Dental fluorosis is characterized by skeletal changes and by mottled enamel of the teeth when exposure to fluoride occurs during enamel formation. [Dorland's Medical Dictionary]
Research from MedLine on Fluoride
Bardsen 1998 - Risk periods in the development of dental fluorosis.
Bardsen 1999 - Dental fluorosis among persons exposed to high- and low-fluoride drinking water in western Norway.
Borke 1999 - Chronic fluoride ingestion decreases 45Ca uptake by rat kidney
Brothwell 1999 - Fluorosis risk in grade 2 students residing in a rural area with widely varying natural fluoride.
Disanayake 1995 - Skeletal fluorosis with neurological complications.
Ellwood 1998 - Fluoride: how to maximize the benefits and minimize the risks.
Haimanot 1990 - Neurological complications of endemic skeletal fluorosis, with special emphasis on radiculo-myelopathy.
Heller 1997 - Dental caries and dental fluorosis at varying water fluoride concentrations.
Hu 1988 - Fluoride in cerebrospinal fluid of patients with fluorosis.
Ismail 1999 - Fluoride supplements and fluorosis: a meta-analysis.
Jackson 1999 - Dental fluorosis in children residing in communities with different water fluoride levels: 33-month follow-up.
Kavanagh 1998 - Fluoride in tea--its dental significance: a review.
Kumar 1989 - Trends in dental fluorosis and dental caries prevalences in Newburgh and Kingston, NY.
Kumar 1998 - Changes in dental fluorosis and dental caries in Newburgh and Kingston, New York.
Kumar 1999 - Fluoride exposure and dental fluorosis in Newburgh and Kingston, New York: policy implications.
Kurttio 1999 - Exposure to natural fluoride in well water and hip fracture: a cohort analysis in Finland.
Mascarenhas 1998 - Fluorosis risk from early exposure to fluoride toothpaste.
McGill 1995 - Endemic fluorosis.
Morgan 1998 - Investigation of the possible associations between fluorosis, fluoride exposure, and childhood behavior problems.
Mullenix 1995 - Neurotoxicity of sodium fluoride in rats.
Pearce 1999 - Effect of in situ plaque mineral supplementation on the state of saturation of plaque fluid during sugar-induced acidogenesis.
Riordan 1993 - Dental fluorosis, dental caries and fluoride exposure among 7-year-olds.
Warren 1999 - Systemic fluoride. Sources, amounts, and effects of ingestion.
Warren 1999 - A review of fluoride dentifrice related to dental fluorosis.
Calgary Regional Health Authority Position Statement on Fluoridation 1997
Risk periods in the development of dental fluorosis. Bardsen A, Bjorvatn K, Clin Oral Investig 1998 Dec;2(4):155-60
Laboratory of Dental Research, Faculty of Dentistry, University of Bergen, Norway. email@example.com
"In order to study the age-related susceptibility to dental fluorosis, 40 children who had been lifelong consumers of moderate-
to high-fluoride water ... were examined, as well as a group of older siblings (n = 40) who were born 6
months to 6 years before the fluoride-containing drinking water was introduced to the household. ... As compared to
their older siblings, the prevalence of dental fluorosis was significantly higher in the children who had consumed moderate-to
high-fluoride water throughout their lives. ... Fluoride exposure starting
during the 1st year of life showed the highest odds ratio as compared to exposure only after 2 years of age. The findings
indicate that early mineralizing teeth (central incisors and first molars) are highly susceptible to dental fluorosis if exposed to
fluoride from the first and--to a lesser extent--also from the 2nd year of life."
Dental fluorosis among persons exposed to high- and low-fluoride
drinking water in western Norway. Bardsen A, Klock KS, Bjorvatn K, Community Dent Oral Epidemiol 1999 Aug;27(4):259-67
Department of Dental Research, Faculty of Dentistry, University of Bergen, Norway. firstname.lastname@example.org
"... In order to prevent dental fluorosis, groundwater wells should routinely be analysed for fluoride."
Chronic fluoride ingestion decreases 45Ca uptake by rat kidney
membranes. Borke JL, Whitford GM, J Nutr 1999 Jun;129(6):1209-13
"High exposures to fluoride (F-) may occur in environments rich in F- from natural or industrial sources and from misuse of
F--containing dental care products, particularly by children. Both acute and chronic exposures to elevated levels of F- have
negative effects on several calcium-dependent processes, including kidney glomerular and tubular function. ..."
Fluorosis risk in grade 2 students residing in a rural area with widely
varying natural fluoride.
Brothwell DJ, Limeback H, Community Dent Oral Epidemiol 1999 Apr;27(2):130-6
Community Dental Services, Wellington-Dufferin-Guelph Health Unit, Guelph, Ontario, Canada. email@example.com
CONCLUSIONS: These findings indicate that fluorosis is an important concern in non-fluoridated areas. Fluoride
supplements should not be recommended unless an independent home water test is performed. Breast-feeding for 6 months
or more may protect children from developing dental fluorosis in the permanent incisors."
Skeletal fluorosis with neurological complications.
Disanayake JK, Abeygunasekara A, Jayasekara R, Ratnatunga C, Ratnatunga NV, Ceylon Med J 1994 Mar;39(1):48-50
Department of Surgery, University of Peradeniya, Sri Lanka.
"A case of skeletal fluorosis with spinal cord compression from Kekirawa following consumption of water with high
fluoride content for about 20 years is described. ... The need to search for a
cost effective method of defluoridation of water is stressed."
Fluoride: how to maximize the benefits and minimize the risks. Ellwood RP, Blinkhorn AS, Davies RM, Dent Update 1998 Nov;25(9):365-72
Dental Health Unit, Turner Dental School.
"This article reviews current thinking on the rational use of fluoride for the safe and effective prevention of dental caries, so
that benefits may be maximized and risks minimized. "
Neurological complications of endemic skeletal fluorosis, with special
emphasis on radiculo-myelopathy.
Haimanot RT, Paraplegia 1990 May;28(4):244-51
Department of Internal Medicine, Faculty of Medicine, Addis Ababa University, Ethiopia.
"The results of surveys carried out between 1976 and 1985 in the fluorosis-endemic area of the Ethiopian Rift Valley is
summarised... The neurological
manifestations ... occurred after
exposure to high fluoride (greater than 4 ppm) for longer than 10 years. These deficits were clearly found to be a
consequence of fluoride deposition in bones, resulting in generalised sclerosis and osteophytosis, with reduction in the
diameter of the intervertebral foramina and of the spinal conal. Advanced osteosclerosis commonly causes severe spastic
quadriparesis in flexion, accompanied by distressing spasms and urinary incontinence."
Dental caries and dental fluorosis at varying water fluoride concentrations.
Heller KE, Eklund SA, Burt BA, J Public Health Dent 1997 Summer;57(3):136-43
School of Public Health, University of Michigan, Ann Arbor 48109-2029, USA. firstname.lastname@example.org
"The purpose of this study was to investigate the relationships between caries experience and dental fluorosis
at different fluoride concentrations in drinking water. The impact of other fluoride products also was assessed. ... In addition to fluoridated water, the use of fluoride supplements was associated with both lower caries
and increased fluorosis. CONCLUSIONS: A suitable trade-off between caries and fluorosis appears to occur around 0.7
ppm F. Data from this study suggest that a reconsideration of the policies concerning the most appropriate concentrations for
water fluoridation might be appropriate for the United States."
Fluoride in cerebrospinal fluid of patients with fluorosis.
Hu YH, Wu SS, J Neurol Neurosurg Psychiatry 1988 Dec;51(12):1591-3
Department of Neurology, Affiliated Hospital of Shihezi Medical College, Xinjian, Republic of China.
The CSF fluoride level of individuals drinking water with normal fluoride content and of patients with endemic fluorosis
were studied. ... Fluoride was revealed in every CSF sample of the
control group and its mean value was lower than that of the blood. ... The
results suggests that fluoride is a normal component of CSF. In severe cases of fluorosis or breakdown of the blood-brain
in some diseases of the central nervous system, the CSF fluoride value might be increased.
Note: Where is the control group drinking water without fluoride?
Fluoride supplements and fluorosis: a meta-analysis. Ismail AI, Bandekar RR, Community Dent Oral Epidemiol 1999 Feb;27(1):48-56
Department of Cariology, Restorative Sciences, and Endodontics, School of Dentistry, University of Michigan, Ann Arbor
48109-1078, USA. email@example.com
"This paper presents a systematic review of the dental literature that was carried out to investigate whether the regular use of
fluoride supplements in non-fluoridated communities during the period of tooth development increases the risk of dental
fluorosis. ... This
review confirmed that in non-fluoridated communities the use of fluoride supplements during the first 6 years of life is
associated with a significant increase in the risk of developing dental fluorosis."
Dental fluorosis in children residing in communities with different water fluoride levels: 33-month follow-up.
Jackson RD, Kelly SA, Katz B, Brizendine E, Stookey GK,
Pediatr Dent 1999 Jul-Aug;21(4):248-54
Oral Health Research Institute, Indiana University School of Dentistry, USA.
"...In February 1992 and December 1994, children who were residents of one of three communities with varying levels of
fluoride in their communal water supply were examined for dental fluorosis. ... RESULTS: ... In the negligibly and optimally fluoridated communities, the incidence of dental fluorosis
increased by 12% and 7%, respectively. In the 4X optimally fluoridated community, all the children examined had evidence of
fluorosis at both examinations. CONCLUSION: Fluoride continues to be the primary therapeutic agent for the prevention of
dental caries in adults and children. ... continued monitoring
of the prevalence of dental fluorosis in young children is needed to determine if any additional steps are even necessary to
restrict fluoride intake during the years that enamel formation is occurring."
When reading numerical data, remember that if the level of problem is high to start with, even a large increase will be a low percentage of increase - so in the 4X (high level) community they had 100% fluorosis each time which means no increase.... if the level is low to start with, then a small increase in numbers is a high percentage of increase
Fluoride in tea--its dental significance: a review. Kavanagh D, Renehan J, J Ir Dent Assoc 1998;44(4):100-5
"It has long been accepted that fluoride accumulates in the leaves of the tea plant. Camellia sinensis. In addition it is known
that some of this fluoride is released into the infusion which is drunk as tea. The exact concentration of fluoride in a cup of
tea and the effects of this fluoride have been the subject of many international studies. ... By identifying potential sources of high fluoride ingestion, recommendations can
be made to reduce consumption from these sources in patients who may be at risk of dental fluorosis. ..."
Trends in dental fluorosis and dental caries prevalences in Newburgh and Kingston, NY.
Kumar JV, Green EL, Wallace W, Carnahan T, Am J Public Health 1989 May;79(5):565-9
Bureau of Dental Health, New York State Department of Health, Albany 12237.
"A study was undertaken in New York State to determine the changes in dental fluorosis prevalence from 1955 to 1986 in
fluoridated Newburgh and non-fluoridated Kingston children. ... The increased risk for dental
fluorosis for Kingston residents appears to be from the use of fluoride tablets. An analysis of dental caries data revealed that
caries prevalence declined substantially in both fluoridated and non-fluoridated areas."
Changes in dental fluorosis and dental caries in Newburgh and Kingston,
New York. Kumar JV, Swango PA, Lininger LL, Leske GS, Green EL, Haley VB, Am J Public Health 1998 Dec;88(12):1866-70
New York State Department of Health, Albany 12237-0619, USA.
"This study sought to determine whether the prevalence of dental fluorosis and dental caries had changed in a
fluoridated community and a nonfluoridated community since an earlier study conducted in 1986. ... RESULTS: Estimated dental fluorosis prevalence rates were 19.6% in Newburgh and 11.7% in Kingston. The greatest
disparity in caries scores was observed between poor and nonpoor children in nonfluoridated Kingston. CONCLUSIONS:
The prevalence of dental fluorosis has not declined in Newburgh and Kingston, whereas the prevalence of dental caries has
continued to decline."
Fluoride exposure and dental fluorosis in Newburgh and Kingston, New
York: policy implications.
Kumar JV, Swango PA, Community Dent Oral Epidemiol 1999 Jun;27(3):171-80
Bureau of Dental Health, New York State Department of Health, Albany 12237-0619, USA. firstname.lastname@example.org
"This analysis was conducted to determine the changes in the effect of exposure to fluoridation and other
sources of fluoride on dental fluorosis in children attending Newburgh and Kingston school districts in New York State.
... RESULTS: Children examined in 1996 were at higher risk for both
questionable and very mild to severe dental fluorosis if they received fluoride from water or daily tablet use, or started
brushing before the age of 2 years. The increase in risk from 1986 to 1995 was greater for African-American children.
CONCLUSION: This analysis showed that the risk of developing dental fluorosis did not decline over time in these
Exposure to natural fluoride in well water and hip fracture: a cohort
analysis in Finland. Kurttio P, Gustavsson N, Vartiainen T, Pekkanen J, Am J Epidemiol 1999 Oct 15;150(8):817-24
"... the authors studied a cohort of persons born in 1900-1930 (n = 144,627), ... among younger women, those aged 50-64 years, higher fluoride levels increased the risk of
hip fractures. Among older men and women and younger men, no consistent association was seen. ... The results suggest that fluoride increases the risk of
hip fractures only among women. "
Fluorosis risk from early exposure to fluoride toothpaste. Mascarenhas AK, Burt BA, Community Dent Oral Epidemiol 1998 Aug;26(4):241-8
Section of Health Services Research, College of Dentistry, Ohio State University, Columbus, USA. email@example.com
"OBJECTIVES: To quantify the risk of fluorosis from fluoride
toothpaste in a population whose only potential source of fluoride was fluoride toothpaste. ... Among children with fluorosis, beginning brushing before the age of
2 years increased the severity of fluorosis significantly ... CONCLUSIONS: Fluoride toothpaste use before the age of
6 years is a risk indicator for fluorosis in this study population."
McGill PE, Baillieres Clin Rheumatol 1995 Feb;9(1):75-81
Stobhill Hospital NHS Trust, Glasgow, UK.
"The presence of excessive quantities of fluorine in drinking water is accompanied by a characteristic sequence of changes
in teeth, bone and periarticular tissues. These changes lead to a variable degree of locomotor disability, ranging from
simple mechanical back pain to severe, crippling, combined locomotor and neurological impairment. In endemic areas, a
substantial proportion of the population may be affected, posing a severe public health problem. In some areas, the
hazards to human health are not fully appreciated and are under-reported. The maximum impact is felt in those
communities engaged in physically strenuous activities, either agricultural or industrial. The need of these often isolated
communities in economically hard-pressed countries, for the provision of low-fluoride drinking water remains a hope
rather than an expectation at the present time."
Investigation of the possible associations between fluorosis, fluoride
exposure, and childhood behavior problems. Morgan L, Allred E, Tavares M, Bellinger D, Needleman H, Pediatr Dent 1998 Jul-Aug;20(4):244-52
Harvard School of Dental Medicine, Boston, Massachusetts, USA.
"This study investigated the potential association between fluoride exposure and behavior problems in children, as
well as the prevalence of and risk factors for fluorosis. ... CONCLUSION: Although there was no association between the fluoride exposures in aggregate and fluorosis,
there was a significant association between supplemental fluoride exposure from ages 0-3 years and fluorosis. There was no
association between behavior problems and dental fluorosis in this population."
Neurotoxicity of sodium fluoride in rats. Mullenix PJ, Denbesten PK, Schunior A, Kernan WJ,
Neurotoxicol Teratol 1995 Mar-Apr;17(2):169-77
"Fluoride (F) is known to affect mineralizing tissues, but effects upon the developing brain have not been previously
considered. ... Fluoride exposures caused sex- and dose-specific behavioral deficits with
a common pattern. ... the severity of the effect on behavior increased directly with
plasma F levels and F concentrations in specific brain regions. Such association is important considering that plasma
levels in this rat model ... are similar to those reported in humans exposed to high levels of
Effect of in situ plaque mineral supplementation on the state of saturation
of plaque fluid during sugar-induced acidogenesis.
Pearce EI, Margolis HC, Kent RL Jr, Eur J Oral Sci 1999 Aug;107(4):251-9
"Dental plaque fluid is normally supersaturated with respect to enamel mineral but this may change to a state of
undersaturation when plaque pH falls following sugar exposure, placing the adjacent enamel at risk of caries. [ i.e., When the saturation falls, the enamel minerals will dissolve in the fluid] ...... some evidence was obtained that the test mouthrinses can counteract the fall in saturation level found when plaque is
exposed briefly to sucrose. Potential long-term benefits of the test mouthrinses deserve further study."
Dental fluorosis, dental caries and fluoride exposure among 7-year-olds.
Riordan PJ, Caries Res 1993;27(1):71-7
Health Department of Western Australia, University of Western Australia, Perth.
aim of this study was to record age of weaning and fluoride exposure from water, toothpaste and supplements, and to relate
these to the presence of caries [tooth decay] and fluorosis in children born in 1983. ... Major risk factors for more severe fluorosis ... were early weaning and swallowing
toothpaste ... Residence in a fluoridated area (OR 2.2) was not a statistically significant risk"
Systemic fluoride. Sources, amounts, and effects of ingestion. Warren JJ, Levy SM, Dent Clin North Am 1999 Oct;43(4):695-711
"Fluoride may be ingested from a variety of sources, including many foods and beverages. ... the prevalence of dental fluorosis has increased in North America, suggesting that the levels of fluoride
ingestion need to be closely monitored. ... Dietary fluoride supplements should
be considered a targeted, preventive procedure only for those at elevated caries risk, and before prescribing them, careful
consideration should be given to other fluoride sources, including home and child-care water supplies, foods, and beverages. "
A review of fluoride dentifrice related to dental fluorosis. Warren JJ, Levy SM, Pediatr Dent 1999 Jul-Aug;21(4):265-71
Department of Preventive & Community Dentistry, College of Dentistry, University of Iowa, USA.
"... While the caries decline can be largely attributed to widespread fluoride dentifrice use, as well as many other sources of fluoride, several recent studies have attributed much of the increase in fluorosis prevalence to early
use of fluoride dentifrice..."
Buying Water Filters
The decision on whether or not to use water filtration equipment to treat
drinking water is personal and not addressed by the Feingold Program.
Consumer Reports, however, recommends having water tested periodically if
there is concern about its taste, odor or possible contamination. If a
problem is discovered, it will be possible to shop for the most effective
unit to serve the specific situation.
Besides cost, other issues that might be disucssed with a prospective
- Location and size of the unit
- Which specific contaminents will the unit remove and to what level
- Speed of the unit's operation and its total daily output
- How often will the filter element need changing and by whom
- Will the filter itself add any residual chemicals to the water as it is
- What special steps should be taken if the water system will not be used
for a period of time
- Will any part of the system need cleaning, how often, with what substances
and by whom
- Any other issues of particular concern