The fluoridation farce

Part 2: Water fluoridation is not effective

Share on facebook
Facebook
Share on twitter
Twitter
Share on email
Email
Share on linkedin
LinkedIn
Share on pinterest
Pinterest
Share on whatsapp
WhatsApp
Australia’s dental decay crisis says a lot about the effectiveness of fluoridation; the early fluoride studies were dubious to say the least; all large-scale studies since then have shown little or no difference in tooth decay rates between fluoridated and non-fluoridated areas; and pro-fluoride studies are notoriously lacking in quality.
  • 90% of Australians receive chemically fluoridated water, yet we have a dental decay crisis;
  • The 1950s “21-city” Dean study was found to be erroneous several times;
  • The original studies are “especially rich in fallacies, improper design, invalid use of statistical methods, omissions of contrary data, and just plain muddleheadedness and hebetude.”
  • Here are 16 large-scale, population-based studies showing fluoridation is ineffective;
  • Fluoride causes a layer that’s far too thin to work;
  • Not a single Australian published study was good enough for the 2015 Cochrane review;
  • All 19 studies in the Cochrane review were poor quality, lacking control for major confounders;
  • 70 years of fluoridation and still no Randomised Controlled Trial – and we’re adding a hazardous industrial waste chemical to our drinking water. That is nothing short of astounding!
Australia’s dental decay crisis

With around 90 per cent of our population receiving fluoride in their drinking water, Australia is one of the most fluoridated countries in the world. So naturally you would expect our tooth decay rates to be impressive and of course noticeably less than countries not adding fluoride to their water at all.

Unfortunately our dental statistics say otherwise. In November 2018, the Australian

Institute of Health and Welfare reported that 42 per cent of all children aged 5 to 10 have experienced tooth decay in their primary teeth; about 25 per cent of children aged 6 to 14 have experienced decay in their permanent teeth; and that all Australians aged 15 and over have an average 12.8 decayed, missing or filled teeth amongst a total of 32 teeth. In March 2018, the Oral Health Tracker revealed that 90 per cent of adults have some form of tooth decay.  AIHW also revealed that in 2016-2017, there was a staggering 132,700 hospitalisations involving general anaesthesia for dental procedures. In NSW alone, the state’s hospitalisation data shows that tooth decay and other preventable dental problems resulted in 16,700 NSW adults and children in hospital in 2015-16. The data also showed more than 100 children a week are having multiple rotting teeth extracted, filled and capped under general anaesthetic.

In fact with approximately 11 million newly decaying teeth arising every year, tooth decay is Australia’s most prevalent health problem and the second-most costly disease linked to diet after diabetes.

So, despite the alleged benefits of fluoride that are confidently and assertively promoted by our government health bodies, the undeniable fact is that tooth decay is still occurring at near epidemic proportions in this country. Some have even referred to it as a “dental decay crisis”.

Meanwhile, the Council of Australian Governments (COAG) is still recommending that every town in Australia with a population more than 1,000 should be fluoridated and most state health departments are determined to increase the rates of fluoridation.

A zealous belief in fluoride is born

Given this obvious and somewhat unusual disparity we need to examine some of the earlier efficacy studies to see where this all began. There were two key fluoride studies undertaken in the United States in the 1940s that perhaps stand out as the most influential studies ever conducted in the history of fluoridation.

Unfortunately, to this day, they still form the foundation of many pro-fluoridationist’s zealous belief in fluoride and they are often referred to repeatedly in support of fluoride’s alleged success. Those studies are the well-known two-part, 21-city “Dean study” (conducted by H. Trendley Dean, Francis Arnold and Elias Elvove) in 19421,2 and other early trials that collectively form a study conducted between 1945 and 1955 in the US, Canada and a little later in New Zealand.

H. Trendley Dean admitted the data in his famous 21-city "Dean study" was not valid

“Unfortunately”, because both of these pivotal studies involved a blatant lack of scientific methodology and possibly a deliberate aim to achieve a specific agenda. And yet, despite the obvious bias, they also provided the stimulus for a wave of endorsements that would firmly establish the belief that a highly-toxic, untreated-and-contaminated, non-pharmaceutical-grade, industrial-waste chemical, when added to our drinking water, will protect us against tooth decay.

What even most fluoride advocates don’t know is that Dean’s data has been shown to be erroneous several times. In conducting his study, Dean had access to far more comprehensive data – in fact dental records from 272 cities or regions from 26 separate states of America – and yet he only chose to publish data from 21 cities in four states. This immediately reeks of a biased methodology to say the least. In 1960, when testifying in several court hearings, Dean himself admitted that his data was not valid, acknowledging that some of the cities did not meet the study’s criterion and therefore were not selected. The dental data available from all the sources shows a complete lack of correlation when plotted.

This was in fact later demonstrated by Rudolf Ziegelbecker3, an Austrian statistician, who conducted a far more comprehensive and robust study, examining all the data he could find from the Unites States and Europe and compared the rates of tooth decay against natural fluoride levels in the water. He found no correlation at all between fluoride levels and reduced dental caries. The only correlation he did find was the direct link between fluoride and the damage it causes to teeth in the form of dental fluorosis – as the fluoride level increases, so did the rate of fluorosis. This correlation was clear and acknowledged well before fluoride was added to public water supplies and has since been demonstrated again and again over 70 years of fluoridation. The reality is; fluoride damages our teeth and therefore our bones.

Deans study
Figure 1: Dean’s misleading study showing the apparent relation between rates of dental caries in permanent teeth observed in school children aged 12 to 14 from selected 21 cities in four states of USA. (Ref 1,2)
Figure 2: Zeigelbecker’s comprehensive study showing decay rates against fluoride concentration. (Ref 3)
Figure 3: Zeigelbecker’s study showing fluorosis rates against fluoride concentration.(Ref 3)

Zeigelbecker and his son also conducted a subsequent study including dental data from the World Health Organisation in several individual countries and again found no correlation between tooth decay and naturally occurring levels of fluoride in drinking water.4

As for the further trials in the US, Canada and New Zealand, several researchers have thoroughly investigated  these trials and found many weaknesses in methodologies, including a very obvious lack of control of the participating communities and confounding factors.5-9  This is an unfortunate common characteristic of pro-fluoride studies that has continued ever since.

In 1980, when reviewing these trials, Dr Hubert Arnold, a statistician from the University of California, summed it up quite well:

“The announced opinions and published papers favoring mechanical fluoridation of public drinking water are especially rich in fallacies, improper design, invalid use of statistical methods, omissions of contrary data, and just plain muddleheadedness and hebetude. Many of the blunders were so glaring that I gave them to my beginning freshman classes in statistics at the very first meeting. The students see through them straightway, and are afforded great amusement. Uproarious laughter frequently ensues. No special statistical equipment is necessary to detect those peccancies. Of course the class and the Group soon tired of those infantilities, and sought and found greater challenge.”10

In 1996, Dr Philip Sutton, an Australian Doctor of Dental Science and senior research fellow in the Department of Oral Medicine and Surgery at the Dental School of the University of Melbourne, published two books 6-8 heavily criticising and again exposing the extremely poor methodology used in the early trials. The last of these was titled “The greatest fraud: fluoridation.” His critiques have never been successfully refuted by fluoride proponents.

In 2000, all available fluoride studies were reviewed by the UK’s York Review11. Of the 214 studies meeting the inclusion criteria, the review concluded “The quality of studies was low to moderate”. In October 2004, after a number of misleading statements by various pro-fluoride bodies, a clarification letter was published, concluding:

Dr Philip Sutton DDS
“The review team was surprised that in spite of the large number of studies carried out over several decades there is a dearth of reliable evidence with which to inform policy. Until high quality studies are undertaken providing more definite evidence, there will continue to be legitimate scientific controversy over the likely effects and costs of water fluoridation.”

It is also worth noting that the York Review itself and its final conclusions regarding the efficacy of fluoridation were heavily biased in favour of fluoride, containing serious errors and omissions that have been well documented.

What do all large-scale fluoridation efficacy studies have in common?

In addition to the early trials, we should examine other significant or major large-scale studies on fluoride’s effectiveness which, by the way, are consistently and irresponsibly ignored by Australia’s National Health and Medical Research Council (NHMRC) and our federal and state health departments.

In 1986-87 the US National Institute of Dental Research conducted the largest national health study in the country, examining over 39,000 children in 84 areas of the US. This study found that children who had lived their whole life in fluoridated areas did not have less tooth decay (measured by DMFT) than children who had lived in non-fluoridated areas.12

Another subsequent study using the same NIDR database, apparently intended to counter that finding, reported that when a more precise measurement of decay DMFS was used, a small benefit from fluoridation was shown – much less than one cavity per child.13 In the study’s abstract, the authors claimed an average 18 per cent reduction in tooth decay in five to seventeen year olds, however the average difference was actually 0.6 of one tooth surface (amongst more than 100 tooth surfaces) – i.e. an absolute difference of 0.6 per cent or slightly more than half of one per cent.

In 1986, Australian scientist Mark Diesendorf conducted a study comparing trends in tooth decay in fluoridated and unfluoridated countries and this was published in Nature journal in July 1986 where Diesendorf concluded:  “Large temporal reductions in tooth decay, which cannot be attributed to fluoridation, have been observed in both unfluoridated and fluoridated areas of at least eight developed countries over the past thirty years. It is now time for a scientific re-examination of the alleged enormous benefits of fluoridation.”14

During the 1980s and early 1990s, John Colquhoun, the former Chief Dental Officer for Auckland, New Zealand, compared the trends in tooth decay rates before, during, and after the introduction of both water fluoridation and fluoride toothpaste in New Zealand among 5-year-old children and found there was no measurable effect on the nation’s downward trend in tooth decay. In fact he found that decay rates were slightly better in non-fluoridated areas.15-21

Initially, because of his dental training, Colquhoun – as he admits – was an “ardent advocate” of fluoridation. But he began to question the apparent results that already looked suspicious and then embarked on a thorough examination of dental records to find that not only was fluoride providing no benefit, it was damaging children’s teeth and therefore probably damaging their bones.

After this realisation, Colqhoun admitted his mistake in supporting fluoridation and did a complete turnaround, trying to undo the damage he had done. But of course his colleagues didn’t take kindly to him challenging the status quo. He explains the rationale and resistance as follows;

“I now realize that what my colleagues and I were doing was what the history of science shows all professionals do when their pet theory is confronted by disconcerting new evidence: they bend over backwards to explain away the new evidence. They try very hard to keep their theory intact — especially so if their own professional reputations depend on maintaining that theory,” said Colquhoun22
“Environmental scientists, as well as many others, tend to doubt fluoridation. In the United States, scientists employed by the Environmental Protection Agency have publicly disavowed support for their employer’s pro-fluoridation policies. The orthodox medical establishment, rather weak or even ignorant on environmental issues, persist in their support, as do most dentists, who tend to be almost fanatical about the subject. In English-speaking countries, unfortunately, the medical profession and its allied pharmaceutical lobby (the people who sell fluoride) seem to have more political influence than environmentalists,” he said.22
“It is my best judgement, reached with a high degree of scientific certainty, that fluoridation is invalid in theory and ineffective in practice as a preventive of dental caries. It is dangerous to the health of consumers,” said Colquhoun.

In 1989, Hildebolt et al23 published their study involving dental decay data from 6,584 school children in Missouri. They found “there were no significant differences between those children drinking optimally fluoridated water and those drinking sub-optimally fluoridated water.”

In 1990, Mark Diesendorf published his paper; “Have the benefits of water fluoridation been overestimated?”24, highlighting the ineffectiveness of fluoridation, as demonstrated in various studies.

In 1994, Professor Steelink obtained dental records of all 26,000 school children in Tucson, Arizona, along with information on the fluoride content of Tucson water. He found a distinct correlation: “When we plotted the incidence of tooth decay versus fluoride content in a child’s neighbourhood drinking water, a positive correlation was revealed. In other words, the more fluoride a child drank, the more cavities appeared in the teeth.”25

In 1994, Professor Teotia and his team published the results of a comprehensive, long-term, epidemiological study, which involved examining the teeth of 400,000 children in both fluoridated and non-fluoridated areas of India over a period of 30 years.26 They found that tooth decay increases as fluoride intake increases and stated that tooth decay results from a deficiency of calcium and an excess of fluoride.

“The only practical and effective public health measure for the prevention and control of dental caries is the limitation of the fluoride content of drinking water to less than 0.5 ppm, and adequate calcium nutrition (dietary calcium greater than 1g/day). The World Health Organisation policy and recommendations on fluorides are not universally acceptable, especially for the environment of developing countries, with nutritional deficiencies, endemic fluorosis, and different caries prevalence trends. In the light of our scientific data, WHO recommendations require modifications to achieve dental health for all by the year AD 2000.”26

 In 1996, a large Australian study conducted by Spencer, Slade and Davies claimed in their abstract that the results support water fluoridation. In fact the study found an average difference in tooth decay in permanent teeth (DMFS) between children who lived their whole life in fluoridated versus non-fluoridated communities of between 0.12 and 0.3 tooth surfaces per child. Amongst 128 tooth surfaces, that’s an absolute saving of 0.09 to 0.23 per cent, i.e. a small fraction of one percent.27

Spencer, Slade and Davies also conducted another study in 1996, claiming 65 per cent less tooth decay in fluoridated Townsville, also with a tiny absolute difference. For more details, please read our article: The history of fluoride in Queensland.

In 1999, Dr David Locker BDS, PhD, of the University of Toronto and Howard Cohen BA, MA, PhD, co-authored an article on the science and ethics of fluoridation and concluded; “Canadian studies of fluoridated and nonfluoridated communities provide little systemic evidence regarding the benefits to children of water fluoridation. Ethically, it cannot be argued that past benefits, by themselves, justify continuing the practice of fluoridation.”28

In 1997 John Colquhoun also demonstrated that decay rates were coming down before fluoridation was introduced in Australia and New Zealand and have continued to decline even after its benefits would have been maximized22. As the following chart from his paper shows, many other factors are responsible for the decline of tooth decay.

Figure 4: Tooth decay rates of 5-year-old children in New Zealand before and after fluoridation (Ref 22)

In 2004, Australian pro-fluoridationists Jason Armfield and John Spencer from the University of Adelaide studied dental health records of 13,000 children in South Australia, comparing children aged 10 to 15 years who had always drank fluoridated water for all their lives to children who had never drunk fluoridated water. Their paper reported “no significant difference” in decay of permanent teeth, but subsequently they publicly denied their own result.29

In 2009, the results of the multi-million-dollar, long-term Iowa Fluoride Study, funded by the US National Institute of Health, were published. This study, which monitored 600 Iowa children from birth to adolescence over a 12-year period, found no significant difference in tooth decay rates between fluoridated and unfluoridated groups. However, the study did find yet again that fluoride intake was significantly associated with dental fluorosis.30

In 2013, Alexis Zander from the University of NSW published the results of a relatively small study; relevant however due to its focus on rural Australian towns or communities where decay rates are normally higher, more severe and generally less treated than those in our cities. This cross-sectional survey measured the oral health of 434 children aged 3 to 12 years in three small rural or regional areas. The study found that socioeconomic status, tooth-brushing and Aboriginal status were significantly associated with tooth decay and that gender, water fluoridation and parental education were not.31

Perhaps the most significant large-scale study was published in 2014 by the WHO Global Oral Health Program, using statistics measuring decayed, missing and filled permanent teeth (DMFT) amongst 12 year olds from industrialised western countries between 1960 and 2014. This study clearly showed that fluoride treatments (including water and salt fluoridation) do not reduce dental caries and that the substantial decline in tooth decay over the last 70 years has occurred just as precipitously in fluoridated and non-fluoridated countries. This study also shows that several countries without fluoride and without fluoridated salt are actually performing better than Australia where 92 per cent of our population receives fluoridated water.32

Figure 5: Tooth decay comparison of fluoridated and non-fluoridated countries – WHO data on DMFT for 112 year olds, involving no water or salt fluoridation.32

In 2015, the Cochrane Collaboration, acknowledged internationally as the gold standard in the review of health science, published the results of a substantial meta-analysis, which involved the review of 155 studies of fluoridation. The authors of the Cochrane review could find no high-quality research showing that:

  • Fluoridation provided any benefit to adults;
  • Fluoridation provided additional benefits over and above topically applied fluoride;
  • Fluoridation reduced inequalities among children from different socio-economic groups or that;
  • Tooth decay increased in communities when fluoridation is stopped.

Also, the Cochrane review didn’t regard the studies claiming to show that water fluoridation reduces decay in children as applicable to today’s society, as nearly all the studies reviewed (dating back to the 1940s – 1960s) had a high risk of bias and were conducted prior to the availability of fluoride toothpaste and other sources of fluoride.33

Other large-scale studies conducted in Australia, Britain, Canada, Sri Lanka, Greece, Malta, Spain, Hungary, and India have revealed a similar theme – either no correlation between water fluoride and tooth decay, or a positive correlation, in other words more fluoride, more decay and more dental fluorosis.3,14,24,26,34,35

And where fluoridation has been discontinued in communities, from Canada, Germany, Cuba and Finland, for example, the rate of tooth decay has not increased, instead it has continued to decline.

A layer too thin to work?

Fluoride scientists and promoters have long believed that fluoride makes surface tooth enamel more resistant to decay. Some believed that fluoride contacting the surface of the tooth (from toothpaste and fluoridated water) simply changed the main mineral in the enamel, hydroxyapatite, into a more decay-resistant material called fluorapatite.

In 2011, however, a team of scientists from the Saarland University in Germany examined this belief in a study titled, “Elemental Depth Profiling of Fluoridated Hydroxyapatite: Saving Your Dentition by the Skin of Your Teeth?” They found that this fluorapatite layer formed in this way is only six nanometers thick. It would take almost 10,000 layers like this to span the width of a human hair. That’s at least 10 times thinner than previous studies indicated. The scientists questioned whether a layer so thin, which is quickly worn away just by ordinary chewing, can in fact protect our teeth from decay.36

In June 2019, a study evaluating the effectiveness of fluoride varnish applied topically to preschool children revealed interesting results. A large number of the children in the study developed new caries lesions (demineralisation of enamel) regardless of the fluoride varnish use. The authors cited other studies, stating, “The cause of dental caries, and of the increase in caries with age, is the excessive exposure to sugar, not the lack of fluoride exposure.”37,38 They concluded; “Our study highlighted that increasing the exposure to professionally applied fluoride through varnish made hardly any difference for the risk of developing new caries in children.”39

The authors also point out that numerous other recent clinical trials, in low and high caries-risk populations, have failed to show a protective effect of fluoride varnish applications.40,41

In the context of the Saarland University study, if fluoride varnish containing around 22,000ppm fluoride or even regular toothpaste containing around 1,000ppm fluoride doesn’t provide continuous protection, how can fluoridated water containing 1ppm fluoride possibly be effective, especially when more than 99 per cent of the fluoride in the water doesn’t even touch the teeth!?

The US National Research Council also reported that saliva/fluoride levels in individuals consuming 1mg/L fluoridated water is only 0.016mg/L  which is 75,000 times less concentrated than fluoride contained in toothpaste and therefore drinking fluoridated water is completely unable to affect teeth topically.

The quality of pro-fluoridation studies

We often hear the question; “But there’s overwhelming scientific evidence to show that fluoride is effective at reducing tooth decay….right?”

Actually the evidence is remarkably underwhelming and is often used in a misleading way. It’s not necessary, however, to focus on individual pro-fluoride studies to find out why. Even the Cochrane Review, published in 2015, provided an invaluable insight into the quality – or the conspicuous lack of quality – of pro-fluoride studies conducted in Australia and elsewhere. Of the 277 studies deemed eligible by the Cochrane team, 155 studies met the inclusion criteria for the review and then only 107 were suitable for quantitative analysis. From these only 19 studies published between 1951 and 2015 met the inclusion criteria for dental caries, although around 70 per cent of these studies were conducted before 1975. All 19 of these included studies were judged to have a high risk of bias overall and all 19 were deemed to have a high risk of bias specifically due to a lack of control for confounding factors.

It is also worth noting that not one published Australian caries study met the inclusion criteria – emphasising the consistently poor quality of Australian fluoride studies. The most common weakness was a distinct lack of control for major confounding factors.

It is also remarkable that in 70 years of fluoridation, there has never been a randomised controlled trial (RCT) of the alleged benefits of fluoridation.

Conclusion

With the great majority of the Australian population receiving fluoridated water, rampant rates of tooth decay across the country, a plethora of evidence to show that water fluoridation is anything but effective and the extremely poor quality of pro-fluoridation studies, our federal and state health departments and the NHMRC continue to arrogantly defend and promote fluoride as being safe and effective at protecting us against tooth decay. The only question remaining therefore is, how long will this fluoridation farce continue?

References

  1. Dean, HT, et al, 1941: “Domestic water and dental caries II. A case study of 2,832 white children aged 12 to 14 years, of 8 suburban Chicago communities, including Lactobacillus Acidophilus studies of 1,761 children,” Public Health Reports 56, 1941.
  2. Dean, HT, et al., “Domestic water and dental caries V additional studies of the relation of fluoride domestic waters to dental caries experience in 4,435 white children aged 12 to 14 years, of 13 cities in 4 states,” Public Health Reports 57, no 32; 1942.
  3. Ziegelbecker, R and Ziegelbecker RC, “WHO data on dental caries and natural fluoride levels,” Fluoride, no 4 (1993).
  4. Ziegelbecker, R., “Fluoridated water and teeth,” Fluoride 14, no3. 1981.
  5. De Stefano, TM, “The fluoridation research studies and the general practitioner,” Bulletin of Hudson County Dental Society, Feb 195.
  6. Sutton, PRN, “Fluoridation: errors and omissions in experimental trials,” 1st Edition, Australia: Melbourne University Press, 1959.
  7. Sutton, PRN, “Fluoridation: errors and omissions in experimental trials,” 2nd Edition, Australia: Melbourne University Press, 1959.
  8. Sutton, PRN, “The greatest fraud: fluoridation,” Lorne, Australia: A Factual Book, Kurunda Pty Ltd, 1966.
  9. Ziegelbecker, R., “A critical review on the fluorine caries problem,” Fluoride 3, no.2, 1970.
  10. Letter from Hubert A Arnold, PhD, University of California (Davis) to Dr. Ernest Newbrun, Medical Sciences Building 653, San Francisco, California, May 28 1980; available here.
  11. Marian McDonagh, et al, “A Systematic Review of Public Water Fluoridation,” NHS Centre for Reviews and Dissemination, 2000.
  12. Yiamouyiannis, JA, “Water fluoridation and tooth decay: results from the 1986-87 National Survey of US school children,” Fluoride 23, no.2, 1990.
  13. Brunelle, JA and Carlos JP, “Recent trends in dental caries in US children and the effect of water fluoridation,” Journal of dental research 69, 1990.
  14. Diesendorf M 1986, “The mystery of declining tooth decay.” Nature 322:125-129.
  15. Colquhoun J. “New Evidence on Fluoridation, “Social Science & Medicine 19, no. 11, 1984.
  16. Colquhoun J. “Influence of Social Class and Fluoridation on Child Dental Health,” Community Dentistry and Oral Epidemiology 13, no. 1. 1985.
  17. Colquhoun J. “Child Dental Health Differences in New Zealand, “Community Health Studies 11, no. 2, 1987.
  18. Colquhoun J. “Flawed Foundation: A Re-examination of the Scientific Basis for a Dental Benefit from Fluoridation,” Community Health Studies 14, no. 3. 1990.
  19. Colquhoun J. “Possible Explanations for Decline in Tooth Decay in New Zealand,” Community Dentistry and Oral Epidemiology 20, no. 3. 1992.
  20. Colquhoun J. “Dental Caries Among Children in New Zealand, “Community Dentistry and Oral Epidemiology 23, no. 6, 1995.
  21. Colquhoun J. “Education and Fluoridation in New Zealand: An Historical Study,” Ph. D. diss. , University of Auckland, New Zealand, 1987.
  22. Colquhoun J. “Why I changed my mind about fluoridation.” Perspectives in Biology & Medicine. 1997.
  23. Hildebolt CF, et al, “Caries prevalences among geochemical regions of Missouri.” American Journal of Physical Anthropology, 1989.
  24. Diesendorf M. “Have the benefits of water fluoridation been overestimated?” International Clinical Nutrition Review 10(2): 292-303, 1990.
  25. Jones T, Steelink C, Sierka J. “Analysis of the causes of tooth decay in children in Tucson, Arizona.” Paper presented at Annual Meeting of the American Association for the Advancement of Science, San Francisco, USA, February 1994. Abstract in Fluoride 27 (4) 238, 1994.
  26. Teotia SPS, et al, “Dental caries: A disorder of high fluoride and low dietary calcium interactions (30 years of personal research).” Fluoride 27(2):59-66 · January 1994.
  27. Spencer, AJ, Slade GD, Davies, M. “Water Fluoridation in Australia, “Community Dental Health 13, suppl.2, 1994.
  28. Cohen, H and Locker, D “The Science and Ethics of Water Fluoridation, “Journal of the Canadian Dental Association, 2002.
  29. Armfield JM and Spencer AJ; “Consumption of Nonpublic Water: Implications for Children’s Caries Experience,” Community Dentistry and Oral Epidemiology 32, no. 4, 2004.
  30. Warren JJ, Levy SM, Broffitt B, et al, “Considerations on Optimal Fluoride Intake Using Dental Fluorosis and Dental Caries Outcomes— A Longitudinal Study, “Journal of Public Health Dentistry 69, no. 2, 2009.
  31. Zander A, et al, “Risk factors for dental caries in small rural and regional Australian communities.” Rural Remote Health. 2013; 13(3):2492. Epub 2013 Aug 13.
  32. World Health Organisation (WHO) Oral Health Country/Area Profile Programme (CAPP); Collaborating Centre for Education, Training and Research in oral Health; Malmo University, Sweden; June 2012.
  33. Iheozor-Ejiofor, et al, “Water fluoridation to prevent tooth decay,” Cochrane Library
  34. Diesendorf M, “A re-examination of Australian fluoridation trials”. Search 17 256-261 1986. June 2015.
  35. Gray AS. “Fluoridation: Time for a new base line?” Journal of the Canadian Dental Association 53 763-765 1987.
  36. Müller F, et al, “Elemental Depth Profiling of Fluoridated Hydroxyapatite: Saving Your Dentition by the Skin of Your Teeth?” Langmuir, Langmuir2010262418750-18759; November 2010.
  37. Sheiham A, James WP, “Diet and Dental Caries: The Pivotal Role of Free Sugars Reemphasized,” Journal of Dental Research. Oct 2015.
  38. Simón-Soro A, Mira A, “Solving the etiology of dental caries.” Trends Microbiol. Feb 2015.
  39. de Sousaa, et al, “Fluoride Varnish and Dental Caries in Preschoolers: A Systematic Review and Meta-Analysis,” Caries Research, June 2019.
  40. Weyant RJ, et al, “Topical fluoride for caries prevention: executive summary of the updated clinical recommendations and supporting systematic review,” Journal of American Dental Association, Nov 2013.
  41. Jiang et al., 2014; Tickle et al., 2017; Agouropoulos et al., 2014; Oliveira et al., 2014; Anderson et al., 2016; Braun et al., 2016; Muñoz-Millán et al., 2018.