Reasons for Topical Fluoride Refusal

The origins of fluoride refusal in the U.S. are traced back to water fluoridation opposition by the John Birch Society during the Soviet era.²² As such, most relevant studies in the dental literature focus on community resistant to water fluoridation, for which limited knowledge and risk-benefit misperceptions are the main determinants.²³

There are only three publications on topical fluoride refusal. Two publications reported that parents of children with autism spectrum disorders have a higher likelihood of refusing topical fluoride during dental visits.^24,25 Only one other study to date has identified factors related to topical fluoride refusal.¹¹ In a three-clinic study in Washington state, fluoride refusal was significantly associated with vaccination refusal.¹¹ Fluoride refusal was more common among parents under age 35 years and those with a college degree.¹¹ The implication of this study was that a potential strategy to reduce fluoride refusal was to address vaccine refusal. However, subsequent analyses found that different behavioral and social factors were related to vaccination and fluoride refusal behaviors, indicating that different solutions are needed to solve these related problems separately.²⁶

The association between vaccination and fluoride refusal highlights the relevance of the vaccine literature in identifying the potential causes of fluoride refusal. Similar to topical fluoride, there are more parents who are hesitant about vaccines than those who refuse vaccines.²⁷ Parent attitudes and beliefs about health are important determinants of vaccine hesitancy. Most common is the belief that vaccines are unsafe and lead to conditions like autism spectrum disorders²⁸, which parallel concerns about fluoride. Many parents believe vaccines are no longer necessary.^29–31 These beliefs are spread through social networks, the media, and anti-vaccine websites, where information seeking may be compromised when the parent’s primary goals are control and certainty over perceived risks.^32–37 Low health literacy influences the way parents understand and process information about vaccine necessity, safety, and risks.³⁸ Studies have also found that vaccine refusal is bimodal, with the highest rates present at the highest and lowest ends of the income spectrum, and that the reasons for refusal are different for these two groups.³⁹ Other factors include religious beliefs, a desire for autonomy, and concerns about the true intent of vaccines (i.e., financial interest of pharmaceutical companies, government conspiracy).^40–47 These factors have led to a growing number of vaccine-hesitant parents.¹⁹

Another potential cause of fluoride refusal is rooted within the dental profession and relates to the provision of fluoride treatment that may not always be based on a child’s risk for developing caries. A recent Cochrane Review reported caries prevention benefits associated with fluoride varnish in children and adolescents.⁵ The studies in this systematic review focused on high-risk children, as is the case with almost all published fluoride trials. But not all low-income children are at high risk for caries. This means that recommendations for fluoride should be based on risk, but there is little evidence that this is what actually occurs in practice. Thus, the potential problem is dentists who indiscriminately recommend fluoride varnish for all children regardless of risk. The phenomenon of fluoride refusal in higher-income parents may be a response to recommendations for fluoride treatment when there is little perceived need for fluoride. Fluoride refusal behaviors may also occur in lower-income parents, who may feel disempowered during dental visits because of perceptions that dental offices discriminate against lower-income families.⁴⁸ Reactance, a concept from psychology that describes parent responses to influences perceived to constrain behaviors (e.g., a dentist telling a parent “all children get fluoride, therefore you should do it”), could help to explain fluoride refusal behaviors.⁴⁹