ARCPOH Guidelines for use of fluorides (2019)

Australian Research Centre for Population Oral Health

“Guidelines for use of fluorides in Australia: update 2019.” Published 23 December 2019. Available here.

An open letter to all attendees of the ARCPOH workshop 2019

24 May 2020

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Presenters at the ARCPOH Workshop 2019: Peter Arrow, Janis Baines, David Brennan, Susan Cartwright, Cathy Connor, Stuart Dashper, Loc G Do, Michael Foley, Diep H Ha, Jane Harford, Lisa Jamieson, Woosung Sohn, John Spencer, Kaye Roberts-Thomson. (Missing: Frederick Wright and Utz Mueller - see footnote 1)

The 2019 Guidelines begin by stating; "Fluoride use is the cornerstone of dental caries prevention." And yet, as we demonstrate in this letter and our articles, fluoride is a bioaccumulating developmental neurotoxin that you have all recommended.

Dear ARCPOH Workshop 2019 Attendee

TO: all Workshop (2019) Attendees (including the ARCPOH Executive Group)
Peter Arrow, Janis Baines, David Brennan, Susan Cartwright, Cathy Connor, Stuart Dashper, Loc G Do, Michael Foley, Diep H Ha, Jane Harford, Lisa Jamieson, Utz Mueller, Woosung Sohn, A. John Spencer, Kaye Roberts-Thomson, Frederick Wright, Jacqueline Aldis, Sandra Anderson, Derek Bazen, Linda Bertram-Takacs, Bijun Cai, Lyn Carman, Mikaela Chinotti, Sergio Chrisopoulos, Deborah Cole, Yvonne Dimitropoulos, Ian Epondulan, Catherine Feeney, Mario Ferrari, Ashlea Furlan, Martin Hall, Chris Handbury, Kelly Hennessy, Matthew Hopcraft, Eithne Irving, Kostas Kapellas, Jeroen Kroon, Yvonne Lai, Dianne Lantry, Adrienne Lewis, Liana Luzzi, Rahul Nair, Stuart Marshall, Angela Masoe, Jenny McKibben, Jennifer Miller, Paula Moynihan, Carol Nevin, Kristy Nixon, Peter Osborne, Mark Penrose, Melissa Plath, Anil Raichur, Sarah Raphael, Tanya Schinkevitsch, Susanne Sofronoff, John Skinner, Youngha Song, Nicole Stormon, Karen Smart, W. Murray Thomson (Moderator).

CC:
Federal Minister for Health, Greg Hunt; Shadow Minister for Health, Chris Bowen; 
State Ministers for Health: ACT Minister for Health, Rachel Stephen-Smith; ACT Shadow Health Minister: Vicki Dunne; VIC Minister for Health, Jenny Mikakos; VIC Shadow Health Minister, Georgie Crozier; NSW Minister for Health, Brad Hazzard; NSW Shadow Health Minister, Ryan Park; SA Minister for Health, Stephen Wade; QLD Minister for Health, Steven Miles; QLD Shadow Health Minister, Ros Bates; NT Minister for Health & Chief Medical Officer, Natasha Fyles; NT Shadow Minister, Lia Finocchiaro; TAS Minister for Health, Jeremy Rockliff; TAS Shadow Health Minister, Sarah Lovell; WA Minister for Health, Roger Cook; WA Shadow Health Minister, Zak Kirkup; 
Australian Government Chief Medical Officer: Brendan Murphy
Chief Health Officers (State): ACT: Dr Kerryn Coleman; VIC: Professor Brett Sutton; NSW: Dr Kerry Chant; QLD: Dr Jeannette Young; SA: Professor Paddy Phillips; TAS: Nicola Dymond; WA: Dr Andrew Robertston; Chair of Standing Committee on Health, Aged Care and Sport: Trent Zimmerman.
All ADA and AMA State Presidents.

In February 2019, when the national ARCPOH workshop was convened to update the Guidelines for Use of Fluorides in Australia (“the Guidelines”), there was already a substantial body of scientific evidence showing fluoridation chemicals damage the developing brain of the fetus, infant and child. Since then several major US and Canadian studies have been published, bringing the total to 64 fluoride-neurotoxicity studies to date, providing overwhelming evidence that fluoride is a developmental neurotoxin. Many other studies also show other physiological damage caused by fluoride.

The ARCPOH Executive Group and you personally (having accepted the Guidelines) should be aware of several of these studies. We also take this opportunity to address some of the recommendations you have made in the Guidelines (Appendix 1) as follows:

Your recommendation #1: Water fluoridation should be continued as an effective, efficient, socially equitable and safe population approach to the prevention of caries in Australia.

We address the FOUR claims in this recommendation as follows:

1) “EFFECTIVE”

Please read our detailed articles: Water fluoridation is not effective and Dental health in Australia.

In summary:

  1. Australia is facing a dental decay epidemic with more than 40 per cent of all children aged 5 to 10 with decay in their primary teeth, about 25 per cent of children aged 6 to 14 with decay in their permanent teeth and 90 per cent of adults have some form of tooth decay. Most states are reporting a record number of hospitalisations involving major dental procedures under general anaesthesia.Also, in 2016-2017 a total of $10.2 billion was spent on all dental services – up from  $6.6 billion in 2006-2007.3 Australia is one of the most fluoridated countries in the world and yet our dental health statistics clearly show this reckless health intervention is obviously not working;
  2. The original studies on which fluoridation is based were extremely poor quality and possibly fraudulent.4 In 1960, when testifying in several court hearings, Trendley Dean admitted his data was not valid;5
  3. All major large-scale, population based fluoride studies since these early trials have clearly shown there is no difference in dental decay rates between fluoridated and non-fluoridated countries, cities and regions. Many of these studies, however, did confirm the already-established link between fluoridation and dental fluorosis;
  4. The Cochrane Review (2015)6 – the most comprehensive meta-review of fluoride’s effectiveness ever conducted – found no high-quality research showing that fluoridation provided any benefit to adults; provided additional benefits over and above topically applied fluoride; reduced inequalities among children from different socio-economic groups; or that tooth decay increased in communities when fluoridation is stopped. Also, they 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;
  5. Not one single published Australian fluoride efficacy study met the relaxed inclusion criteria for the Cochrane Review (2015). ALL 19 studies included in this review were deemed poor quality and the majority were conducted pre-1975. Accordingly, NHMRC relies on numerous other relatively small-scale fluoride efficacy studies, but these also range from poor to extremely poor quality and none of these studies control for all major confounding factors;
  6. If fluoride works at all, it only works topically, not ingested. The US CDC stated “Ingestion of fluoride is not likely to reduce tooth decay” while the US NRC has stated “the major benefit of fluoride is topical and not systemic”. The NRC 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;
  7. The major causes of tooth decay are sugar, refined carbohydrates, processed and junk food and inadequate dental hygiene (including regular visits to a dentist) – NOT a lack of fluoride;
  8. Are you aware that less than five per cent of the world’s population receives fluoridated water and that 98 per cent of Europe have ceased, rejected or banned fluoride? Find out exactly why each individual European nation, after carefully considering this matter, made their decision, here.

Not one single published Australian fluoride efficacy study met the relaxed inclusion criteria for the Cochrane Review (2015). ALL 19 studies included were deemed poor quality and the majority were conducted pre-1975.

2) “EFFICIENT”

Our article The source of fluoride reveals water fluoridation is in fact an extremely inefficient means of delivering a dental treatment.  Our article Cost effectiveness, also shows that figures used by fluoridation proponents are grossly exaggerated.

3) “SOCIALLY EQUITABLE”

Again, the Cochrane Review (2015) found no high-quality research showing fluoridation reduced inequalities among children from different socio-economic groups. Lower socio-economic status (SES) areas generally have compromised diets (involving more sugar, processed and junk foods and poorer dental hygiene) and therefore these areas naturally demonstrate higher rates of dental decay. 

The 2018 National Oral Health Plan identified four priority population groups that have poorer oral health than the general population and also experience barriers to accessing oral health care. These four groups are:

  • People who are socially disadvantaged or on low incomes;
  • Aboriginal and Torres Strait Islander Australians;
  • People living in regional and remote area; and
  • People with additional and/or specialised health care needs

So it’s blatantly obvious: low socio-economic status generally correlates with poorer dental health. Unfortunately, these sub-population groups also have significantly higher rates of other dietary-related health issues such as obesity, high blood pressure and Type 2 diabetes, so they are more susceptible or sensitive to fluoride toxicity. In other words, in low or lower SES regions, fluoridation would NOT reduce the incidence of tooth decay but it WOULD increase the risk of other physiological damage.

The Cochrane Review (2015) found no high-quality research showing fluoridation reduced inequalities among children from different socio-economic groups.

4) “SAFE”

To date, 64 studies7 involving nearly 24,000 children have associated exposure to fluoridation chemicals with IQ loss in humans, while more than 60 studies have found that fluoride exposure impairs the learning and/or memory capacity of animals.

Please read our detailed articles;

A response to the Australian Medical Association and Major studies clearly show the neurological damage of fluoride.

In summary, having personally accepted the Guidelines, you should especially be aware of these neurotoxicity studies or reviews:

  • In 2006 the US National Research Council published “Fluoride in Drinking Water”, the most authoritative review of fluoride’s toxicity. It stated unequivocally that “fluorides have the ability to interfere with the functions of the brain and the body.”8
  • In 2012 a Harvard-funded meta-analysis9 found that children ingesting higher levels of fluoride tested an average 7 IQ points lower in 26 out of 27 studies. Many of these studies involved total exposures to fluoride no more than what millions of Australians receive. Philippe Grandjean, MD, PhD and the study’s co-author stated; “Fluoride seems to fit in with lead, mercury, and other poisons that cause chemical brain drain.”
  • In 2017 the Bashash study10, spanning 13 years, found that every one milligram per litre increase in fluoride in pregnant women’s urine – approximately the difference caused by ingestion of fluoridated water – was associated with a reduction of their children’s IQ by an average 5 to 6 points. Leonardo Trasande, a leading physician unaffiliated with the study, said it “raises serious concerns about fluoride supplementation in water.”11
  • In 2018 the Canadian Malin study12 found iodine-deficient adults with higher fluoride levels had a greater risk of hypothyroidism (known to be linked to lower IQ). According to the Australian Thyroid Foundation, more than 50% of children and pregnant or breastfeeding women living in Australia have been shown to be iodine deficient, and are at risk of developing thyroid disease. The study’s author Ashley Malin said “I have grave concerns about the health effects of fluoride exposure.”13
  • In 2019 the NIH-funded Green study,14published in the Journal of the American Medical Association Pediatrics found every 1mg/L increase in fluoride in Canadian pregnant women’s urine was linked to a 4.5 decrease in IQ in their male children. The physician editor of JAMA Pediatrics said “I would not have my wife drink fluoridated water” if she was pregnant.15
  • In 2019 the Canadian Riddell study16 found that children and teenagers living in fluoridated regions were nearly THREE TIMES more likely to develop ADHD or ADHD symptoms, compared to those in non-fluoridated regions. This reinforced earlier studies linking fluoride to ADHD in Mexico (2018)17and the US (2015).18
  • In 2019 a systematic review19of 149 human studies and 339 animal studies by the US National Toxicology Program concluded that “fluoride is presumed to be a cognitive neurodevelopmental hazard to humans.”
  • In 2020 the Till study,20another NIH-funded study in Canada, found that babies fed formula mixed with fluoridated water averaged 4 IQ points less than those mixed with non-fluoridated water. Losses of non-verbal IQ were even more serious, an average of 9 points.

Many studies also show fluoride damages the kidneys, thyroid gland, pineal gland, bones and teeth; inhibits enzymes and cell proteins21and contributes to iodine deficiency.22

Before going any further, with this compelling evidence, we ask how any science or health professional can personally continue to endorse water fluoridation? If you simply rely on NHMRC’s fluoride review process and recommendations, we urge you to refer to the section below and especially to read the two articles mentioned.

In 2019 the Canadian Riddell study found that children and teenagers living in fluoridated regions were nearly THREE TIMES more likely to develop ADHD or ADHD symptoms, compared to those in non-fluoridated regions.

Your recommendation #3: The level of fluoride in the water supply should be within the range 0.6–1.1 mg/L.

This recommendation complies with and repeats NHMRC’s recommended fluoride concentration, however it also ignores two important issues:

In April 2015, the US Department of Health & Human Services (HHS) admitted that the fluoride levels, which had been promoted and encouraged as safe for decades, have damaged children’s teeth.  With the huge increase in dental fluorosis, HHS stated that water fluoride levels should be lowered to 0.7 mg/L. This represented a 42 per cent decrease from the maximum 1.2mg/L and 30 per cent lower than the most common 1mg/L. More details are available here.

If fluoride is damaging their teeth, we hope, in light of the 64 neurotoxicy studies, and especially the recent US and Canadian studies, you are more concerned that fluoride is damaging their brain and cognitive functioning.

Please see below regarding dental fluorosis in the US and especially Australia where NHMRC downplays or hides the real effect of dental fluorosis.

Also, as you know, it is not the concentration of fluoride (mg/litre) that is the most relevant parameter but the total dose (mg/day), including total fluoridated water consumption and all other sources of fluoride

In April 2015, the US Department of Health & Human Services (HHS) admitted that the fluoride levels, which had been promoted and encouraged as safe for decades, have damaged children’s teeth.

Your recommendation #5: People in non-fluoridated areas should obtain the benefits of fluoride in drinking water by using bottled water with fluoride at approximately 1 mg/L.

For decades, fluoride tablets were recommended in Australia where fluoridated water was not available, despite these supplements NEVER being approved by the US FDA or the Australian TGA. In 2005 ARCPOH reversed this decades-long ritual, recommending NOT to use tablets and instead to add fluoride drops to non-fluoridated water depending on age. Then in 2012, ARCPOH recommended NOT to use fluoride drops or tablets, instead recommending fluoridated bottled water where fluoridated tap water is not available. 

In the latest Guidelines, ARCPOH again recommends fluoridated bottled water containing around 1mg/L and maintains this recommendation despite the overwhelming evidence of developmental neurotoxicity (especially the recent US and Canadian studies) and despite this concentration being at least 40 percent higher than the concentration in US or Canada. It is also relevant that temperatures in Australia are generally higher than many regions of Canada, so water consumption in Australia is generally higher.

It is also interesting that ARCPOH appears to be the only body in Australia currently recommending fluoridated bottled water for people (including young children) where fluoridated tap water is not available, despite overwhelming evidence that fluoride is a developmental neurotoxin; and yet no Disclaimer of Liability is included in the Guidelines. 

ARCPOH again recommends fluoridated bottled water containing around 1mg/L and maintains this recommendation despite the overwhelming evidence of developmental neurotoxicity (especially the recent US and Canadian studies) and despite this concentration being at least 40 percent higher than the concentration in US or Canada.

Your recommendation #6: From the time that teeth first erupt (about six months of age) to the age of 17 months, children’s teeth should be cleaned by a responsible adult, but not with toothpaste.

This recommendation reveals double standards: you acknowledge that fluoride toothpaste should not be used in the first 17 months of life; however you effectively continue to endorse both the use of fluoridated water for the reconstitution of baby formula and the consumption of fluoridated water in this infant and early childhood stage when they are most sensitive to fluoride toxicity and bioaccumulation rates are highest.

Please read our article Fluoride and our young, including details of how, in 2016, NHMRC substantially increased (from 71% to 100%) the Upper Level of Intake (ULI) for infants and children up to 8 years of age. This means, despite the risks of fluoride toxicity at this highly-sensitive, neuro-developmental stage, Australia’s upper fluoride limits for infants and children are now significantly higher than or DOUBLE the upper limits used in the United States and elsewhere.

You should also be aware that infants in Australia consuming baby formula made with fluoridated water are ingesting up to 250 times more fluoride than those consuming breast milk. Do you personally feel this is appropriate, especially given the above studies?

It should also be noted, there are non-fluoridated toothpastes available that are formulated to allow babies and toddlers to swallow the toothpaste, e.g. “Jack and Jill” brand toothpaste.

Infants in Australia consuming baby formula made with fluoridated tap water are ingesting up to 250 times more fluoride than those consuming breast milk.

Your recommendation #7: For children aged 18 months to five years (inclusive), the teeth should be cleaned twice a day with toothpaste containing 0.5–0.55mg/g fluoride (500–550ppm). Toothpaste should always be used under the supervision of a responsible adult. A small pea-sized amount should be applied to a child-sized soft toothbrush and children should spit out, not swallow, and not rinse. Young children should not be permitted to lick or eat toothpaste. Standard toothpaste is not recommended for children under six years of age unless on the advice of a dental professional or a trained health professional."

This recommendation is reassuring, however many Australian parents are either unaware or complacent about the toxicity of fluoride toothpaste, often not regularly or closely supervising their child while brushing and even allowing their children to use adult toothpaste. Also, toothpaste brands for children are normally flavoured, e.g. strawberry, bubble gum, vanilla, banana and tutti fruity. These appealing flavours may encourage them to brush, but unfortunately they also encourage them to swallow the toothpaste.

In February 2019, the US Centres for Disease Control (CDC) published a study23showing that 38 per cent of children aged 3 to 6 years used more than the recommended amount of toothpaste of a pea-sized amount (normally amounting to about 0.25g) and warned about the risk of dental fluorosis. The CDC used five references for dental fluorosis dated 1988, 1992, 1994, 2014, and 2015, surprisingly without direct references to the NHANES (National Health and Nutrition Examination Surveys) data on dental fluorosis.24  

In March 2019 another study25highlighted the dramatic increases in dental fluorosis and widespread fluoride overexposure with risk of neurotoxicity. This study included the results of the 2011-2012 NHANES survey showing that American adolescents with any form of fluorosis had jumped to a staggering 65 per cent. Even more concerning was the huge increase in combined moderate and severe fluorosis, jumping from 3.7 per cent previously to a massive 30.4 per cent.

Meanwhile, NHMRC downplays or hides the real effect of dental fluorosis in Australia firstly by combining non-fluoridated and fluoridated statistics; and secondly by engineering a more favourable outcome by re-classifying the universal moderate grade while simultaneously upgrading the threshold for fluorosis of aesthetic concern. For more details, please read our article on dental fluorosis.

It is also worth noting that several other studies link the incidence of dental fluorosis in children with various physiological harms, including neurological damage (reduced IQ).

NHMRC downplays or hides the real effect of dental fluorosis in Australia firstly by combining non-fluoridated and fluoridated statistics and secondly by engineering a more favourable outcome by re-classifying the universal moderate grade while simultaneously upgrading the threshold for fluorosis of aesthetic concern.

Violation of medical ethics

Fluoridation is a serious violation of medical ethics: there is no individual consent, no control of dose, no regard for individual circumstances or disadvantaged groups, no ongoing monitoring or testing; and fluoridation chemicals have never been proven safe. A Randomised Controlled Trial has NEVER been conducted. The fluoridation of public water supplies contradicts the Australian Medical Association’s Code of Ethics and the Australian Medical Council’s Code of Conduct, specifically regarding Informed Consent. More here.

Read more about ethics here.

Reliance on NHMRC

NHMRC’s blatantly biased fluoridation review methodology consistently reveals a specific agenda to defend fluoridation regardless of its harm. Please be sure to read our detailed articles:

Can the NHMRC be trusted?
A response to NHMRC – the bioaccumulation of fluoride

Conclusion

With all this evidence, we ask again how any scientist or health professional can continue to endorse water fluoridation and embrace and uphold the first introductory statement in the Guidelines; “Fluoride use is the cornerstone of dental caries prevention”?

We therefore suggest that ARCPOH’s Executive Group urgently review these Guidelines. Also, the Disclaimer in this document states the Guidelines: “reflect the consensus view of the 60 attendees at the workshop”. We therefore ask you, as a science or health professional who was included in this consensus and therefore personally and officially accepted these Guidelines, to seriously consider your continued support and endorsement of Australia’s water fluoridation program – a program that is clearly NOT safe, NOT effective and NOT ethical.

Sincerely,
The Management Committee

Fluoride Free Australia Inc.
Click here to read another 270+ quotes about fluoride from other science and health professionals

Reference notes:

  1.  Utz Mueller is a Belgian toxicologist. Belgium has never added fluoridation chemicals to its drinking water and officially banned salt fluoridation and fluoride supplements in the form of gum, tablets and drops in 2002. For reasons why most European nations ceased, rejected or banned fluoride please read our article 98% of Europe say NO to fluoride.
  2. AIHW, March 2018 Oral Health Tracker and AIHW November 2018 Report.
  3. Oral health and dental care in Australia; AIHW; 20 March 2019, available here.
  4. Letter from Hubert A Arnold, PhD, University of California (Davis) to Dr. Ernest Newbrun, May 28 1980; available here. Refer to our article Water fluoridation is not effective for more details.
  5. F.B.Exner, “Analytical Commentary on the 1960 Testimony of D. H. Trendley Dean in the Suit to Enjoin Fluoridation of Chicago’s Water, Part II,” in Fluoridation: Its Moral and Public Aspect; A New and Comprehensive Study (New York), The Greater New York Committee Opposed to Fluoridation (undated).
  6. Zipporah Iheozor‐Ejiofor et al; Water fluoridation for the prevention of dental caries; Cochrane Collaboration/Cochrane Database of Systematic Reviews; 18 June 2015.
  7. Fluoride Action Network website (Fluoridealert.org); Fluoride and IQ: The 64 Studies; Jan 2020. Available here.
  8. US National Research Council, Fluoride in Drinking Water, 2006, p. 222.
  9. Choi et al, Developmental Fluoride Neurotoxicity: A Systematic Review and Meta-Analysis, Environmental Health Perspectives, July 20, 2012.
  10. Bashash et al, Prenatal Fluoride Exposure and Cognitive Outcomes in Children at 4 and 6-12 Years of Age in Mexico, Environmental Health Perspectives, Sept. 19, 2017.
  11. Dana Dovey, “Children’s IQ Could be Lowered by Mothers Drinking Tap Water While Pregnant,” Newsweek, Sept. 19, 2017
  12. Malin et al, Fluoride Exposure and Thyroid Function Among Adults Living in Canada: Effect Modification by Iodine Status, Environment International, Dec. 2018.
  13. Brian Bienkowski, “We Add It to Drinking Water for Our Teeth – But is Fluoride Hurting Us?” Environmental Health News, Oct. 10, 2018.
  14. Green et al, Association Between Maternal Fluoride Exposure During Pregnancy and IQ Scores in Offspring in Canada, Journal of the American Medical Association Pediatrics, Aug. 19, 2019
  15. Ben Guarino, “Study Raises Questions About Fluoride and Children’s IQ,” Washington Post, Aug. 20, 2019
  16. Riddell et al, Association of Water Fluoride and Urinary Fluoride Concentrations with Attention Deficit Hyperactivity Disorder in Canadian Youth, Environment International, Dec. 2019
  17. Bashash et al, Prenatal Fluoride Exposure and Attention Deficit Hyperactivity Disorder (ADHD) Symptoms in Children at 6-12 Years of Age in Mexico City, Environment International, Dec. 2018
  18. Malin et al, Exposure to Fluoridated Water and Attention Deficit Hyperactivity Disorder Prevalence Among Children and Adolescents in the United States: An Ecological Association, Environmental Health, Feb. 27, 2015.
  19. Till et al, Fluoride Exposure From Infant Formula and Child IQ in a Canadian Birth Cohort, Environment International, Jan. 2020.
  20. National Toxicology Program, Draft NTP Monograph on the Systematic Review of the Fluoride Exposure and Neurodevelopmental and Cognitive Health Effects, Sept. 6, 2019.
  21. Waugh DT; Fluoride Exposure Induces Inhibition of Sodium-and Potassium-Activated Adenosine Triphosphatase (Na +, K +-ATPase) Enzyme Activity: Molecular Mechanisms and Implications for Public Health; Int J Environ Res Public Health 21 April 2019. 
  22. Waugh DT; ‘Fluoride Exposure Induces Inhibition of Sodium/Iodide Symporter (NIS) Contributing to Impaired Iodine Absorption and Iodine Deficiency: Molecular Mechanisms of Inhibition and Implications for Public Health,’ 26 March 2019; Int. J. Environ. Res. Public Health 2019, 16(6), 1086.
  23. Centres for Disease Control; Use of Toothpaste and Toothbrushing Patterns Among Children and Adolescents — United States, 2013–2016. Morbidity and Mortality; Thornton-Evans et al, Feb 1, 2019.
  24. Fluoride Action Network website (Fluoridealert.org); Toothpaste and Toothbrushing: a new report by the CDC; 4 Feb 2019. Available here.
  25. Neurath, C. et al; Dental Fluorosis Trends in United States Oral Health Surveys: 1986–2012; March 2019.