The fluoride debate has been ongoing for 50 years. In the past few months I sense a renewed vigor on the side of organized dentistry to promote water fluoridation. For example, a recent study from Australia showed a 10% reduction in cavities and was heralded “Water fluoridation good for adults as well as kids”. I have never seen such a headline for the 85% reduction in cavities from using xylitol. The only attention to xylitol came after a poorly designed xylitol study supposedly showed “scant benefits” – which were in fact the same 10% reduction in decay. (Read more about this study in “Xylitol in the News: Reading Beyond the Headlines“.)

The fluoride argument is between advocates of water fluoridation (who appear to use textbook data and sensational headlines) vs. the “anti-fluoridationists” who seem prepared to endure fillings, root canals, and even lost teeth, rather than put a grape-seed amount of fluoride toothpaste on their toothbrush. Like extreme politics, most of us are not interested in joining either side. We would like to know the truth and know if fluoride is good or bad for us. Is it the best way to prevent cavities or does it ruin our health?

Two sides

I am convinced fluoride-containing products can be very useful for dental health, but I also believe it is time to end public water fluoridation. This is an unpopular middle position, which is not tolerated by either side of the debate. The ADA (and most dentists) think poorly of a dentist who is against water fluoridation, yet the “anti-fluoridationists” will not endorse my book because I recommend fluoride toothpaste and mouth rinses to stimulate the natural repair of damaged teeth and help them be more resistant to cavities.

I think we can learn most about water fluoridation by taking a look at the time-line of the story. At the end I am also providing a link to my chapter on Fluoride from Kiss Your Dentist Goodbye, for references and extra detail.

Natural fluoride

Fluoride compounds occur naturally in the water in many parts of the world and have been used for farming and drinking for hundreds of years. If you pour water over a block of salt, you’ll know some salt dissolved, because the water tastes salty. There’s no taste change, but fluoride is absorbed into any water that percolates through rock that contains fluoride. Plants grown in these areas will absorb fluoride from the soil and any food or drinks made from their stems or leaves (like tea) will naturally contain fluoride.

Artificial fluoridation

Controversy over fluoride began a generation ago when a decision was made to add artificial fluoride to US water supplies. Times have changed, our knowledge of fluoride has matured, and today we know more effective ways to prevent cavities. The idea that we need fluoridated water is out-dated and there are legitimate concerns about potential health hazards from ingesting too much.

This story begins with a simultaneous sequence of events in the early 1900s. Dentistry was evolving from a barbershop business into a respected profession. Many dentists were excited about a new silver filling developed in France, which gave them the opportunity to repair decayed teeth, rather than extract them. Suddenly saving teeth became the focus of dentistry’s mission.

Colorado Brown Stain

In the early 1900s in Colorado, a young dentist noticed stains and pitting in the surface of his patients’ teeth. Later it was shown that the problem was caused by an excessive amount of naturally occurring fluoride in this Colorado water supply. Too much fluoride can damage enamel-forming cells if consumed while the tooth is forming, which is during the first three years of a baby’s life. The damage is caused by fluoride being absorbed into the blood stream and then dispersed throughout the body in sufficient concentration to kill enamel-forming cells. The effects will not be seen until the permanent teeth erupt at 7 to 8 years old. The result is permanent staining and pitted defects in adult teeth.

Travel became easier around this time and gave dentists the opportunity to gather at professional meetings to discuss interesting clinical cases. “Colorado Brown Stain” was one of the topics discussed. To everyone’s surprise, similar staining had been noticed by dentists from other communities – including parts of Idaho, Ireland and other places around the world. In each case the teeth were pitted, yellowish-brown and unattractive. With the advance of photography, dentists could compare and categorize the markings into mild, moderate or severe. Initially no one knew the reason, but many believed it was something in water.

An ALCOA problem

During these same years, a factory in Bauxite, Arkansas began to ramp up production of a lightweight new metal called aluminum, which promised benefits for aircraft and opportunities for US industry and the military. Problems began when children growing up in the area around the factory began to erupt their adult front teeth at 7 and 8 years of age. By 1931 the community near the factory was convinced that aluminum had caused the ugly brown stains in their children’s teeth and feared it was a sign of aluminum toxicity. Here is a link to the time-line of aluminum manufacture at Bauxite:

Fluorosilicic acid is a fluoride by-product of aluminum manufacture that had been released into the water supplies near the company. To exonerating the industry and dispel toxicity fears, the company (later to become the Aluminum Company of America – ALCOA) began testing the water. This was the era of the great depression and a little before World War II, so no doubt the company was relieved to show fluoride had caused this staining, not aluminum. The aluminum company continued to fund tests and finally gathered support for an idea that has linked dentistry with ALCOA ever since.

Ideas and Experiments

Testing showed that the severity of tooth mottling depended on the amount of fluoride in the water. At high concentrations the mottling was bad and teeth were brown and deeply pitted. At low concentrations the damage was less visible. At 1-part-per-million, the markings were faint and white. The mottling was called “fluorosis” and dentists confirmed that although damaged, these teeth were strong and could resist cavities. From this observation the idea of adding fluoride to water launched. The United States Public Health Service said 1-part-per-million would be the correct level to protect teeth and by 1945 the American Dental Association agreed to artificially add 1 part-per-million sodium fluoride to the water of Grand Rapids, Michigan.

Don't want to lookNot all fluoride is the same, and there are many fluoride compounds, all with varying stability and properties. Some fluoride compounds are only available as liquids, while others are powders. Today you will often find a harsh product called stannous fluoride in toothpastes (a tin derived fluoride) and sodium fluorosilicate in our water supplies. Sodium fluoride is one of the most stable salts of fluoride, but it is also the most expensive.

Water fluoridation

In 1952 the Michigan experiment ended, shortened because the results were hailed as such a success. The study showed fluoride lowered tooth decay by 60%. Such a study would not stand modern analysis, and today we know any reduction in decay from community fluoridation is 10 – 20% , which may not be clinically significant. (To put this in perspective, xylitol studies consistently indicate xylitol reduces children’s tooth decay by 80-95%).

Within a couple of years engineered, man-made fluoride was added to US water supplies across the country. Many dentists and physicians objected, but fluoridation had the support of the American Dental Association. Today fluoride is added to 78% of our water supplies and it is important to note that although sodium fluoride was the fluoride originally agreed for this use, other less expensive fluorides (fluorosilicic acid and sodium fluorosilicate) – which are by-products of the aluminum and fertilizer industries – became the fluoride chosen for almost all our water supplies.

Dentists know teeth – not water chemistry

As a newly graduated dentist I knew nothing of this story, but I was trained to enthusiastically endorse fluoride and extol its benefits. I remember how we ridiculed anyone who disputed fluoride. I believe dentists know plenty about teeth but they do not learn the complicated chemistry of water in enough detail to give endorsement of fluoridation. Mineral content can vary and there is impact from pH, other chemicals in the water, and reactions with the metals in pipes and plumbing that carry water to homes. Dentists know that despite fluoridation we have an epidemic of tooth decay in many fluoridated cities. Today, in Rochester, NY (fluoridated years ago) most city children have decayed teeth by age 4 and poor oral health that continues throughout life.

We have learned much since fluoridation began, and we know dental benefits from drinking (or ingesting) fluoride are virtually nill. There is no reason to consume fluoride for its tooth-strengthening effect, because this occurs as fluoride contacts the outside tooth surface. We can easily use products made with the correct kind of fluoride (sodium fluoride) at the best dilution, applied directly on our teeth, to prevent cavities. Stronger fluoride does not repair or remineralize teeth as effectively as a small amount of dilute sodium fluoride regularly brushed or rinsed over the outside of teeth. We can enjoy the benefits of fluoride to strengthen and heal without all the concern that come from drinking and consuming fluoride in foods and drinks. Today fluoride toothpaste and rinses are easily accessed and we no longer need artificially fluoridated water.

Over exposure

Everything about fluoride indicates that although a tiny amount may be helpful, excess is damaging. Fluoridation of water makes it impossible to escape fluoride exposure, often from unknown or unexpected sources, making it impossible to learn the extent of our own exposure. Fluoride is concentrated if you boil water or prepare sauces by reduction. A similar problem occurs when foods or drinks are processed in fluoridated areas. Fluoride concentrations are high in many dehydrated products and powders (like iced teas) and this is worse if they are reconstituted with fluoridated water. Foods grown or processed in fluoridated areas are transported to different regions and we have no idea of the amount present in them. The fact is, we are all being exposed to an unknown but ever-increasing amount of fluoride, which was not a problem in the 1900s but is a serious and valid concern today. Any fluoride ingested is absorbed into the blood and travels to every part of the body. The amount of fluoride that remains in your body will depend on many factors, but is greatest in infants (80% retention) and elderly women. Fluoride is excreted by the kidneys which explains why fluoridated water is problematic for kidney patients or anyone on dialysis – and fluoridated water must be avoided.

Fluoride can harm babies

Drinks, teas and especially baby formula often contain excessive amounts of fluoride. Formula milk powder should never be mixed with fluoridated water, since this can give a baby far too much fluoride, which can damage adult teeth and possibly pose systemic consequences. It is for the same reason that parents are warned not to use fluoride toothpaste for baby teeth, unless advised to do so for healing or preventing a specific cavity. (NOTE: Wiping erupting baby teeth with xylitol will clean them safely and xylitol has been shown to give 95% protection from cavities).

In Summary

  1. Drinking fluoridated water does not have any benefit over using a fluoride toothpaste or rinse. The main dental benefit from fluoride occurs when it contacts the tooth surface.
  2. Mixing fluoridated water with powdered formula milk can easily damage a baby’s developing adult teeth – making them weaker. Excess fluoride may affect general health. (Even the ADA and AAPD say only bottled water should be used for mixing formula milk. This places an unfair burden on low-income or immigrant families who may not be aware, or may not have the means to purchase bottled water).
  3. Fluoridated water must be avoided by anyone with kidney problems or kidney failure.
  4. Fluoride toothpastes and rinses are available to provide protection for teeth, without the concern of fluoride ingestion.
  5. There may be unintended and detrimental health consequences from adding fluoride to water (and there appears far too little research about this).
  6. It seems logical to assume the chemistry of water fluctuates and differences occur if water is acidic, when other chemicals are added to water, or if old metals in pipes and plumbing interact with the water.
  7. With so many concerns and no specific benefit, it seems logical to end artificial water fluoridation as soon as possible.

Read more about this topic in Dr. Ellie’s book, “Kiss Your Dentist Goodbye“. Chapter 8 is all about fluoride – read it HERE.


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Moms Oral Health Matters

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Ask Dr. Ellie: Granular Xylitol

Ask Dr. Ellie: Granular Xylitol
  • I was wondering about how to use xylitol. i think 2 teaspoons of granules put in a cup ( and periodically put some in my mouth) for my minimum daily consumption of xylitol is a good way to keep measurements accurate. Now my question is when i do this is the best way to just let it sit on/near my toungue until it dissolves? (which would take along time no patience). Or actively move around mouth to disolve it and essentially use like a mini mouthwash? Also will chewing it down so it disolves quicker does that harm the actions of xylitol?
    Also what is your recommened top daily dosage of xylitol? (i read something about higher than 50 grams daily for 3 years can cause tumers is that true?)because if i use it as a sugar substitute i can imagine my daily amount might get high.
    Thanks in advance

    • First let me answer your “maximum” quantity question. In parts of Europe and also in Alaska there are people who have used nothing but xylitol for their lifetime. Studies show that people who have used xylitol in quantities of almost a quarter pound a day – were healthy after many years. However – I DO NOT recommend using xylitol exclusively, because I think there is value in using a variety and to enjoy some other great sweeteners, like honey, maple syrup etc.

      I believe 1-2 teaspoons can offer us amazing oral health benefits. Use the granules in any way you like – just have fun and enjoy! It is frequency and total daily dose that will make the difference. Nibbling xylitol granules during the day is excellent. Xylitol is the EXACT opposite of sugar: for example, we all know that nibbling sugar is the WORST for teeth. Well, nibbling xylitol is the BEST for teeth!

  • Dr. Ellie,

    Thanks so much for your very informative site. The information I’ve read here made me consider whether it is OK for my daughter to brush her teeth on her own. She is almost 7 but I brush her teeth every night with ACT (she brushes herself in the morning). If we are fairly vigilant about taking xylitol, usually about 4-5 exposures a day and at least 1 gram each time, does her brushing technique matter? Even if she’s not that thorough in her brushing, would the xylitol cover for her lack or should I still be careful about her brushing? Thanks!

    • The only benefit to brushing baby teeth is to deliver something useful ( to them ) on the toothbrush. My grandsons often brush with xylitol granules, or if Mom is busy, they eat some directly off a spoon, before bed. If a child has excellent teeth – xylitol is all they need until the age of 5 or 6, when the permanent molars erupt.
      New adult molars need help mineralizing – which happens during their first year in the mouth. Although xylitol keeps these teeth bacterially clean and healthy – they benefit from the dilute fluoride in ACT and/or a rice-grain amount of Crest paste brushed over them. I think it is good to encourage your daughter to brush on her own with a drop of the ACT at this time – and maybe work towards teaching her how to rinse and spit next.

      In a year or two your daughter will want to learn more about where her new teeth are and how to brush the gums around them. That is the reason that we brush adult teeth – to massage the gums and keep the gum circulation healthy. I promise to create a training video about how to do this – very soon!

      • Thank you so much for your response! Looking forward to your training video–videos are always so helpful!!

  • Is it true that xylitol consumed over 50mg (ithink?) over a three year period is dangerous Or a unsubstantiated claim?

    • I am not sure where you read this – but it is not true. During the 1940s xylitol was used in place of sugar in Europe – and was consumed as “table sugar” and used in baking, or wherever sugar was used. The outcome was improved health, better teeth, and less ear infections in children. Diabetics often replace all their sugar with xylitol and seem to find their health improves. I believe the suggested high daily amount of xylitol for general use is about 30- 50 grams a day, but I am not about to recommend that anyone starts to consumes this amount each day!

      I am passionate about xylitol, but there’s no need to replace all the sugar in your diet with it. I prefer to incorporate balance and variety into a varied and healthy diet. My suggestion is to select from a variety of healthy sweeteners – and use them in moderation ( maybe some honey, maple syrup, or raw sugar) to sweeten foods. Keep xylitol as a special product to protect your teeth at the end of meals. You only need a total of one to two teaspoons of xylitol a day ( 5-10 grams) for ultimate oral health.

  • Thanks for this very readable account. I’ve always found it fascinating (and often frustrating) how history shapes our attitudes and practices. We aren’t as rational a species as we tout ourselves to be.

  • Hi! I have been reading and utilizing your system over the past few months, but I wondered if you would mind answering a couple of questions? First, is the flouride in my toothpaste and mouthwash depleting my iodine? I feel that I am low in iodine. Second, my daughter’s front teeth came in last year, and she has some slight discoloration that my dentist says is flourosis. I was SHOCKED! I am now trying to figure out how this happened since her older brother does not have it, but she has three siblings who are younger that I’d like to prevent it in! I’d like to be sure I am understanding when exactly she was ingesting too much flouride. My dentist told me that it was when her permanent teeth were forming under the gum, which I thought was when she was 6 years or so. But this article is saying that it was when she was a baby? Is that correct? She has lived in 3 houses since she was born, so I really need help to narrow this down. Thanks so much for you help!

    • Fluorosis occurs when there is damage to cells ( called ameloblasts) in a baby’s gums. These cells are responsible for the enamel formation in adult teeth. When these cells are affected by too much fluoride they don’t form enamel, so the result is an empty space or void, instead of enamel. This space in the enamel affects the way light reflects on the tooth surface and makes some areas appear too white, yellow or brown. Tooth enamel is forming in adult teeth from birth and for the first 3 years of a baby’s life.

      The remaining part of the tooth (the dentin and the roots) will continue to form for a couple more years, and then when the tooth is almost completely formed, it will begin to erupt. The first adult teeth erupt around age 5 ( molars) but the most visible new teeth erupt at 7 or 8 years of age ( the front incisors). Any damage by too much fluoride during the first 3 years of life will be visible in these permanent teeth that erupt at 7 or 8 years of age. Hypoplastic, or poorly formed molars, may also be a sign of this kind of enamel defect or problem caused between birth and 3 years old.

      If you have thyroid issues or an iodine deficiency – you should seek counsel of a knowledgeable physician. I know people who have decided to watch their diet and monitor their iodine levels while using the fluoride rinses and toothpaste that I recommend. They are happy to be enjoying improved mouth health and they were not affected negatively by using this regimen. If you are concerned about general health it is vital to strive for ultimate oral health. I do not believe anyone can be truly healthy with poor teeth.

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