One of the most significant recent developments in the fluoridation literature has been the publication in the British Dental Journal of Critique of the review of “Water fluoridation for the prevention of dental caries” published by the Cochrane Collaboration in 2024, authored by Tony Walmsley, Ray Lowry, Ahmed Al Rasheed, Colwyn Jones, John Beal, Loc Do and Andrew Rugg-Gunn (Walmsley, A. D., et al. (2026). “Critique of the review of ‘Water fluoridation for the prevention of dental caries’ published by the Cochrane Collaboration in 2024.” British Dental Journal 241(1): 26-30).
For many colleagues this paper will represent much more than another contribution to the academic literature. It is the first substantial peer-reviewed response to the 2024 Cochrane Review from a group of internationally recognised fluoridation researchers and public health experts.
The authors’ central argument is straightforward. They do not dispute the value of systematic reviews. Rather, they argue that the method adopted by Cochrane is poorly suited to evaluating population-wide public health interventions such as community water fluoridation. Restrictive inclusion criteria, designed primarily for clinical interventions and randomised trials, inevitably exclude much of the observational evidence on which public health decisions have always depended.
The result, they suggest, is not an absence of evidence for effectiveness, but an artefact of method.
The paper also highlights several specific concerns. These include the continued exclusion of many high-quality observational studies, limited consideration of fluoridation’s impact on health inequalities, the absence of evidence relating to adults and older people, and the retention of the same fluorosis method criticised following the 2015 Cochrane review. The authors argue that advances in causal inference and modern epidemiology now provide more appropriate approaches for evaluating complex public health programmes.
The wider significance extends well beyond method.
During the past two years the Cochrane review has acquired considerable political influence, particularly in North America, where its conclusions have frequently been cited during debates leading to restrictions or cessation of fluoridation programmes. As the BDJ paper notes, the review has been repeatedly presented in policy discussions as demonstrating “no clear evidence of benefit”, despite the much broader international evidence base continuing to support fluoridation as an effective and equitable public health intervention.
Publication of this critique therefore changes the landscape. Policymakers can no longer claim that the Cochrane review stands unchallenged. A detailed methodological critique has now passed independent peer review in one of dentistry’s leading journals. That does not mean the debate is over, nor that Cochrane’s authors will necessarily accept the criticisms. It does mean that decision-makers should recognise there is an important distinction between the evidence on fluoridation and one particular method of reviewing that evidence.
This debate is unlikely to end with a single paper. But the publication of this critique signals something important. The discussion has moved on from whether fluoridation works to how society should judge evidence for complex public health interventions. As Lawrence Green reminded us, “If we are to have more evidence-based practice, we need more practice-based evidence.” Few public health measures embody that principle more clearly than community water fluoridation.
For BFS members, the paper provides something that has long been needed: a concise, citable explanation of why many
public health specialists have argued that the Cochrane approach systematically underestimates the evidence available for fluoridation. It is likely to become an important reference in future discussions with policymakers, professional organisations and the media.
What Vaccine Hesitancy Research Can Teach Us About Fluoridation Communication
A fascinating new analysis from the Kaiser Family Foundation (KFF) provides insights that extend well beyond vaccination. Although the research focuses on vaccine misinformation in the United States, many of its findings resonate strongly with current experience in community water fluoridation.
The headline finding is encouraging. Contrary to the impression often created by social media, only a very small proportion of Americans consistently believe multiple vaccine myths. At the other end of the spectrum are those who consistently reject misinformation and accept the scientific evidence. Between these two groups, however, lies what KFF describes as the “mixed middle”—around one-third of adults who are neither committed believers nor committed sceptics, but who remain uncertain and susceptible to conflicting messages.
This distinction is highly relevant to fluoridation.
T
hose actively opposed to community water fluoridation are often highly visible and vocal, particularly online, but they represent only a small proportion of the wider population. The greater challenge is not converting committed opponents; it is helping the much larger group of undecided citizens who encounter conflicting information and are unsure whom to trust.
One of the most striking observations from the KFF analysis is that uncertainty appears to be a more important public health challenge than entrenched opposition. Rather than persuading large numbers of people to believe falsehoods outright, misinformation often succeeds by creating doubt, confusion and a sense that “experts disagree”. As KFF President Drew Altman notes, the greatest danger may not be the spread of myths themselves, but the spread of uncertainty about what is true.
This mirrors the experience of fluoridation advocates over many years. Public consultations frequently reveal that relatively few participants have fixed anti-fluoridation beliefs. Instead, many simply have unanswered questions, have encountered alarming claims online, or are uncertain how to judge competing sources of information.
The poll also reinforces another familiar lesson: communication should be audience-specific. Individuals who are firmly committed to conspiracy-based beliefs are unlikely to be persuaded by additional evidence. Resources are generally better invested in the “movable middle”—people who remain open to trustworthy information presented clearly, respectfully and consistently.
The findings also highlight the importance of trusted messengers. Personal healthcare professionals continue to command higher levels of trust than many other information sources, even in today’s highly polarised environment. That has obvious implications for fluoridation, where dentists, dental teams, paediatricians, public health specialists, medical colleagues and local clinicians remain among the most credible voices available.
Perhaps most importantly, the KFF work reminds us that public confidence is influenced as much by the quality of communication as by the quality of science. The evidence for both vaccination and community water fluoridation is extensive and robust. Yet evidence alone is often insufficient. Public understanding depends on sustained engagement, clear explanation, transparency and trusted relationships.
For those working to support community water fluoridation, the lesson is reassuring. We should not mistake a noisy minority for public opinion. The real opportunity lies with the large proportion of the public who are not ideologically opposed, but simply seeking reliable answers. Reaching that audience—before misinformation fills the vacuum—may be one of the most effective investments we can make in protecting evidence-based public health.
Reference
Kaiser Family Foundation (KFF). New KFF Poll Examines Patterns of Belief Across Common Vaccine Myths. Health Information and Trust Initiative, July 2026.
New KFF Poll Examines Patterns of Belief Across Common Vaccine Myths — The Monitor
Original article online at: https://mailchi.mp/facd595032a0/bfs-bulletin-august-2026?e=1c675dc3b0