Neel Kothari considers whether the dental profession might be over-exaggerating the benefits of water fluoridation and downplaying its risks.
There is no doubt that exposure to the fluoride ion has been a paradigm shift in reducing the impact of tooth decay across the world. Put simply, it reduces the critical pH of tooth structures and makes it much harder for teeth to break down. That said, its impact is mostly topical and its addition to drinking water has attracted much controversy over the years.
Proponents for water fluoridation often point to notable past studies largely carried out pre 1975 when toothpaste was unfluoridated, such as the York Review (80% of evaluated studies were before this date), as well as data from across the world showing a reduction in tooth decay with community water fluoridation measures.
However, more recent studies, such as the updated 2024 Cochrane review state: ‘The dental health benefits of adding fluoride to drinking water may be smaller now than before fluoride toothpaste was widely available.’ They go on to say: ‘Analysis of these studies, covering a total of 2,908 children in the UK and Australia, estimates that fluoridation may lead to an average of 0.24 fewer decayed baby teeth per child. However, the estimate of effect comes with uncertainty, meaning it’s possible that the more recent schemes have no benefit.’
Are the claims valid?
This isn’t the same as evidence of no effect, but we can reasonably surmise that the benefits of water fluoridation have significantly lowered since its inception, to the point where it’s now challenging to demonstrate a noticeable benefit.
Nevertheless, this controversial measure has full throttle support from government ministers, successive chief medical and dental officers, as well as the British Dental Association, which claims in a recent press article on the matter (7 March 2025) that fluoridation ‘will deliver a very strong return on their investment’.
Dare I say it, but there will be many reading this article thinking that I am perhaps a tin foil hat wearing conspiracy theorist for daring to question the very maxim that water fluoridation is anything but good. But can a claim like this really be made? Or are the benefits being over exaggerated?
Well, I don’t wear a hat, and after extensively studying this field for more than a decade, I remain convinced that we as a sector are promulgating water fluoridation en-masse because we are biased towards it. We are exaggerating the effect and downplaying the risks for reasons that are entirely unscientific.
For example, the York Review (2000) placed fluorosis rates at 48% and around 12.5% (or one in eight) of children presented with fluorosis that they deemed unacceptable. This is glossed over by most of the literature, not to mention the significant increases in aesthetic demands over the past 50 years – there is no way to ignore how significant this is or how the same subjective assessment would likely raise far higher concerns today, yet anyone studying the literature on this could easily miss it.
Articles from the British Fluoridation Society suggest that this is more of a cosmetic issue than a health issue, but this doesn’t make it any less important to those affected, especially if they go on to then have cosmetic dentistry that comes with a lifetime of maintenance.
Not just bad politics
We in the profession believe that we have a moral impetus to press ahead with water fluoridation; the public remain unconvinced and the science is less than persuading. A recent consultation (7 March 2025) conducted by Department of Health and Social Care (DHSC) surrounding proposals to expand community water fluoridation schemes across the north east of England showed that, of the 140 regional organisations that responded, 82% strongly agreed with its implementation, with 99% citing the benefits of reduced tooth decay.
However, out of the 3,336 respondents from the public, 56% strongly disagreed with its implementation, echoing the results of previous consultations in other parts of the country.
So, what do we do with this 56%? Do we ignore them? Do we belittle them or provide arguments why they are wrong? Well, in my opinion herein lies the crux of the problem. There is no way to really push ahead or lend support to water fluoridation without impacting on the individual rights of the public.
This is not an inconsequential matter as, just like with mandating vaccinations, scepticism and opposition can form, which is incredibly difficult to measure. This is why we need to be sure that what we are supporting is worthy of support and the benefits to the population can be justified. Further, if 99% of supporters think it will reduce tooth decay in today’s day and age, where is the contemporary evidence to support this?
Writing in the Journal of Law, Medicine and Ethics in 2002, Professor James Childress sets out in his eminent paper ‘Mapping the Terrain’ five justificatory conditions by which the ethics of the public interventional measures can be assessed against. These are effectiveness, proportionality, necessity, least infringement and public justification. Based on these criteria, I struggle to see a sound ethical argument as to why we should fluoridate water in 2025 when almost any person can achieve a far superior topical benefit with toothbrushing alone.
There are many arguments for and against water fluoridation that I was unable to cover in the scope of this article. Ultimately, I simply cannot accept that a questionable, very small improvement in decay rates justifies the imposition of a largely unwanted measure that will absolutely result in significant proportions of the public having mottled unaesthetically pleasing teeth.
This makes no sense whatsoever and to push ahead with this is not just bad politics, but crucially its bad science.
Original article online at: https://dentistry.co.uk/2025/05/06/is-the-dental-profession-biased-towards-water-fluoridation/