0.02], those who accessed dental care using public insurance [OR=0.2; p<0.03], and those who avoided fluoride [OR=0.04; p<0.001] were less likely to support CWF.  CONCLUSION: It appears that Canadians still support CWF. In moving forward, policy leaders will need to attend to two distinct challenges: the influence of anti-fluoride sentiment, and the potential risks created by avoiding fluoride. (Quionez CR, Locker D. – Can J Public Health. 2009 Mar-Apr;100(2):96-100) {Ironically, the segment of the population most at risk for dental disease and the group most likely to benefit from water fluoridation policies is often the group most opposed to the practice. RJ}
The global increase in dental caries. A pending public health crisis: A current review of the available epidemiological data from many countries clearly indicates that there is a marked increase in the prevalence of dental caries. This global increase in dental caries prevalence affects children as well as adults, primary as well as permanent teeth, and coronal as well as root surfaces. This increase in dental caries signals a pending public health crisis. Although there are differences of opinion regarding the cause of this global dental caries increase, the remedy is well known: a return to the public health strategies that were so successful in the past, a renewed campaign for water fluoridation, topical fluoride application, the use of fluoride rinses, a return to school oral health educational programs, an emphasis on proper tooth brushing with a fluoride dentifrice, as well as flossing, a proper diet and regular dental office visits. (Bagramian RA, et al. – Am J Dent. 2009 Feb;22(1):3-8)
A systematic review of the efficacy and safety of fluoridation: SCOPE AND PURPOSE: The systematic review was commissioned by the Australian National Health and Medical Research Council (NHMRC) to evaluate the scientific literature relating to the health effects of fluoride and fluoridation. The systematic review's research questions relate to the caries-reducing benefits and associated potential health risks of providing fluoride systemically (via addition to water, milk and salt) and the use of topical fluoride agents, such as toothpaste, gel, varnish and mouthrinse. - RECOMMENDATIONS: Fluoridation of drinking water remains the most effective and socially equitable means of achieving community-wide exposure to the caries prevention effects of fluoride. It is recommended (see also that water be fluoridated in the target range of 0.6-1.1 mg/l, depending on the climate, to balance reduction of dental caries and occurrence of dental fluorosis (Yeung, CA – Evid Based Dent. 2008;9(2):39-43)  (Download Part A - Part B)
Lifetime fluoridation exposure and dental caries experience in a military population: OBJECTIVES: To determine whether exposure to fluoride in drinking water is associated with caries experience in Australian Defence Force (ADF) personnel.
CONCLUSIONS: Degree of lifetime exposure to fluoridated drinking water was inversely associated with DMFT in a dose-response manner among this adult military population. (Mahoney, G, et al. – Community Dent Oral Epidemiol. 2008 Dec;36(6):485-92) {Translation - the greater the exposure to fluoridated drinking water the lower the rate of DMFT (the number of decayed, missing and filled teeth) - RJ.}
Pharmacokinetics of ingested fluoride: lack of effect of chemical compound, CONCLUSIONS: Considered together with published reports, the present findings support the conclusion that the major features of fluoride metabolism are not affected differently by the chemical compounds commonly used to fluoridate water nor are they affected by whether the fluoride is present naturally or added artificially. (Whitford, GM, et al. – Arch Oral Biol. 2008 Nov;53(11):1037-41) - Free Article
Is Water Fluoridation Still Necessary? Water fluoridation has been promoted in many countries as an organized community effort to control dental caries. With the availability of fluorides targeted at individuals and the decline in dental caries, the need for fluoridation has been questioned. Recent reports show that water fluoridation, a community-level intervention, continues to be an efficient method for the delivery of fluoride in many countries. The advantages include its ability to deliver low levels of fluoride to saliva frequently, with high reach, at low cost, and with substantial cost savings. Water fluoridation has the potential to reduce oral health disparities by creating a healthy environment. Other forms of fluoride, such as fluoride toothpaste, and clinical interventions complement dental caries control strategies. (Kumar, JV – Adv Dent Res 20:8-12, July, 2008)
Fluorides in dental public health programs: The use of fluorides in dental public health programs has a long history. With the availability of fluoridation and other forms of fluorides, dental caries have declined dramatically in the United States. This article reviews some of the ways fluorides are used in public health programs and discusses issues related to their effectiveness, cost, and policy. (Kumar JV, Moss ME – Dent Clin North Am. 2008 Apr;52(2):387-401, vii. )
European citizens' opinions on water fluoridation: OBJECTIVES: To understand European citizens' opinions on water fluoridation, as part of research on their attitudes to the tensions between private and public interest.  CONCLUSIONS: While the vast majority of people opposed water fluoridation, this may be indicative of shifts away from public support of population interventions towards private interventions, as well as reduced trust in public agencies. Thus if research were to demonstrate more clear benefits of water fluoridation over and above that which can be achieved by use of fluoride toothpaste, then the public may become more supportive. However, lobby groups are likely to remain influential. (Griffin, M, et al. – Community Dent Oral Epidemiol. 2008 Apr;36(2):95-102)
Prospective study of the association between fluoride intake and dental fluorosis in permanent teeth: CONCLUSIONS: There was no difference between children with and without fluorosis in the permanent central incisors and first molars regarding fluoride intake. However, this study has limitations that must be recognized: fluoride intake was only measured once, and there were no children in the sample with severe degrees of dental fluorosis. (Martins, CC, et al. – Caries Res. 2008;42(2):125-33) 
Effects of long-term fluoride in drinking water on risks of hip fracture of the elderly: an ecologic study based on database of hospitalization episodes: CONCLUSIONS: We cannot conclude that fluoridation of drinking water increases the risk of hip fracture in the elderly. (Park EY, et al. – J Prev Med Public Health. 2008 May;41(3):147-52)
Dental caries of lifetime residents in Baixo Guandu, Brazil, fluoridated since 1953--a brief communication: The addition of fluoride to public water supplies was an important ally in the improvement of the oral health of Baixo Guandu inhabitants. (Saliba, NA, et al. – J Public Health Dent. 2008 Spring;68(2):119-21)
The ethical dilemma of water fluoridation: The aim of this study is to analyze some of the ethical arguments for and against water fluoridation and to determine if empirical data allow to decide if there are correct policies from a bioethical perspective. Autonomy, compulsory medication (mass medication), precautionary principle, justice in health care and ethics of protection are discussed. It is concluded that fluoridation is beneficial and that there is no ethical reason to oppose it, based on a specific kind of ethics developed to analyze and clarify complex public health issues. (Mendoza, VC – Rev Med Chil. 2007 Nov;135(11):1487-93. )
A comparison of dental treatment utilization and costs by HMO members living in fluoridated and nonfluoridated areas:
OBJECTIVES: To compare dental treatment experiences and costs in members of a health maintenance organization (HMO) in areas with and without community water fluoridation.
RESULTS: Community water fluoridation was associated with reduced total and restorative costs among members with one or more visits, but the magnitude and direction of the effect varied with locale and age and the effects were generally small. In two locales, the cost of restorations was higher in nonfluoridated areas in young people (<age 18) and older adults (>age 58). In younger adults, the opposite effect was observed. The impact of fluoridation may be attenuated by higher use of preventive procedures, in particular supplemental fluorides, in the nonfluoridated areas. (Maupom G, et al. – J Public Health Dent. 2007 Fall;67(4):224-33)  Paper discussed here.
Fluoride prevents caries among adults of all ages: CONCLUSIONS: To date, no systematic reviews have found fluoride to be effective in preventing dental caries in adults. The objective of this meta-analysis was to examine the effectiveness of self- and professionally applied fluoride and water fluoridation among adults.  ...These findings suggest that fluoride is effective in preventing caries in adults of all ages. (Yeung, CA – Evid Based Dent. 2007;8(3):72-3)
Effects of fluoridation of community water supplies for people with chronic kidney disease:
- There is no evidence that consumption of optimally fluoridated drinking water increases the risk of developing CKD, although only limited studies addressing this issue are available.
- There is no evidence that consumption of optimally fluoridated drinking water poses any health risks for people with CKD, although only limited studies addressing this issue are available
- There is limited evidence that people with stage 4 or 5 CKD who ingest substances with a high concentration of fluoride may be at risk of fluorosis.
(Ludlow M, et al. – Nephrol Dial Transplant. 2007 Oct;22(10):2763-7
Effectiveness of fluoride in preventing caries in adults: These findings suggest that fluoride {topical and water fluoridation} prevents caries among adults of all ages. (Griffin, SO, et al. – J Dent Res. 2007 May;86(5):410-5)
Community water fluoridation and caries prevention: a critical review: The aim of this paper was to critically review the current role of community water fluoridation in preventing dental caries. Original articles and reviews published in English language from January 2001 to June 2006 were selected through MEDLINE database. Other sources were taken from the references of the selected papers. For the past 50 years community water fluoridation has been considered the milestone of caries prevention and as one of the major public health measures of the 20th century. However, it is now accepted that the primary cariostatic action of fluoride occurs after tooth eruption. Moreover, the caries reduction directly attributable to water fluoridation have declined in the last decades as the use of topical fluoride had become more widespread, whereas enamel fluorosis has been reported as an emerging problem in fluoridated areas. Several studies conducted in fluoridated and nonfluoridated communities suggested that this method of delivering fluoride may be unnecessary for caries prevention, particularly in the industrialized countries where the caries level has became low. Although water fluoridation may still be a relevant public health measure in poor and disadvantaged populations, the use of topical fluoride offers an optimal opportunity to prevent caries among people living in both industrialized and developing countries. (Pizzo, G, et al. – Clin Oral Investig. 2007 Sep;11(3):189-93)
Effects of water fluoride exposure at crown completion and maturation on caries of permanent first molars: Pre-eruptive fluoride exposure has been shown to be important for caries prevention. This paper aimed to determine the relative effects of water fluoride exposure during crown completion (CC) and maturation on caries experience in first permanent molars... In conclusion a high exposure at CC was important for caries prevention irrespective of the effect of exposure at maturation and post-eruption. The strongest caries-preventive effect was produced by a high exposure at CC supplemented by a high exposure at maturation and/or post-eruption, but the latter two phases could not produce a significant caries-preventive effect on their own. Since most of the caries occurred on pit and fissure surfaces, the findings relate to this class of lesion. (Singh KA, et al. – Caries Res. 2007;41(1):34-42)
Fluoride: a controversy revisited: The purpose of this article is to provide a review of the small but loud debate that has surrounded fluoride over the past 50 years. The benefits of fluoridation and its effect on public health are well known throughout the dental community. What is far less well known are the objections from people--in the tradition of the old amalgam and radiograph radiation debates-who feel that fluoride has adverse effects serious enough to warrant a cessation of its use. This article will present both sides of the issue, not to influence the reader, but to allow the reader to realize that this issue exists and to understand what the key arguments are. (Ananian, A. et al. – N Y State Dent J. 2006 Apr-May;72(3):14-8)
Reexamination of hexafluorosilicate hydrolysis by 19F NMR and pH measurement: The dissociation of hexafluorosilicate has been reinvestigated due to recent suggestions that fluorosilicate intermediates may be present in appreciable concentrations in drinking water...  No intermediates were observable at 10(-5) M concentrations under excess fluoride forcing conditions over the pH range of 3.5-5.  ...The buffer capacity of all of these systems was found to be insufficient to prevent acidic shifts in pH when hexafluorosilicate was added. The pH change is sufficient explanation for the observed inhibition of acetylcholinesterase that was previously attributed to hexafluorosilicate hydrolysis intermediates. (Finney, WF, et al. – Environ Sci Technol. 2006 Apr 15;40(8):2572-7)
Fluoride intake from food and liquid in Japanese children living in two areas with different fluoride concentrations in the water supply:   The mean DMFT in the moderate fluoride area (MFA) was significantly lower than that in the low fluoride area (LFA). The severest grade of dental fluorosis observed was 'very mild' according to Dean's fluorosis index in both areas. The total daily fluoride intakes were 0.0252-0.0254 mg F/kg/day in the MFA [average 0.56 ppm] and 0.0126-0.0144 mg F/kg/day in the LFA [0.04 - 0.13 ppm]. Differences in the fluoride concentration of drinking water in this study were reflected in the fluoride intake from the diet in a typical Japanese diet. (Nohno K, et al. – Caries Res. 2006;40(6):487-93)
Dental caries and enamel fluorosis among the fluoridated population in the Republic of Ireland and non fluoridated population in Northern Ireland in 2002: CONCLUSIONS: In 2002 apart from 8-year-olds, caries levels were lower amongst children resident in fluoridated communities in RoI than amongst corresponding age groups in non-fluoridated NI. Caries has declined in fluoridated and non fluoridated groups in both jurisdictions since the early 1960s. In RoI fluorosis levels were higher amongst lifetime residents of fluoridated communities and have increased since 1984. (Whelton, H, et al. – Community Dent Health. 2006 Mar;23(1):37-43) - Free Full Article
Costs and savings associated with community water fluoridation programs in Colorado: CONCLUSION: Colorado realizes significant annual savings from CWFPs; additional savings and reductions in morbidity could be achieved if fluoridation programs were implemented in other areas. (O'Connell, JM, et al. – Prev Chronic Dis. 2005 Nov;2 Spec no:A06)
Blood Lead Concentrations in Children and Method of Water Fluoridation in the United States, 1988-1994: Given these findings, our analyses, though not definitive, do not support concerns that silicofluorides in community water systems cause higher PbB concentrations in children.  Current evidence does not provide a basis for changing water fluoridation practices, which have a clear public health benefit. (Macek, MD, et al. – Environmental Health Perspectives Volume 114, Number 1, January 2006)
Bioavailability of fluoride in drinking water: a human experimental study: It has been suggested that systemic fluoride absorption from drinking water may be influenced by the type of fluoride compound in the water and by water hardness. Using a human double-blind cross-over trial, we conducted this study to measure c(max), T(max), and Area Under the Curve (AUC) for plasma F concentration against time, following the ingestion of naturally fluoridated hard and soft waters, artificially fluoridated hard and soft waters, and a reference water. Mean AUC over 0 to 8 hours was 1330, 1440, 1679, 1566, and 1328 ng F.min.mL(-1) for naturally fluoridated soft, naturally fluoridated hard, artificially fluoridated soft, artificially fluoridated hard, and reference waters, respectively, with no statistically significant differences among waters for AUC, c(max), or T(max). Any differences in fluoride bioavailability between drinking waters in which fluoride is present naturally or added artificially, or the waters are hard or soft, were small compared with large within- and between-subject variations in F absorption. (Maguire, A, et al. – J Dent Res. 2005 Nov;84(11):989-93)
Position of the American Dietetic Association: the impact of fluoride on health, The American Dietetic Association reaffirms that fluoride is an important element for all mineralized tissues in the body. Appropriate fluoride exposure and usage is beneficial to bone and tooth integrity and, as such, has an important, positive impact on oral health as well as general health throughout life. The American Dietetic Association strongly reaffirms its endorsement of the appropriate use of systemic and topical fluorides, including water fluoridation, at appropriate levels as an important public health measure throughout the life span. (Palmer, C, et al. – J Am Diet Assoc. 2005 Oct;105(10):1620-8)
Current scientific evidence: Water fluoridation is not associated with osteosarcoma - The current scientific literature does not support an association between osteosarcoma and drinking water fluoridation, even though in cellular studies, fluoride acts as a mitogen on osteoblasts, and this defines a biologically plausible pathway for it to play a role in the development of osteosarcoma. (San Francisco Department of Public Health, Occupational and Environmental Health Section, October 2005)  SFPHES Reveiw of the Literature (2000 - 2005) (2006 - 2011)
Elevated Serum Fluoride Concentrations in Women Are Not Related to Fractures and Bone Mineral Density - Serum fluoride concentrations were not related to incident osteoporotic fractures with 4 y of observation. Serum fluoride concentrations were not associated with BMD or osteoporotic fractures among female residents of communities with water fluoride concentrations of 52.6 or 210.4 ml/L.  (Sowers M, et al. – J. Nutr. 135:2247-2252, September 2005)

Effective use of fluorides for the prevention of dental caries in the 21st century
The WHO approach:   Effective use of fluorides for the prevention of dental caries in the 21st century: the WHO approach Such reviews concluded that water fluoridation and use of fluoride toothpastes and mouthrinses significantly reduce the prevalence of dental caries. WHO recommends for public health that every effort must be made to develop affordable fluoridated toothpastes for use in developing countries. Water fluoridation, where technically feasible and culturally acceptable, has substantial advantages in public health; alternatively, fluoridation of salt and milk fluoridation schemes may be considered for prevention of dental caries. (Poul Erik Petersen & Michael A. Lennon – Community Dent Oral Epidemiol 2004)
Relative effects of pre- and post-eruption water fluoride on caries experience by surface type of permanent first molars: CONCLUSIONS: Pre-eruption exposure {to fluoridated water} was important for a caries preventive effect on first permanent molars in children 6-15 years old since post-eruption exposure alone could not lower caries levels significantly.  (Singh, KA, Spencer, AJ – Community Dent Oral Epidemiol. 2004 Dec;32(6):435-46)
Epidemiological studies of tooth wear and dental erosion in 14-year-old children in North West England. Part 1: The relationship with water fluoridation and social deprivation.
CONCLUSION: Children in non-fluoridated districts are 1.5 times more likely to have smooth surface wear compared with children in fluoridated districts. Fluoridation and use of fluoridated toothpaste twice a day provide added protection from dental erosion. The risk of tooth wear is greater with increasing affluence. (Bardsley, PF, et al. – Br Dent J. 2004 Oct 9;197(7):413-6; discussion 399)
Effective use of fluorides for the prevention of dental caries in the 21st century: the WHO approach: Research on the oral health effects of fluoride started around 100 years ago; the focus has been on the link between water and fluorides and dental caries and fluorosis, topical fluoride applications, fluoride toothpastes, and salt and milk fluoridation. Most recently, efforts have been made to summarize the extensive database through systematic reviews. Such reviews concluded that water fluoridation and use of fluoride toothpastes and mouthrinses significantly reduce the prevalence of dental caries.  (Petersen PE, Lennon MA – Community Dent Oral Epidemiol. 2004 Oct;32(5):319-21)
Relationship between fluorine in drinking water and dental health of residents in some large cities in China: Our results, together with the previous study, suggest that: (1) dental caries of the study population can be reduced by drinking water fluoridation and that (2) other factors such as economic level, weather, lifestyle, food habits, living condition, etc., of a city can also affect the incidence of dental caries that cannot be predicted by fluoridation alone. Research on the relation between index of fluorosis (IF) and the fluorine concentration in drinking water for the four high fluorine villages showed that the recommended concentration of fluorine in drinking water can protect from dental fluorosis. (Wang, B, et al. – Environ Int. 2004 Oct;30(8):1067-73) experience among schoolchildren in relation to community fluoridation status and town size: {in Seo Paulo State, Brazil} Caries experience and prevalence were significantly lower in fluoridated areas (1.9 DMFT, 2.1 dmft, 20% caries free) than in non-fluoridated areas (2.4 DMFT, 2.4 dmft, 13% caries free).  The results suggest that water fluoridation is an essential public health measure and that town size may affect caries distribution in the Southeast area of Seo Paulo State. (Tagliaferro EP, et al. – Acta Odontol Scand. 2004 Jun;62(3):124-8)
Caries prevalence in a rural Chilean community after cessation of a powdered milk fluoridation program: CONCLUSIONS: Termination of the powdered milk fluoridation scheme resulted in a deterioration of the dental health of children. After three years, dental caries prevalence was higher than that reached at the end of the scheme and equivalent to that of the control community without fluoride exposure. These results emphasize the need to establish and maintain an alternative mechanism of community-based fluoridation of proven effectiveness for the prevention of dental caries in communities where water fluoridation is not available.  (Marieo RJ, et al. – J Public Health Dent. 2004 Spring;64(2):101-5)
Fluoride toxicity: CONCLUSIONS: Many years have passed since domestic water fluoridation was adopted to reduce the incidence of caries in developed countries; however, since there is an additional dose of fluorides ingested with foods and drinks prepared with such waters, the problem has emerged of possible adverse effects on health associated to them, so that in some countries fluorine integrator selling is allowed only with preventive medical prescription.  ...At encephalic level, then, high doses of fluorine cause the onset of neurological symptoms and of a decreased spontaneous motor activity due to a reduction in the number of nicotinic acetylcholine receptors.  Nevertheless, epidemiological studies about fluoride toxicity have established that such oligoelement may be safely used at odontoiatric dosages.  (Giachini M, Pierleoni F – Minerva Stomatol. 2004 Apr;53(4):171-7)
Water fluoridation and dental caries in 5- and 12-year-old children from Canterbury and Wellington: Multivariable analysis confirmed the independent association between water fluoridation and better dental health. CONCLUSIONS: This results of this study show children living in a fluoridated area to have significantly better oral health compared to those not in a fluoridated area. These differences are greater for Maori and Pacific children and children of low socio-economic status.  (Lee M, Dennison PJ – N Z Dent J. 2004 Mar;100(1):10-5)
History of fluoride prevention: successes and problems (literature review):
Recent scientific views, however, confirmed a weak pre-, and peri-eruptive, as well as a strong posteruptive effect of systemically applied fluorides. In countries where caries prevalence is high, but the majority of the population cannot afford fluoridated toothpastes due to low socio-economic conditions, the introduction and extension of salt fluoridation to the whole population is well founded and recommended from a public health view. (Beneczy J, Marthaler TM – Fogorv Sz. 2004 Feb;97(1):3-10)
Optimal fluoride level in drinking water and public health: Water fluoridation is a safe, efficient, and well-proven way of preventing dental decay in the community. In countries such as Israel, where dental care is not covered by the national insurance law, this has an important role in reducing social inequalities in health care. For toddlers and children, water fluoridation is the only way of promoting dental health without a need for regular visits to dental clinics, and without regard to parent awareness and motivation. The other methods of fluoride supplementation do not succeed in reaching the level of safety and cost-efficiency of water fluoridation, and their use is successful only among upper socio-economic classes. Water fluoridation has been defined by the US CDC as one of the main achievements in health care during the 20th century. In spite of the legal difficulties raised by various activist groups, the use of water fluoridation is growing steadily among developed as well as third world countries. The Israeli bylaw of national water fluoridation that is in effect will enable the safe improvement of the overall dental health status of the population at an extremely low cost. (Karsenty E, et al. – Harefuah. 2003 Nov;142(11):754-8, 806)
Successes and drawbacks in the caries-preventive use of fluorides--lessons to be learnt from history: Water fluoridation was the first breakthrough in the practice of preventive cariology on a community level and has remained one of the cornerstones of prevention in dentistry. The concepts regarding the mechanisms of the caries-inhibitory effect, however, have changed in several respects. Today there is general agreement that topical effects on the erupted enamel are most important. The contention that there is no pre-eruptive effect whatsoever has created confusion; there is in fact evidence for a minor pre-eruptive protective effect. Around 1980 many experts believed that fluorides should not be used in high concentrations, for instance above those in dentifrices, because this could block remineralisation in the body of pre-cavity lesions. However, it is now known that such undesirable effects are negligible or non-existent. (Marthaler TM – Oral Health Prev Dent. 2003;1(2):129-40)
An update on fluorides and fluorosis: Decisions concerning use of fluoride in its many forms for caries prevention are more complicated now than in the past because of the need to balance these benefits with the risks of dental fluorosis. This article reviews pertinent literature concerning dental fluorosis (definition, appearance, prevalence), pre- and post-eruptive use of fluoride, esthetic perceptions of dental fluorosis, fluoride levels of beverages and foods, the Iowa Fluoride Study, and the U.S. Centers for Disease Control and Prevention's "Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States." Water fluoridation and use of fluoride dentifrice are the most efficient and cost-effective ways to prevent dental caries; other modalities should be targeted toward high-risk individuals. (Levy SM – Dent Clin North Am. 2003 Apr;47(2):225-43)
History of water fluoridation: Analyses showed that maximum protection against caries is obtained when teeth erupt into an environment with low concentrations of ionic fluoride. The similarity in caries reductions obtained in water fluoridation studies and long-term studies with topically administered fluoride regimens, including fluoride-containing dentifrices, indicates that the pre-eruptive effect of fluoride is of borderline significance relative to the more significant post-eruptive effect. It has taken a long time to show that water fluoridation and topical fluoride programs were thus important measures for the control of caries at the community level.
(Kargul B, et al. – J Clin Pediatr Dent. 2003 Spring;27(3):213-7)
Current and future role of fluoride in nutrition: Fluoride continues to be the cornerstone of dental caries prevention in North America and throughout the world, and there are a variety of sources of fluoride that may contribute to the dietary intakes of fluoride. Although the severe effect of chronic exposures to high levels of fluoride--skeletal fluorosis--is extremely rare in North America, dental fluorosis has become more prevalent. To address the increase in dental fluorosis prevalence, recommendations have been made to reduce fluoride ingestion early in life. These recommendations have included the introduction of lower concentration fluoride dentifrice for use by young children, labeling of the fluoride concentration of bottled water, and revised fluoride supplement guidelines to reduce or eliminate their use. Because our knowledge is incomplete regarding the amount, duration, and timing of fluoride ingestion that can result in dental fluorosis, however, further research is clearly needed before definitive recommendations can be made regarding the use of fluorides, including recommended intakes of fluoride in the diet. (Warren JJ, Levy SM – Dent Clin North Am. 2003 Apr;47(2):225-43)
Decline in enamel hypoplasia in relation to fluoridation in Australians: Enamel hypoplasias are thought to represent calcification disruption indicative of metabolic stress during development. Hypoplasias of permanent maxillary central incisors and mandibular canines have undergone a notable reduction in frequency between Euro-Australian twins born around 1965 and those born ca. 1990. Even when scored very liberally these linear defects are 3.1-4.6 times as prevalent in the earlier Australians, and the discrepancy is proportionately greater among strictly scored defects. Likely correlates of this secular trend logically include reduced childhood fevers and clinical intervention to reduce circum-natal stresses acting on cotwins. However, fluoridation of metropolitan water has emerged as the statistically strongest hypoplasia-preventing factor.   (Corruccini RS, Townsend GC – Am J Hum Biol. 2003 Nov-Dec;15(6):795-9
Fluoridation at fifty: what have we learned? The question posed by the title of this article encompasses more than just the law and science applied to fluoridation. A review of the history and present status of fluoridation policy development and implementation makes it quickly apparent that the lessons learned are applicable to a wide range of public health policy and that the public health community needs to be very concerned about the status and trends of legal precedent. Indeed, in the context of recent U. S. Supreme Court decisions, the need for a comprehensive and coordinated effort to educate the public, legislators, and jurists about the safety and efficacy of community water fluoridation is clear. Two fundamental issues are at the core of this article: (1) the use of science in formulating and defending public health policy, and (2) how to connect scientific fact with the legal process in connection with the actual circumstances regarding a community's health status. The opening section of this article presents an analysis of fluoridation's great success in preventing dental caries over the past 50 years, along with a discussion of current data scientifically demonstrating that fluoride is safe when properly utilized. A second section provides an overview of one state's legislative experience in mandating fluoridation and the political challenges encountered. A final section discusses the legal issues associated with fluoridation, including the bases of legal challenges to public laws mandating it. (Pratt, E, et al. – J Law Med Ethics. 2002 Fall;30 (3 Suppl):117-21)
This report has considered the scope for further research that could help to inform risk management decisions on water fluoridation. Our starting point was the knowledge base that is already established. Much of this was recently reviewed in the report prepared by the York NHS CRD, and we have not attempted to duplicate their work.We have, however, taken account of additional information (eg, on pharmacology and toxicology) that did not fall within the scope of the York Review.  ...There is almost universal agreement that tooth decay in children is related to social class.The majority of the research conducted to date indicates that water fluoridation reduces dental caries inequalities between high and low social class groups. Further studies are recommended that look at appropriate measures of social inequalities related to water fluoridation, dental caries and fluorosis and possible confounding factors. Water Fluoridation and Health: (Medical Research Council working group report, September 2002)

Free Article:
The York Review - A systematic review of public water fluoridation: a commentary: The body of evidence available on the efficacy and safety of water fluoridation was of lower quantity and quality than had previously been reported.
> The best available evidence (from studies that met inclusion criteria) suggests that fluoridation of drinking water supplies reduces caries prevalence but is associated with dental fluorosis.
> The balance of the evidence did not show an association between any fractures and water fluoridation.
> No associations between water fluoridation and human cancer were found. (Treasure, ET, et al. – British Dental Journal 192, 495 - 497 (2002))  another commentary
A blind caries and fluorosis prevalence study of school-children in naturally fluoridated and nonfluoridated townships of Morayshire, Scotland: CONCLUSIONS: Considerable caries benefit has accrued to those Morayshire rural children who have received naturally fluoridated water (at 1 ppm) throughout their lives, as compared to their socioeconomically similar, nonfluoridated rural counterparts. Furthermore, in spite of all but two subjects claiming to have brushed regularly with fluoridated dentifrice (and no evidence of the availability of nonfluoridated toothpaste being purchasable in the five townships), only borderline mild fluorosis disadvantages have been noted clinically, and none by the subjects' own aesthetic perceptions. Finally, no evidence was found to suggest any delay in permanent tooth eruption patterns of the F subjects. It would seem appropriate therefore, that adjustment of Scots' drinking waters' natural fluoride levels to 1 ppm should be pursued to extend similar dental advantages to the vast majority of that population (both young and old) which, it is well documented, has the worst dental health of mainland UK. (Stephen, KW, et al. – Community Dent Oral Epidemiol. 2002 Feb;30(1):70-9) - Free Article
Association of Down's syndrome and water fluoride level: a systematic review of the evidence: BACKGROUND: A review of the safety and efficacy of drinking water fluoridation was commissioned by the UK Department of Health to investigate whether the evidence supported a beneficial effect of water fluoridation and whether there was any evidence of adverse effects. Down's syndrome was one of the adverse effects reported. The aim of this review is to examine the evidence for an association between water fluoride level and Down's syndrome. - CONCLUSIONS: The evidence of an association between water fluoride level and Down's syndrome incidence is inconclusive. (Whiting P, et al. – BMC Public Health. 2001;1:6. Epub 2001 Jul 24)
Water fluoridation, osteoporosis, fractures--recent developments:   RESULTS: Thirty-three studies were identified. Adverse effects in animal feeding studies were only seen at doses much greater than those currently used in artificial water fluoridation. The majority of animal studies showed no effect or a beneficial effect of low fluoride doses. The results of ecological studies were conflicting. One of the two cohort studies showed an increase in fracture incidence at fluoride levels four times greater than optimal water fluoridation and the other showed no effect after 20 years' optimal fluoridation. The cross-sectional studies showed a favourable effect on bone mineral density. The clinical trials predominantly showed increased bone density in several sites associated with fluoride treatment of 9-22.6mg fluoride per day for one-four years.
CONCLUSION: These studies provide a substantial body of evidence that fluoride at up to 1ppm does not have an adverse effect on bone strength, bone mineral density or fracture incidence. (Demos LL, et al. – Dent J. 2001 Jun;46(2):80-7)
Water fluoridation: Community fluoridation - are there benefits? Objective: To compare changes in dental health between non-fluoridated Stourbridge and the towns of Dudley, Sedgeley and Coseley, Brierley Hill and Kingswinford, and Halesowen that were artificially fluoridated in 1987. Conclusion: Drinking water fluoridation is associated with an increase in the percentage of 5-year-old children with no experience of tooth decay (Treasure, E – British Dental Journal 190, 26 (2001)
Effect of long-term exposure to fluoride in drinking water on risks of bone fractures: It is concluded that long-term fluoride exposure from drinking water containing > or =4.32 ppm increases the risk of overall fractures as well as hip fractures. Water fluoride levels at 1.00-1.06 ppm decrease the risk of overall fractures relative to negligible fluoride in water; however, there does not appear to be similar protective benefits for the risk of hip fractures. (Li Y, et al. – J Bone Miner Res. 2001 May;16(5):932-9)  Free Article
Systematic review of water fluoridation: OBJECTIVE: To review the safety and efficacy of fluoridation of drinking water. DESIGN: Search of 25 electronic databases and world wide web. Relevant journals hand searched; further information requested from authors. Inclusion criteria were a predefined hierarchy of evidence and objectives. Study validity was assessed with checklists. Two reviewers independently screened sources, extracted data, and assessed validity.
RESULTS: 214 studies were included. The quality of studies was low to moderate.
CONCLUSIONS: The evidence of a beneficial reduction in caries should be considered together with the increased prevalence of dental fluorosis.  There was no clear evidence of other potential adverse effects. (McDonagh MS, et al. – BMJ. 2000 Oct 7;321(7265):855-9)
Can Fluoridation Affect Lead(II) In Potable Water? Hexafluorosilicate and Fluoride Equilibria In Aqueous Solutions: Conclusion - Recent reports on the possible effects of water fluoridating agents, such as hexafluorosilicic acid, sodium hexafluorosilicate, and sodium fluoride are inconsistent with accepted scientific knowledge, and the authors fail to identify or account for these inconsistencies.  Many of the chemical assumptions are scientifically unjustified, and alternate explanations (such as multiple routes of Pb exposure) have not been satisfactorily addressed.  At present, there is no evidence to suggest that the common practice of fluoridating drinking water has any untoward health impacts via effects on lead(II) when done properly under established guidelines so as to maintain total water quality.  Our conclusion supports both EPA and PHS/CDC policies on water fluoridation. (Urbansky E.T. & Schock M.R. – Intern. J . Environ. Studies, 2000, Vol. 57. pp. 597-637
The prevalence of dental caries and fluorosis in Japanese communities with up to 1.4 ppm of naturally occurring fluoride:   RESULTS: The prevalence of dental caries was inversely related and the prevalence of fluorosis was directly related to the concentration of fluoride in the drinking water. The mean DMFS in the communities with 0.8 to 1.4 ppm fluoride was 53.9 percent to 62.4 percent lower than that in communities with negligible amounts of fluoride. Multivariate analysis showed that water fluoride level was the strongest factor influencing DMFS scores. The prevalence of fluorosis ranged from 1.7 percent to 15.4 percent, and the increase in fluorosis with increasing fluoride exposure was limited entirely to the milder forms. (Tsutsui A, et al. – J Public Health Dent. 2000 Summer;60(3):147-53) Free Article
Community water fluoridation, bone mineral density, and fractures: prospective study of effects in older women: CONCLUSIONS: Long term exposure to fluoridated drinking water does not increase the risk of fracture. (Phipps KR, et al.- BMJ. 2000 Oct 7;321(7265):860-4)
RE: "Safe Drinking Water Act", June 29, 2000: Numerous large-scale epidemiological studies of water fluoridation have been conducted, making fluoridation one of the most widely studied public health measures. Because these large investigations have been consistently validated, water fluoridation is not as frequently studied as in past decades. Water fluoridation is a perfect example of how well designed studies stand the test of time and scientific scrutiny. Studies included in the review articles listed continue to be referenced today and have become "classics" in the public health field. Many well-documented studies have compared the decay rates of children before and after fluoridation in the same community, as well as with children in naturally fluoridated and/or nonfluoridated communities. Because of the high geographic mobility of our populations and the widespread use of fluoride toothpastes, supplements and other topical agents, such comparisons are becoming more difficult to conduct. (Richard F. Mascola, DDS and John S. Zapp, DDS – ADA 2000)  Free Article
Risk of enamel fluorosis in nonfluoridated and optimally fluoridated populations: considerations for the dental professional:  CONCLUSIONS: Enamel fluorosis in the nonfluoridated study sample was attributed to fluoride supplementation under the pre-1994 protocol and early toothbrushing behaviors. Enamel fluorosis in the optimally fluoridated study sample was attributed to early toothbrushing behaviors, inappropriate fluoride supplementation and the use of infant formula in the form of a powdered concentrate. CLINICAL IMPLICATIONS: By advising parents about the best early use of fluoride agents, health professionals play an important role in reducing the prevalence of clinically noticeable enamel fluorosis. (David G. Pendrys – J Am Dent Assoc. 2000 Jun;131(6):746-55.
Indigenous Australian dental health: a brief review of caries experience:  Abstract - The indigenous community in Australia is an at risk population for oral diseases such as dental caries. The majority of communities are isolated and dental services in these areas are limited. Oral hygiene standards are poor and this combined with a diet rich in refined carbohydrates has led to high incidences of dental caries. In addition, diabetes, which is related to obesity (and a diet high in sugar and fat) has been linked to increases in oral disease. Caries prevalence was found to be low in areas where fluoridation levels in the water were high. The fact that the fluoride supplementation appears to improve oral health to a significant degree suggests that implementation of fluoride treatment programmes for school children and, where viable, fluoridation of water sources would be appropriate. In addition, dental education programmes should receive high priority. (Martin-Iverson N, et al. – Aust Dent J. 2000 Mar;45(1):17-20.)
Why We Have Not Changed Our Minds about the Safety and Efficacy of Water Fluoridation: A Response to John Colquhoun - The opponents of fluoridation are a heterogeneous group and cannot easily be categorized by any single characteristic. Among their number are right-wing extremists, misguided environmentalists ("Greens"), chiropractors, persons concerned about the costs of fluoridation, food faddists, and antiscience "naturalists." Other opponents have emerged, including the self-proclaimed "neutrals" who try to portray an image of dispassionate open-mindedness but clearly have accepted the opposition's arguments irrespective of whether they have been adequately tested and answered [6,31,32]. Others have been described as the "born-again antifluoridationists" [33], who previously accepted the mainstream belief in the benefits of fluoridation but have experienced an epiphany so that the scales have fallen from their eyes and they have seen the light [2,34,35]. Clearly Colquhoun falls in this latter category. However, it is important to recognize that simply by claiming to be a former advocate and now clearly being a dedicated opponent of fluoridation in no way validates his judgment nor excuses his distortion of the literature. (Ernest Newbrun, D.M.D., Ph.D.and Herschel Horowitz – Perspectives in Biology and Medicine 42:526-541, 1999)
The effect of fluoride treatment on bone mineral in rabbits: Fluoride therapy has been used clinically for many years, but its use remains controversial and many basic questions remain unanswered. Accordingly, this study returns to an animal model to study the effects of high doses of fluoride on bone mineral in rabbits. Twelve rabbits, aged 3(1/2) months at the start of the study, received drinking water fluoridated at 100 ppm {note - that's 100 times the recommended level - rj} while their 12 control counterparts drank distilled water. All rabbits were sacrificed after 6 months. Fluoride was readily incorporated into femoral cortical bone (7473 +/- 966 ppm F versus 1228 +/- 57 ppm in controls; P < 0.00005). Fluoride therapy led to increased mineralization, as measured by density fractionation (P < 0.0005 for the distributions). The bone mineral itself was altered, with a significant increase in the width of crystals (66.2 +/- 2.0 A versus 61.2 +/- 0.9 A; P < 0.01). The microhardness of both cortical and cancellous bone in the femoral head of fluoride-treated rabbits was greater than that in the controls (P < 0.05). The phosphate, calcium, and carbonate contents in the bone was the same in both groups. Finally, fluoride administration did not affect the architecture or connectivity of cancellous bone in the femoral head. Previously published data [1] indicated that the mechanical properties of bone were adversely affected; this suggests that the effect of high doses of fluoride on the strength and stiffness of bone may be mediated by its effect on bone mineral. (Chachra D, et al. – Calcif Tissue Int. 1999 Apr;64(4):345-51)
Drinking water fluoridation and bone: Accordingly, in most epidemiological studies in humans bone mass was not altered by optimal drinking water fluoridation. In contrast, studies on the effect on hip fracture rate gave conflicting results ranging from an increased fracture incidence to no effect, and to a decreased fracture rate. As only ecological studies have been performed, they may be biased by unknown confounding factors -- the so-called ecological fallacy.  However, the combined results of these studies indicate that any increase or decrease in fracture rate is likely to be small. It has been calculated that appropriately designed cohort studies to solve the problem require a sample size of >400,000 subjects. Such studies will not be performed in the foreseeable future. Future investigations in humans should, therefore, concentrate on the effect of long-term drinking water fluoridation on bone fluoride content and bone strength. (Allolio B, Lehmann R – Exp Clin Endocrinol Diabetes. 1999;107(1):12-20)

Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries - Fluoridation of community drinking water is a major factor responsible for the decline in dental caries (tooth decay) during the second half of the 20th century. The history of water fluoridation is a classic example of clinical observation leading to epidemiologic investigation and community-based public health intervention. Although other fluoride-containing products are available, water fluoridation remains the most equitable and cost-effective method of delivering fluoride to all members of most communities, regardless of age, educational attainment, or income level. (Reported by Div of Oral Health, National Center for Chronic Disease Prevention and Health Promotion, CDC., October, 1999)
Dental caries and dental fluorosis among schoolchildren who were lifelong residents of communities having either low or optimal levels of fluoride in drinking water: CONCLUSIONS: Findings from the present study suggest that water fluoridation still is beneficial and that dental sealants can play a significant role in preventing dental caries. In addition, findings from this survey appear to support the premise that the difference in dental fluorosis prevalence between fluoridated and nonfluoridated communities has narrowed considerably in recent years. (Selwitz RH, et al., J Public Health Dent. 1998)
Fluoridation--the Israel experience: There have been suggestions, mainly in the lay press, that fluoridation might affect immunity. Careful examination of various studies on fluoride and immune function do not support this suggestion. Whilst fluoride at high concentrations can have inhibitory effects on lymphocyte and polymorphonuclear leucocyte function, these concentrations are many times higher than levels which would be expected from fluoridation. Fluoride can act as an immunological adjuvant. There is no evidence of any deleterious effect on specific immunity following fluoridation nor any confirmed reports of allergic reactions. (Challacombe SJ – Community Dent Health. 1996 Sep;13 Suppl 2:69-71)
Fluoridation--the Israel experience: Epidemiological studies have shown that 5- and 12-year-old children living in fluoridated areas (in Israel) have considerably less dental caries than those receiving unfluoridated water. (Kelman AM – Community Dent Health. 1996 Sep;13 Suppl 2:42-6)
The effectiveness of community water fluoridation in the United States: Grand Rapids, the first city in the world to implement controlled water fluoridation, has served as a model for thousands of other communities. Fluoridation is one of the greatest public health and disease-preventive measures of all time. Its advantages include effectiveness for all, ease of delivery, safety, equity, and low cost. Today, nearly 56 percent of the US population lives in fluoridated communities (62% of those on central water supplies). Previously observed caries reductions of one-half to two-thirds are no longer attainable in the United States because other fluoride methods and products have reduced the caries prevalence in all areas, thus diluting the measurement of effectiveness, and because benefits of fluoridation are dispersed in many ways to persons in nonfluoridated areas. Water fluoridation itself, however, remains as effective as it ever was among groups at high risk to dental caries. Contrary to early beliefs that stressed the importance of preeruptive fluoride exposure, fluoridation also provides an important source of topical fluoride and facilitates remineralization. Although data on effectiveness and safety are compelling, future progress of water fluoridation will be affected by economic, political, and public perception factors. (Horowitz, HS – J Public Health Dent. 1996;56(5 Spec No):253-8)
Water fluoridation and osteoporotic fracture: Data on the relationship between fluoride intake and hip fracture risk at the individual level, and data relating fluoridation to bone mineral density are required. Until these become available, the burden of evidence suggesting that fluoridation might be a risk factor for hip fracture is weak and not sufficient to retard the progress of the water fluoridation programme.
(Hillier S, Inskip H, Coggon D, Cooper C. – Community Dent Health. 1996 Sep;13 Suppl 2:63-8)
Cancer and fluoridation: The present paper gives a brief overview of the evidence that fluoride in drinking water has not been shown to cause an increase in the risk of developing cancer and of the errors in the analyses that purport to show such an increase. (Cook-Mozaffari P. – Community Dent Health. 1996 Sep;13 Suppl 2:56-62)
Thirty-eight years of water fluoridation--the Singapore scenario: Singapore is the first country in Asia to institute a comprehensive fluoridation programme which covers 100 per cent of the population. The water was fluoridated at 0.7 ppm fluoride using sodium silicofluoride. The ten year study on the effects of water fluoridation in Singapore showed a decrease in caries prevalence in the children. In the permanent dentition the reduction was 52.3 per cent for Chinese and 31 per cent for Malays in the 7 to 9 year old age group. A similar trend was observed in the mixed dentition in which the decrease was 32.5 per cent for Chinese and 30.6 per cent for Malays. Because of the availability and use of other fluoride products, dental fluorosis was observed in children in later years. Although the decline in dental caries after 10 years of water fluoridation was not comparable to those achieved in other countries, this study further documents water fluoridation as the most cost-effective public health measure for the prevention of dental caries. (Loh, T – Community Dent Health. 1996 Sep;13 Suppl 2:47-50)  Free Article
Drinking water and cancer:  Any and all chemicals generated by human activity can and will find their way into water supplies. The types and quantities of carcinogens present in drinking water at the point of consumption will differ depending on whether they result from contamination of the source water, arise as a consequence of treatment processes, or enter as the water is conveyed to the user. Source-water contaminants of concern include arsenic, asbestos, radon, agricultural chemicals, and hazardous waste. Of these, the strongest evidence for a cancer risk involves arsenic, which is linked to cancers of the liver, lung, bladder, and kidney. The use of chlorine for water treatment to reduce the risk of infectious disease may account for a substantial portion of the cancer risk associated with drinking water. The by-products of chlorination are associated with increased risk of bladder and rectal cancer, possibly accounting for 5000 cases of bladder cancer and 8000 cases of rectal cancer per year in the United States. Fluoridation of water has received great scrutiny but appears to pose little or no cancer risk. (Morris RD – Environ Health Perspect. 1995 Nov;103 Suppl 8:225-31)  Free Article
Fluoride exposure and childhood osteosarcoma: a case-control study; CONCLUSIONS: Fluoride exposure does not increase the risk of osteosarcoma and may be protective in males. The protective effect may not be directly due to fluoride exposure but to other factors associated with good dental hygiene. There is also biologic plausibility for a protective effect. (Gelberg KH, et al. – Am J Public Health. 1995 Dec;85(12):1678-83)
Dental fluorosis and caries prevalence in children residing in communities with different levels of fluoride in the water:   CONCLUSIONS: The ingestion of water containing 1 ppm or less fluoride during the time of tooth development may result in dental fluorosis, albeit in its milder forms. However, in these times of numerous products containing fluoride being available, children ingesting water containing 1 ppm fluoride continue to derive caries protection compared to children ingesting water with negligible amounts of fluoride. Thus, the potential for developing a relatively minor unesthetic condition must be weighed against the potential for reducing dental disease. (Jackson RD, et al. – J Public Health Dent. 1995 Spring;55(2):79-84)
Effects of fluoridated drinking water on bone mass and fractures: the study of osteoporotic fractures: Our results do not support the findings from recent ecological studies which showed an increased risk of hip fracture among individuals exposed to fluoridated public water. (Cauley JA, et al. – J Bone Miner Res. 1995 Jul;10(7):1076-86)
Fluorides and Oral Health – Report of a WHO Expert Committee on Oral Health Status and Fluoride Use, 1994:   Conclusion of ‘Fluoride in drinking-water’ section: Community water fluoridation is safe and cost-effective and should be introduced and maintained wherever socially acceptable and feasible.
2016 update of Fluoride and Oral Health: Provided that a community has a piped water supply, water fluoridation is the most effective method of reaching the whole population, so that all social classes benefit without the need for active participation on the part of individuals. Water fluoridation has been endorsed by the world’s leading science and health organizations, including WHO, the International Association for Dental Research (IADR) and FDI World Dental Federation.  Free Article
Acute fluoride poisoning from a public water system: In May 1992, excess fluoride in one of two public water systems serving a village in Alaska caused an outbreak of acute fluoride poisoning.  ...We estimated that 296 people were poisoned; 1 person died.  ...The fluoride concentration of a water sample from the implicated well was 150 mg per liter {150 times normal}, and that of a sample from the other system was 1.1 mg per liter. Failure to monitor and respond appropriately to elevated fluoride concentrations, an unreliable control system, and a mechanism that allowed fluoride concentrate to enter the well led to this outbreak.  Discussion: 'The findings of our investigation should be of concern both to health care providers of patients with acute fluoride poisoning and to public health and other officials responsible for water fluoridation. The efficacy of fluoridation in preventing dental caries has been well documented, and the safety of this practice is supported by the extreme rarity of incidents of overfluoridation. We believe that the practice of fluoridation of public water systems should continue. However, public health officials must make certain that standard safety equipment is installed, that water-system operators are properly trained, and that routine, systematic monitoring and follow-up of fluoride concentrations in water systems and inspection of fluoridation units are undertaken. (Gessner BD, et al. – N Engl J Med. 1994 Jan 13;330(2):95-9)
Efficacy of preventive agents for dental caries. Systemic fluorides: water fluoridation: The effectiveness of fluoridation has been documented by observational and interventional studies for over 50 years. Data are available from 113 studies in 23 countries. The modal reduction in DMFT values for primary teeth was 40-49% and 50-59% for permanent teeth. The pattern of caries now occurring in fluoride and low-fluoride areas in 15- to 16-year-old children illustrates the impact of water fluoridation on first and second molars. The secular changes in caries in Hartlepool, a natural fluoride area in the North East of England, shows only a modest change between 1949 and 1989. Information on the pre-eruptive effects of water fluoridation has been reviewed, suggesting that fluoridation should start at birth to provide optimal protection to primary teeth. At 15 years of age, the maximum DMFS reduction in a fluoridated area was due about half to the pre-eruptive and about half to the post-eruptive effect of fluoride. (Murray JJ – Caries Res. 1993;27 Suppl 1:2-8
Dental caries and fluoride exposure in Western Australia: Bivariate analysis revealed all fluoride exposure to be associated with reduced caries experience, but there were large correlations between some variables. When unconditional logistic regression analysis was used, the most important (p less than 0.05) odds ratios associated with no caries experience were for residence in a fluoridated area from four to 12 years of age and early use of toothpaste. (Riordan, PJ – J Dent Res. 1991 Jul;70(7):1029-34)
A half-century of community water fluoridation in the United States: review and commentary: Abstract - The nearly 50-year history of community water fluoridation is reviewed with the major emphasis on the benefits and safety of fluoridation. Other aspects of water fluoridation also described include the apparent reduction in measurable fluoridation benefits because of the abundance of other fluoride sources, the diffusion of fluoridation effects into fluoride-deficient communities, preeruptive and posteruptive effects, technical and cost aspects, sociopolitical and legal issues that affect the successful fluoridation of communities, and alternatives to community water fluoridation. The majority of studies have evaluated the effectiveness of water fluoridation on the permanent teeth of children, while there are fewer studies on deciduous teeth and in adults; the relationship between fluoride ingestion and bone health needs further clarification; the sociopolitical issues of fluoridation need to be better understood. (Ripa LW – J Public Health Dent. 1993 Winter;53(1):17-44)
Caries prevention--fluoride: reaction paper: Although the prevalence of caries has declined in young persons in developed countries, there is still a need for water fluoridation. The effectiveness of fluoride is dependent on the ambient levels of fluoride in the oral cavity. Fluoride appears to exert the bulk of its protective effect locally by promoting remineralization of early carious lesions. Nevertheless, fluoride tablets continue to be prescribed as if the action of fluoride is expressed systemically. There is an urgent need to explore the clearance of fluoride from the mouth and to develop methods to ensure constant levels of fluoride in the oral cavity, thereby reducing both the need for frequent exposure and the amount necessary for clinical effect. (Bowen WH – Adv Dent Res. 1991 Dec;5:46-9) {Often, when controversial papers are published, like the Clarkson paper below, others are offered an opportunity to respond immediately} 
Caries prevention--fluoride: Convincing evidence exists that fluoride has a major effect on the demineralization and remineralization of dental hard tissues, and that it interferes with the acid production from "cariogenic" bacteria. However, it has also been shown to be physiologically harmful if fluoride concentrations and/or exposure periods are inappropriate.  ...The benefits and problems associated with the systemic route of fluoride administration are discussed with special reference to caries control and fluoride's mechanism of action and its toxic effect. The same discussions are focused on the role of the topical effects of fluoride, with particular emphasis placed upon: low vs. high fluoride concentrations; calcium fluoride vs. fluorhydroxyapatite; and fluoride distribution, in both the mouth and in the teeth. The benefits and problems associated with the systemic route of fluoride administration are discussed with special reference to caries control and fluoride's mechanism of action and its toxic effect. The same discussions are focused on the role of the topical effects of fluoride, with particular emphasis placed upon: low vs. high fluoride concentrations; calcium fluoride vs. fluorhydroxyapatite; and fluoride distribution, in both the mouth and in the teeth. The benefits and problems associated with the systemic route of fluoride administration are discussed with special reference to caries control and fluoride's mechanism of action and its toxic effect. The same discussions are focused on the role of the topical effects of fluoride, with particular emphasis placed upon: low vs. high fluoride concentrations; calcium fluoride vs. fluorhydroxyapatite; and fluoride distribution, in both the mouth and in the teeth.  (Clarkson BH – Adv Dent Res. 1991 Dec;5:41-5)
Recent trends in dental caries in U.S. children and the effect of water fluoridation:  The decline in dental caries in U.S. schoolchildren, first observed nationwide in 1979-1980, was confirmed further by a second national epidemiological survey completed in 1987. Mean DMFS scores in persons aged 5-17 years had decreased about 36% during the interval, and, in 1987, approximately 50% of children were caries-free in the permanent dentition. Children who had always been exposed to community water fluoridation had mean DMFS scores about 18% lower than those who had never lived in fluoridated communities. When some of the "background" effect of topical fluoride was controlled, this difference increased to 25%. The results suggest that water fluoridation has played a dominant role in the decline in caries and must continue to be a major prevention methodology. (Brunelle JA1, Carlos JP. – J Dent Res. 1990 Feb;69 Spec No:723-7)
NTP Toxicology and Carcinogenesis Studies of Sodium Fluoride (CAS No. 7681-49-4)in F344/N Rats and B6C3F1 Mice (Drinking Water Studies): There was no evidence of carcinogenic activity in female F344/N rats receiving sodium fluoride at concentrations of 25, 100, or 175 ppm (11, 45, or 79 ppm fluoride) in drinking water for 2 years. There was no evidence of carcinogenic activity of sodium fluoride in male or female mice receiving sodium fluoride at concentrations of 25, 100, or 175 ppm in drinking water for 2 years. Dosed rats had lesions typical of fluorosis of the teeth and female rats receiving drinking water containing 175 ppm sodium fluoride had increased osteosclerosis of long bones. (Natl Toxicol Program Tech Rep Ser. 1990 Dec;393:1-448) 
Fluoride: Benefits And Risks of Exposure: Together, these studies indicate that fluoride in drinking water is beneficial to dental health. However, recent studies have reported declines in caries prevalence in nonfluoridated areas that are comparable in magnitude to declines noted in fluoridated areas. While these estimates of caries decreases in nonfluoridated areas appear accurate, conclusions cannot be drawn from these studies concerning the independent effects of fluoridated drinking water on caries prevalence since other possible sources of fluoride exposure were not measured. Fluoride sources, other than in drinking water, may provide a level of caries protection similar to fluoridated drinking water. (Laurence S, et al. – Crit Rev Oral Biol Med. 1990;1(4):261-81)
Effectiveness of water fluoridation:  Abstract - The efficacy of communal water fluoridation in reducing dental caries has been reviewed based on surveys conducted in the last decade of caries prevalence in fluoridated and nonfluoridated communities in the United States as well as in Australia, Britain, Canada, Ireland, and New Zealand. The efficacy is greatest for the deciduous dentition, with a range of 30-60 percent less caries in fluoridated communities. In the mixed dentition (ages 8 to 12), the efficacy is more variable, about 20-40 percent less caries. In adolescents (ages 14-17), it is about 15-35 percent less caries. Current data on caries prevalence in adults and seniors are extremely limited and include several populations living in communities with higher than optimal fluoride levels. For these adults and seniors, a range of 15-35 percent less caries would also apply. Viewed in toto, the current data for children, adolescents, adults and seniors show a consistently and substantially lower caries prevalence in fluoridated communities. For an accurate measurement of the efficacy of water fluoridation in reducing dental caries, it is essential that only persons with a record of continuous or long-term residency in fluoridated versus nonfluoridated areas be included in such assessments. Because of the high geographic mobility in our society and the widespread use of fluoride dentifrices, supplements, and other topical fluoride agents, such comparisons are becoming more difficult to conduct. Accordingly, the effectiveness (rather than the efficacy) of water fluoridation has decreased as the benefits of other forms of fluoride have spread to communities lacking optimal water fluoridation. (Newbrun E – J Public Health Dent. 1989;49(5 Spec No):279-89)
Treatment of Bone Weakness in Patients with Femoral Neck Fracture by Fluoride, Calcium, and Vitamin D:  Twenty-three of 46 patients, aged 56 to 95 years, with fracture of the femoral neck (FNF) completed the first trial of 10 months treatment with oral sodium fluoride 60 mg and calcium 1800 mg on alternate days and 1 ıtg of vitamin D1 daily.  In 17 patients the treatment improved the amount and quality of trabecular bone. Cortical thickness increased in nine patients and there were no losses of amount or mineralisation. The treatment was well tolerated by most patients and there were no major side-effects or signs of bone demineralisation. The study also revealed an unexpected rapid post-fracture deterioration of bone tissue in untreated FNF patients; thus there is an increased risk of further fractures which calls for the use of an effective treatment to increase bone mass. (Mackie et al. – J Bone Joint Surg Br 1989 71-B (1): 111)  Free Article
Fluorides, facts and fanatics: public health advocacy shouldn't stop at the courthouse door: One of the more controversial American public health issues is fluoridation of municipal water supplies. Opponents occasionally succeed in halting fluoridation through local referenda, but the courts usually uphold fluoridation laws. In 1982, however, an Illinois trial judge ruled that a state law authorizing fluoridation was unconstitutional. Although unimpressed by the plaintiff's evidence purporting to show fluoridation's risks, the judge was compelled to rule against the state because it had failed to counter with evidence on the safety of fluoridated water. Christoffel analyzes the trial court's decision and its subsequent reversal by the Illinois Supreme Court. He urges public health professionals to assume advocacy roles by ensuring that the scientific rationale behind public health regulations becomes part of the legislative record and by forcefully supporting public health policies in all forums, including the courts. (Christoffel T – Am J Public Health. 1985 Aug;75(8):888-91)  Free Article
Thirty years of fluoridation: a review: Fluoride contributes to stability of both teeth and bones and to reduction of caries, especially if ingested before eruption of teeth. Reduction of caries continues at about 60% in persons drinking fluoridated water only as long as fluoride washes over teeth. One-half the population of the US does not have access to water with an optimal fluoride concentration of about 1 mg/L. Misinformation about fluoridation contributes to reluctance of communities to supplement the natural but inadequate fluoride of those water supplies. Fluoridation of water has no positive or negative effect on incidence or mortality rates due to cancer, heart disease, intracranial lesions, nephritis, cirrhosis, mongoloid births, or from all causes together. The collective decision to increase the natural fluoride content of water supplies is not an infringement of civil rights, nor does it establish a precedent in the binding sense of the law. Supplemental fluoride in water makes it available to all members of the community in a safe, practical, economical and reliable manner. Fluoridation saves money in dental costs and time lost from work. Fluoridation is an appropriate action of government in promoting the health and welfare of society. (Richmond VL – Am J Clin Nutr. 1985 Jan;41(1):129-38)

Fluoridation of Water and Cancer: A Review of the Epidemiological Evidence - The justification for such a measure as the addition of fluoride to the water supplies of entire communities must rely on strong scientific evidence pointing not only to its effectiveness but to its safety, even though the recommended level in the public water supply is similar to that yielded by many natural sources. From the first, therefore, the safety of the fluoridation of water to the optimum concentration (1 milligram per litre) has been a paramount consideration, and fluoridation programmes were both preceded and accompanied by investigations ofthe health of populations exposed to fluoride in water. Allegations that fluoridation causes cancer have naturally given rise to great public concern. Authoritative advice on all aspects of the evidence, in relation to the addition of fluoride to the drinking water of whole communities to achieve a concentration of 1 milligram per litre, has recently been obtained from the Department's independent expert scientific advisers. They considered all the available evidence on the biological effects of fluoride in short-term tests, and animal carcinogenicity tests, as well as the direct and extensive studies of human populations reviewed in the present Report. They concluded that there is no evidence leading to an expectation of hazard through the induction of heritable abnormalities, and no reliable evidence of any hazard to man in respect of cancer. (1985 Report of the Working Party )  Other download options
Fluorine and thyroid gland function: a review of the literature: Published data failed to support the view that fluoride, in doses recommended for caries prevention, adversely affects the thyroid. (Bergi H, et al. – Klin Wochenschr. 1984 Jun 15;62(12):564-9)  Free Article
The alleged association between artificial fluoridation of water supplies and cancer - a review: Since 1945, artificial fluoridation of water supplies has been used with success to reduce the incidence of dental caries in many areas where the natural fluoride content of the water is low. However, since 1975, it has been maintained that such artificial fluoridation is followed by an increased risk of cancer. These allegations originate from a single source. The present review, which covers re-examinations of the same data as well as evidence from scientific and governmental bodies in many countries, shows these assertions to be erroneous. (J. Clemmesen – Bull World Health Organ. 1983; 61(5))  Free Article
Fluoridation of water supplies and cancer mortality I: A search for an effect in the UK on risk of death from cancer: Claims that the mortality from cancer has been increased in urban populations as a result of the fluoridation of water supplies have been given publicity in the press and on the radio and television, and questions have consequently been asked in Parliament with a view to stopping plans for further fluoridation. These. claims have been based on an analysis of the trend in cancer mortality rates in American towns by Yiamouyiannis and Burk1" and more recently on an analysis of crude cancer mortality in two British towns-Birmingham, where the water supply was fluoridated in October 1964, and Manchester, where there has been no fluoridation. CONCLUSION: Examination of the trend in mortality for cancer in the seven cities in England and Wales with populations of over 400 000* and in England and Wales as a whole between 1959-63 and 1974-8 provides no reason to suppose that any unique factor, such as fluoridation of the water supplies, has affected the death rate for cancer in Birmingham since 1964. (Paula Cook-Mozaffari, et al. – Journal of Epidemiology and Community Health, 1981, 35, 227-232)  Free Article
Fluoridation of water supplies and cancer mortality II: Mortality trends after fluoridation:  In the past two years much publicity has been given to Burk's claim that the mortality from cancer in Birmingham increased sharply following fluoridation of the water supply in 1964 and, specifically, that it increased more sharply than in other British towns. This claim is not supported by detailed examination of age-standardised mortality rates in England and Wales' and we have, therefore, re-examined the data to see what led Burk to his conclusion. Conclusions Claims that unusual increases in cancer mortality have occurred in England after fluoridation have been examined and have been shown to rest on incorrect arithmetic, on the use of inappropriate statistical methods, and on examination of too restricted a part of the available data. Studies from other parts of the world which have examined trends in cancer mortality after fluoridation, or which have made geographical comparisons between fluoridated and unfluoridated areas, have been reviewed. There is no evidence either from England and Wales or from elsewhere in the world that the addition of fluoride to water supplies has increased the risk of dying from cancer. (Paula Cook-Mozaffari – Journal of Epidemiology and Community Health, 1981, 35, 233-238)  Free Article
Fluoridation and mortality--an epidemiologic study of Pennsylvania communities: Fewer health measures have been accorded more clinical and laboratory research, epidemiologic study, massive clinical trials of total community populations, and public attention )both favorable and adverse) than the fluoridation of public water supplies. As a result, knowledge of the dental and nondental physiological effects of fluoridation has increased significantly since Grand Rapids, Mich., was first experimentally fluoridated in 1945. There is now considerable evidence that fluoridation of community water supplies is both effective and safe. In 1975, the Council on Foods and Nutrition of the Americal Medical Association updated its earlier statement confirming the efficacy and safety of fluoridation under controlled administration. Jackson provides a list of 22 statements and findings supportive of fluoridation from lay, legal, and professional groups throughout the world. However, controversy (maintained by a segment of the general public and professional community) continues regarding possible adverse effects of fluoridation on human health. The National Cancer Institute and the National Heart and Lung Institute  have recently issued statements that refute claims suggesting a relationship between fluoridated water and mortality from cancer and heart disease. No clear evidence was found to suggest that fluoridation under controlled administration adversely affects overall mortality or diabetes mortality. Under controlled administration, fluoridation may have no significant effect on either mortality rate. The inconsistent relationships found between high levels of fluoride and cerebrovascular disease mortality require further investigation. (Tokuhata, GK, et al. – Public Health Reports, Vol. 93, January-February 1978, pp. 60-68)

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Statewide Antifluoridation Initiatives: A New Challenge to Health Workers - Fluoridation of municipal drinking waters remains an issue of contention in the western United States. Spirited campaigns recently have been waged in Oregon and Washington by those who oppose fluoridation. The approach of the opposition was unique: statewide prohibition campaigns launched simultaneously in neighboring states. The enabling vehicle for introduction of these campaigns was the public initiative process. ...A disquieting aspect of these recent campaigns was the central role in each state of the National Health Federation. The Federation, based in Monrovia, California, is "dedicated to the protection of health freedoms," emphasizing that the patient should be free to choose alternate forms of health care, and that the choice should be free of governmental restriction or "monopolistic control". ...The Federation challenges pasteurization of milk, fluoridation of public water supplies and immunizations, and promotes Laetrile, Krebiozen, mega-vitamin therapy, naturopathic medicine, chelation therapy, and a variety of alternative health care practices. (Caswell A, et al. – AJPH January, 1978, Vol. 68, No. 1)
Water fluoridation and congenital malformations: no association -The incidence of selected congenital malformations in areas with fluoride supplementation of public water supplies was compared with the incidence in areas where the water supply is deficient in fluoride. Comparison of the incidences of several common birth defects (including Down's syndrome) in fluoridated and nonfluoridated areas revealed no substantial or significant differences in which there was a consistent pattern for both sets of data. (Erickson JD – J Am Dent Assoc. 1976 Nov;93(5):981-4) 
Grand Rapids Fluoridation Study—Results Pertaining to the Eleventh Year of Fluoridation: In all studies the findings show a reduction of 60-65 per cent in the prevalence of caries in the permanent teeth of children born subsequent to the change in water supply. Furthermore, the evidence strongly suggests beneficial effects on teeth which were formed, or erupted, prior to the initiation of water fluoridation. In all these studies particular attention and interest has been paid to any effects fluoridation might have on other biologic systems of the body. In none of the studies has there been any scientific evidence to suggest an adverse effect on any segment of a rather large population living under divergent environmental conditions. These observations, in conjunction with the fact that millions of people have used naturally fluoridated waters for generations, attest to the complete safety of the procedure. (Francis A. Arnold, Jr. – Am J Public Health Nations Healthv.47(5); 1957 May)  Free Article
Urinary fluoride levels associated with use of fluoridated waters:
Surveys in two areas contribute additional evidence that no hazard of cumulative toxic fluorosis is associated with the use of fluoridated water containing 100m fluoride. Within 1 week, the concentration of fluoride in the urine equaled that in the drinking water for adults. For children, the period of adjustment was considerably longer {3-5 years}.  (Zipkin, RC – Public Health Rep. 1956 August; 71(8))  Free Article
Toxicological Evidence for the Safety of the Fluoridation of Public Water Supplies: The extravagance of the variously motivated statements frequently heard in opposition to fluoridation wherever it is under consideration may lead officials who must explain this prophylactic measure to the public to discount the fact that many citizens still remain unconvinced of the safety of this procedure, despite the assurances of medical, dental, and public health authorities. CONCLUSIONS: The results of animal experimentation show that the prolonged intake of quantities of fluoride too small to induce dental fluorosis does not give rise to any of the nondental manifestations of chronic intoxication by fluorides. Epidemiologic data and clinical and radiographic examinations of exposed industrial workers indicate that only when the fluoride content of a water supply exceeds 5 or 6 ppm will its prolonged usage give rise to detectable osseous changes and then only in the most susceptible persons. The evidence as a whole is consistent in offering assurance that bringing the fluoride concentration in communal water supplies to that known to be optimal for dental health is a prophylactic public health procedure which has an ample margin of safety. (Francis F. Heyroth, M.D. – Am J Public Health Nations Health. 1952 December; 42 (12))

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Studies on Mass Control of Dental Caries Through Fluoridation of the Public Water Supply: Summary -  Fluoridation of the Grand Rapids public water supply began in January 1945. Analysis of the 1949 dental examinations at Grand Rapids shows a reduced amount of dental caries experience when compared with the pre-fluoridation rates of 1944-45. The findings indicate that the reduction is most pronounced in the younger age groups whose dentition was largely calcified following the addition of one part per million of fluoride (F) to the previously fluoride-free public water supply. Sufficient time has not elapsed to evaluate water fluoridation in the older age groups. (Dean HE, et al. – Public Health Rep. 1950 October 27; 65(43)) [This article starts about 1/2 way through the document - RJ]

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The Newburgh-Kingston Caries Fluorine Study (Dental Findings after Three Years of Water Fluoridation): SUMMARY
1) The DMF rate for permanent teeth shows a consistent downward trend in Newburgh from 21.0 to 14.8 per 100 permanent teeth. This indicates a saving of 6.5 permanent teeth per 100 in Newburgh as compared with a rate of 21.3 per 100 in Kingston at the last examination. This represents a saving of 30 per cent.
2) Among first molars, which account for the major part of the caries problem in children, after three years of fluoride experience, Newburgh's rate was 48.0 DMF per 100 first molars, while Kingston's was 58.7, or a difference of 10.7 DMF per 100 first molars. This represents a saving of 18 per cent in DMF first molars.
3) The greatest benefits are noted in the younger age groups.
4) The differences between Newburgh and Kingston as represented in these data suggest the possibility of benefits from exposure to fluoridated water subsequent to enamel calcification and subsequent to eruption of the first molars.
5) We cannot entirely rule out the possibility of variation in the interpretations of the examiners. The fact that more than one examiner was used might alter the differences between Newburgh and Kingston to some extent. However, the size of the differences in the DMF rates of the two cities is such that it is unlikely that an examiner bias could vitiate them.
6) These data are preliminary and it will be necessary to continue collecting data for the proposed duration of the study, that is, through 1954 to 1956, to obtain additional information concerning the caries prophylactic value of fluorine.  (David B, et al. – Am J Public Health Nations Health. 1950 June; 40(6))