• The paper by Choi & Simon uses 50-year-old evidence while claiming to cite to the latest evidence on fluoridation benefits and harms.

• The paper dismisses stronger evidence of fluoride neurotoxicity and its costs while relying on outdated low-quality evidence of dental effectiveness.

• Fluoridation proponents are relying on evidence from their grandparent’s time.

• The Choi & Simon paper misrepresents the current science to produce grossly unreliable and invalid results, warranting its retraction and a warning notice.

There are major errors in a recently published paper in JAMA Health Forum on the cost-benefit of stopping fluoridation.

A widely publicized cost-benefit analysis of the effect of stopping fluoridation in the US, claiming increased tooth decay and economic costs would result, has been challenged by scientific and dental experts calling for its retraction because of serious errors. The experts say Choi & Simon misrepresented evidence and based their analysis on outdated studies that are contradicted by the latest studies.

In a letter to the editor and publisher of the journal JAMA Health Forum, the experts gave detailed reasons why the errors produce not just wildly overstated dental benefits for fluoridation, but also grossly devalued countervailing neurotoxic risks as well as costs of dental fluorosis. The net result if Choi & Simon had followed the latest scientific evidence, is that stopping fluoridation would actually produce the opposite of their conclusion: tooth decay would not meaningfully increase while the risk of lowered IQ would be eliminated and the cost of objectionable dental fluorosis would be avoided. The net economic benefit of stopping fluoridation would be $100 billion per year from avoided child IQ loss, and $3 billion per year for the cost of repairing objectionable dental fluorosis. In contrast, a corrected estimate of the cost of any increase in tooth decay, which is of low certainty to begin with, is only $0.6 billion per year.

The experts pointed out that:

An increase of $0.6 billion, when considered in the larger perspective of all dental spending in the US of $174 billion per year, represents only 0.3% of the total cost. Fluoridation is not playing a significant role in controlling the cost of dental care in the US.

The Choi & Simon paper is using 50-year-old evidence while claiming to cite to the latest evidence on fluoridation benefits and harms.

They have grossly misrepresented what was found in their references: the 2024 Cochrane systematic review on fluoridation’s current (in)effectiveness, and the 2024 National Toxicology Program systematic review on fluoride’s neurotoxicity. A cost-benefit analysis using the actual results of these systematic reviews shows that the dental benefits of fluoridation today are far smaller than 50 years ago and are greatly outweighed by health and economic harms from neurotoxicity and dental fluorosis—producing a huge net economic loss. This is the opposite of Choi & Simon’s conclusions and invalidates their paper, warranting its retraction.

While this may be difficult for long-time fluoridation advocates to believe, the fact is that water fluoridation today produces very little reduction in tooth decay. According to the Cochrane 2024 review, the widespread adoption of fluoridated toothpaste – a much more effective and targeted method of getting fluoride onto tooth surfaces – has made fluoridated water an anachronism. It might have helped in our grandparent’s time, but today offers little meaningful benefit.

In glaring double standard, Choi & Simon dismiss the stronger evidence of fluoride neurotoxicity and its costs while relying on outdated low-quality evidence of dental effectiveness.

The scientific evidence for the neurotoxic risks from fluoride, especially loss of child IQ, has been rapidly accumulating, especially in just the last 10 years, while 50 years ago neurotoxicity hadn’t even been considered.

To justify excluding neurotoxicity from cost-benefit calculations, Choi & Simon argue exposures in fluoridated US communities “… are not definitively associated with worse neurobehavioral outcomes,” citing an editorial by a dentist defending fluoridation and misrepresenting the NTP’s systematic review findings. The NTP, in fact, found lower IQ in 18 of 19 high-quality studies. For other neurotoxic effects like ADHD, 8 of 9 high-quality studies had worse outcomes with higher fluoride.

Importantly, 9 of 12 high-quality studies finding significantly worse IQ or other outcomes were at fluoride levels (water, urine, or total intake) in the same ranges as found with artificial fluoridation in the US. Thus, the NTP found great consistency of significant adverse effects even among studies with exposures directly applicable to artificial fluoridation.

Fluoridation proponents are relying on evidence from their grandparent’s time.

That was also a time when lead paint and leaded gasoline were blanketing the world in lead contamination producing a generation that was recently estimated to have lost more than 5 IQ points on average. And for some of the most lead poisoned children, it caused severe cognitive and behavioral problems, including violent behavior that was largely responsible for the peak in violent crimes in America in the 1990’s.

Just as much of the dental establishment that has championed fluoridation for over 75 years is defending fluoridation today, the lead industry defended itself by denying the health harms and claiming lead was a huge benefit to society because it allowed less expensive gasoline and more “hygenic” paint. The industry even got some doctors to claim lead was not a problem at “low exposure” levels.

Today, Fluoride is the New Lead.

The Choi & Simon paper misrepresents the current science to produce grossly unreliable and invalid results, warranting its retraction and a warning notice for readers.