Today's topic is difficult for me to write. As a practicing pediatrician for 33 years in private practice and 11 years in academic pediatrics, it never occurred to me that fluoride (water fluoridation) is not necessarily a good thing for children's health. That is, not until the past few years when I began reading credible sources describing a number of reasons for concern. Bear with me as we will look at another "sacred cow" of popular belief, that on close analysis gives more than a little cause for concern. Once again, as Paul Harvey used to say, "Now for the rest of the story!"

To set the stage for the discussion to follow, in the United States it has become an almost unquestioned practice to rely on fluoride in two forms to reduce the probability or incidence of caries (cavities). It goes without saying that tooth decay is a legitimate real problem both in children and among adults, although particularly so among the former. Furthermore, tooth decay and closely related dental abscesses, periodontal infections, etc. are believed to play a role in causing other health problems, such as inflammation that might contribute to the development of autoimmune diseases, arthritis, etc. Nevertheless, a close inspection of available data produces a much more complex and nuanced picture with regard to the overall, net effect on health from fluoride than might appear to be the case. So strap on your seat belt and hold on the ride!

For the following discussion I will rely heavily upon a provocative 2014 book (Fluoride Controversies: A Physician's Perspective on the Devastating Health Consequences of Fluoride) written by Dr. James P. Fredenberg, an anesthesiologist whose foray into the arena of fluoride toxicity began when he experienced significant health challenges from exposure to fluoride. He discovered that frequent use of a mainstay form of inhalational (breathing in) anesthesia called sevoflurane that contains a form of fluorine in its structure, was responsible for his progressive neurological complaints and low thyroid function. This occurred because of the interaction of the fluoride component of the gas with the glass in the nebulizer used for administration of the gas. This led to his becoming an expert about fluoride and its various chemical forms, as well as the risks of these forms for toxicity from exposure. Our discussion will center on the central question whether or not fluoride, speaking about its addition to community water supplies, is a good thing. The answer of course is the relative benefits versus overall risks to health. The "risk to benefit ratio" is a foundational concept in the field of medicine. A corollary is the fundamental medical precept of Hippocrates (ca. 460-ca. 377 B.C.) "primum non nocere," Latin for "first do no harm." Fluoridation of many municipal water supplies is generally viewed by citizens as well as by most physicians who take care of children as a good thing – obviously predicated upon the assumption that the net benefits are greater than overall health risks. We will see that this assumption is probably unwarranted.

Fluoride, fluorine, and hydrogen fluoride (the "fluoride" in toothpaste and fluoridated water)

Before plunging further into the subject, we will need to cover a little of the "sciencey" stuff about what we call "fluoride." This will make the rest of the discussion make more sense. To get your attention, we begin with the fact that technically speaking, fluoride as a physical entity does not exist independently in nature! Flourine is an element, just as gold, silver, and aluminum are.

Unlike the latter three, which you can hold and admire, fluorine the element is so toxic that if you could hold it you would not survive. It is a highly toxic gas and does not exist naturally in nature, but always exists in combination with another element. A highly toxic fluorine atom, when bound to anything else, is called a fluoride or a fluoride compound. The "personality or behavior" or chemical characteristics, of the bound fluoride depends on what the fluoride atom is hitched to. Most common "companions" of fluorine are sodium, potassium, or calcium. Almost all compounds which have the fluorine or fluoride atom in their chemical structure derive the fluoride from the rock or mineral in nature known as calcium fluoride.

Whew! Hang on, we're almost there! This calcium fluoride rock is the fluoride ancestor of nearly all the manmade fluoride compounds that exist in the world today. In order to put the fluoride atom to work, it needs to be taken from the calcium fluoride rock and transformed into a liquid or gaseous form known as hydrogen fluoride. Chemists use the mined rock, calcium fluoride, to synthesize the far more chemically useful compound known as hydrogen fluoride or HF. HF also happens to be HIGHLY toxic. At approximately room temperature, HF can exist as either a gas or a liquid called hydrofluoric acid. It also easily dissolves in water. Whenever the H+ and the Fl- comprising HF separate from each other to become free "floating" fluoride ions, this fluoride ion becomes highly toxic. This free fluoride ion is the active ingredient in toothpaste and fluoridated water! Holy Cow! Water fluoridation programs in the United States and other countries which have them use either sodium fluoride (NaF), hydrofluorosilicic acid (HFSA) or the sodium salt of that acid (NaSF), all technical grade chemicals to adjust the fluoride level in drinking water to about 0.7–1 mg/L.

Benefits of Fluoride (water fluoridation)

Tooth decay is reduced to some degree by fluoride in water and applied topically. Early studies seemed to indicate as much as a 60% reduction, but subsequent studies have suggested a much more modest effect. A largely sympathetic official review of fluoridation by the British government in 2000 found that most studies of the effectiveness of fluoridated water were of "moderate" quality and that water fluoridation may be responsible for 15 percent fewer cavities (A Systematic Review of Public Water Fluoridation by the NHS Centre for Reviews and Dissemination September 2000). According to World Health Organization data (2012) covering the years from 1970 to 2010 comparing tooth decay trends in 12-year-olds in four fluoridated vs four unfluoridated countries, the rates dropped similarly among all eight countries. Furthermore, a number of published reports have found similar rates of tooth decay in fluoridated and non-fluoridated areas within several countries. Other countries that do not fluoridate water include Austria, Denmark, Sweden, Finland, France, Germany, and as of April 9, 2003, Switzerland – when Basel's 41-year water fluoridation program was terminated. According to Dr. Fredenberg, from the last two decades of the water fluoridation program in the United States, research data shows no significant difference in the decay rates between fluoridated and non-fluoridated areas, but dental fluorosis can now be found in over 40% of adolescent children.

By now you must be wondering what the big deal about water fluoridation is if it does reduce the rate of tooth decay – which as you have already seen, is not nearly as clear-cut as it might appear. The answer of course is the relative weight of the benefits to any risks inherent to the practice – the risk-to-benefit ratio that is the single essential parameter by which public policy decisions must be made.

Toxicity of Fluoride

Now look carefully at the graphic at the beginning of this article. Notice the Directions for Water Fluoridation in the upper right corner. Notice also the warning "Do not take internally" as well as to "avoid contact with skin, eyes, mouth, & clothing" – and for good measure, to "avoid breathing fumes or vapor." And this is what we put into our water!? The general standard for fluoride content sufficient to provide the protection against caries is 1 ppm, or 1 mg/liter (1000 ml or about 33 ounces). With approximately 64% of the U.S. population drinking fluoridated water (compared to about 5% of the world's population), how in the world can this substance added to many municipal water supplies be toxic!? But hold on, it gets worse. Most people use fluoridated toothpaste as well. A typical "ribbon" of toothpaste on a toothbrush would average about 1.5 ml. In 1.5 ml of toothpaste it has been estimated you would find about 2.25 mg of fluoride. There is a warning on fluoridated toothpaste to "call poison control" if one has swallowed a significant amount of fluoridated toothpaste. So one might logically wonder if you should call poison control if you consume over two liters (2 mg of fluoride) of fluoridated water, as might well happen in the course of a hot summer day! It is considered good for general health (and for maximizing your ability to rid the body of the large toxic burden from the numerous chemicals in our bodies and toxins in the foods we eat) for an adult to drink at least eight glasses of water daily. This is the reason parents are warned not allow children to use more than a pea size glob of toothpaste (which would contain about 0.3 mg of fluoride).

On July 29, 2013, the Supreme Court of Israel ruled that Israel must stop adding fluoride to drinking water within one year after a decision based on fluoride's potential toxicity. Only 3% of Western Europeans drink fluoridated water. Most of the rich, developed nations in the world do not fluoridate their water. In addition to increasing recognition of and concern about the potential toxicity of fluoride, increasing doubts have arisen about the only valid reason even to consider continuing this practice – the reduction in tooth decay we have alluded to. Remember, there is no biological need for fluoride in the human body! Fluorine and fluoride are toxins.

The only negative effect of fluoride that is recognized by most consumers and even by professionals (including dentists) is what is called dental fluorosis. This is a mottling of teeth from fluoride exposure that is unsightly but not painful. It has been reported to occur in over 40% of adolescents and a smaller percentage of younger children exposed to fluoride in water and/or from fluoride in toothpaste. Now we will look at a number of additional negative health consequences from fluoride, some of which are potentially serious, and some of which are believed to be fairly common. You will soon see why more and more countries like Israel have abandoned the practice of fluoridating water supplies and more communities in the United States are opting out.

Before outlining the array of potential negative effects of fluoride exposure, we must consider a very important concept – that of acute vs chronic exposure. Acute fluoride toxicity is uncommon but easily recognized when it occurs. Chronic fluoride toxicity is just the opposite. It is common, but very subtle in its presentation. Most people understand that a single sun exposure poses little risk for skin cancer. Likewise, smoking a single cigarette is unlikely to cause lung cancer. It is obvious, however, that frequent daily exposure to the respective agent over many years poses a substantial risk for skin or lung cancer respectively. Who would argue then that because a single exposure to a small amount of fluoride is "not dangerous" (i.e. a pea sized amount of toothpaste, or a glass of fluoride-containing water) it is not dangerous to engage in such small exposures daily for many years – and that in fact, because of a relatively minor degree of protection against cavities, it is wise to add fluoride to drinking water!? There is not a single biological function that requires the presence of a fluoride containing molecule. In that regard, fluoride is every bit like lead, mercury, and arsenic; and we generally accept that it is unwise to place these toxins directly in our bodies. Lead and mercury are harmful in any amount if you are a biological entity like a bird, a fish, human, or even a plant. Direct biological benefits from these substances are non-existent. The risk with all these toxic substances, fluoride included, is that they accumulate in the body.

It is continuous, chronic exposure over many years that poses the risk that is undeniable. There is no simple test to determine cumulative exposure of this nature, because such chronic accumulation of fluoride ends up being stored in the bones and tissues, and a blood level will not detect it. Fluoride may cause or contribute to the development of the diseases or biological functions in the chart shown above. There are probably more, but there is sufficient evidence for those shown above to consider that they are possible consequences of fluoride exposure. For the interested reader, the source identified below the table below is recommended. Among the primary sources cited in the article are the Harvard School of Public Health, the National Institutes Health (NIH), and the National Academy of Science.

Another reason that water fluoridation is unnecessary, leaving aside the numerous potential harms from the process is that many people are already getting more than the recommended 1 mg per day just from foods and beverages. Fruit juices, baby foods, and other select items are particularly high, due to processing and pesticide residues. Dental fluorosis, or fluoride toxicity, is a growing problem. An article in the British Medical Journal, Aug. 26, 2000;189:216-220 reported that 54% of the children living in fluoridated areas have signs of fluorosis.


  • Autoimmune disease
  • Arthritis
  • Cognitive development impairment in children (lower IQ)
  • Disturbed synthesis of collagen (main structural protein of connective tissue)
  • Gastrointestinal disorders
  • Hyperactivity
  • Immune system suppression with increased risk of cancer and infectious diseases
  • Impaired antioxidant defense systems
  • Increased lead absorption
  • Increased risk of dementia
  • Increased uptake of aluminum (aluminum in the presence of fluoride is extremely toxic)
  • Osteoporosis
  • Skin rashes and acne
  • Sperm damage and increased infertility
  • Thyroid gland impairment with low thyroid function

Israel Joins Most of the World in Banning Water Fluoridation - Posted August 15, 2013 by WashingtonsBlog

Marketing of Fluoride

By now you are probably beginning to wonder how this practice of putting fluoride in our drinking water and widespread use of fluoridated toothpaste became so widely accepted in the United States.

Right off the bat, a clue is to "follow the money." Prior to municipal water fluoridation, proper disposal of this toxic waste derived product cost aluminum and phosphate fertilizer companies substantial sums of money to carry out proper disposal of this highly toxic waste. Then it was discovered that fluoridated water, in a concentration approximating 1 part per million (ppm) or 1 mg/liter, in some studies did appear to reduce the probability of caries (cavities) – initially estimated to be between 40% and 60%. All of a sudden, rather than having to pay large sums of money for toxic waste disposal, the companies could sell it for municipal water fluoridation.

In the last analysis, whether or not fluoridation is a wise public health intervention depends upon the balance of risk to benefit. Dr. Fredenberg and increasing numbers of experts and researchers are coming to the conclusion that it is not justified. Two primary factors would seem to explain why this practice has come to be so widely accepted in the United States:

  1. Aluminum and phosphate fertilizer manufacturing companies can sell toxic fluoride waste products rather than having to pay large sums for its proper disposal.
  2. Chronic fluoride exposure leads to progressive accumulation in the body, and identifying fluoride as the cause of its various toxic manifestations in these cases is very difficult since blood levels are not elevated. Thus most consumers and policy makers are unaware of the real dangers of fluoride exposure.

Concluding Comments

A careful analysis of information from sources about fluoridation that are not biased because of financial gains suggests that the health risks of long-term exposure to fluoride in water are substantial and health gains are limited. It must also be remembered that even topical application of fluoride to the teeth can contribute a significant load from this toxin if careful rinsing of the mouth is not done sometime following the application before material is swallowed. Likewise, fluoride-containing toothpaste can contribute to long-term toxicity if swallowed. This is particularly true in the case of young children who often are given pleasant flavored brands. Yet another potential source of fluoride that can be absorbed into the body is fluoride-containing shower water.

My recommendation to parents is to avoid fluoridated water of any sort at all times, including using a water filter that will effectively remove fluoride from drinking water. It is important to remember when adding water to powder forms of formula to use water free of fluoride. An inexpensive filter system that can be kept in the refrigerator is the Zero water pitcher sold in stores such as Walmart. This is the only inexpensive filter of the water pitcher type I am aware of that removes fluoride. Particular care should be taken to make sure that young children (or older ones, for that matter!) do not swallow fluoridated toothpaste. A shower filter can be installed to remove this source of fluoride exposure. Finally, I encourage you to join the movement to promote community safe, fluoride-free water.

Bose Ravenel, M.D., F.A.A.P. offers an integrative and functional approach to ADD/ADHD and other chronic health problems. He is in practice at Robinhood Integrative Health, 3288 Robinhood Rd., WS. For an appt., call 336-768-3335 or visit


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