91680 • Fluoride: A Risk-Benefit Review

Table of Contents

91680 • Fluoride: A Risk-Benefit Review

How to Receive Credit

Course Overview

Audience

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. FLUORIDE IN THE UNITED STATES

WATER FLUORIDE REGULATIONS

WATER FLUORIDE LEVELS

3. FLUORIDE IN THE DIET

TOLERABLE UPPER INTAKE LEVELS OF FLUORIDE

MEASURING FLUORIDE INTAKE

DIETARY SURVEYS

URINARY FLUORIDE LEVELS

4. ASSESSING THE RISKS OF FLUORIDE

FLUOROSIS

ONCOLOGIC CONCERNS

NEUROLOGICAL CONCERNS

ENDOCRINE CONCERNS

5. PRACTICE PEARLS

6. CONCLUSION

Works Cited

91680 • Fluoride: A Risk-Benefit Review

Chelsey McIntyre, PharmD

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

Water fluoridation has a long history of controversy that dates back to the very first fluoridation initiatives in the United States. Through an examination of the history of water fluoridation, current regulatory standards, methods of measuring fluoride intake, and the scientific literature surrounding potential health concerns, including dental fluorosis, neurological effects, endocrine impacts, and oncologic risk, participants in this course will develop the knowledge needed to counsel patients accurately and confidently on fluoride-related questions in clinical practice.

91680 • Fluoride: A Risk-Benefit Review

Education Category. Community Health

Release Date. 06/01/2026

Expiration Date. 05/31/2029

How to Receive Credit

To complete this course for continuing education credit please go to http://www.netce.com/course/3522 in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

Course Overview

Water fluoridation has a long history of controversy that dates back to the very first fluoridation initiatives in the United States. Through an examination of the history of water fluoridation, current regulatory standards, methods of measuring fluoride intake, and the scientific literature surrounding potential health concerns, including dental fluorosis, neurological effects, endocrine impacts, and oncologic risk, participants in this course will develop the knowledge needed to counsel patients accurately and confidently on fluoride-related questions in clinical practice.

Audience

This course is designed for healthcare professionals involved in patient teaching related to fluoride and related benefits and risks.

Course Objective

The purpose of this course is to provide healthcare professionals with a balanced, evidence-based review of fluoride exposure, equipping them to communicate the risks and benefits of water fluoridation and other fluoride sources at levels commonly encountered in the United States.

Learning Objectives

Upon completion of this course, you should be able to:

1. Review the history and current state of water fluoridation in the United States.

2. Discuss the risks and benefits of fluoride at the levels found in artificially fluoridated water.

3. Outline the limitations of methods for assessing fluoride exposure.

4. Explain the conflicting findings associated with varying levels of fluoride exposure.

Faculty

Chelsey McIntyre, PharmD, is a clinical pharmacist who specializes in drug information, literature analysis, and medical writing. She earned her Bachelor of Science degree in Genetics from the University of California, Davis. She then went on to complete her PharmD at Creighton University, followed by a clinical residency at the Children’s Hospital of Philadelphia (CHOP). Dr. McIntyre held the position of Drug Information and Policy Development Pharmacist at CHOP until her move to Washington state in 2017, after which she spent the next six years as a clinical editor for Natural Medicines, a clinical reference database focused on natural products and alternative therapies. She continues to create rigorous professional analysis and patient education materials for various publications while also practicing as a hospital pharmacist. Her professional interests include provider and patient education, as well as the application of evidence-based research to patient care.

Faculty Disclosure

Contributing faculty, Chelsey McIntyre, PharmD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

John M. Leonard, MD

Mary Franks, MSN, APRN, FNP-C

Randall L. Allen, PharmD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Fluoride is a mineral that occurs naturally in rocks, soil, water, and air. Adequate exposure to this mineral can help to reduce the development of dental cavities in humans by inhibiting the breakdown of teeth, promoting tooth remineralization, and inhibiting bacteria [1]. Most of the earth's water naturally contains some amount of fluoride, although these levels are typically inadequate to impact dental health.

The addition of fluoride to drinking water has long been considered one of the greatest public health achievements of the 20th century, and it is often viewed as a cornerstone strategy in the prevention of dental cavities. Numerous observational studies conducted prior to 1975 identified a consistent reduction in cavities in both adults and children living in communities with naturally or artificially fluoridated water. When considered together, these studies found that water fluoridation reduced the cavity rate across the population by about 25% [2].

After the introduction of fluoridated water in the United States—which began in 1945—many other dental health initiatives were implemented and broadly adopted. These include improved access to dental care, routine dental cleaning at home, the widespread availability of fluoride-containing toothpaste, and the use of fluoride treatments during dental visits. Despite these advancements, cavities continue to be the most common chronic disease in U.S. children [3].

Most research assessing the benefits of fluoridated water was conducted prior to the advent and widespread adoption of these dental health measures. As a result, it is unclear whether the fluoridation of community water continues to provide the level of benefit first seen in those foundational studies [5]. However, water fluoridation ensures ubiquitous access to fluoride across entire communities, regardless of socioeconomic status. Many proponents of fluoridated water point to its ability to reach children and adults who may otherwise have inadequate access to routine dental care [5].

2. FLUORIDE IN THE UNITED STATES

When fluoride enters the mouth via drinking water, toothpaste, or fluoride treatments, saliva concentrations of fluoride increase by 100- to 1,000-fold for approximately one to two hours. During this time, the mouth is exposed to high concentrations of fluoride, allowing it to exert its beneficial effects on the teeth, plaque, and bacteria. Additionally, when fluoride is brushed onto the teeth via toothpaste, some fluoride is directly absorbed by dental plaque [4].

WATER FLUORIDE REGULATIONS

In the United States, water fluoridation is controlled at the state or municipal level. The decision to fluoridate water is based on local voter and government preference, as well as the features of local water sources. Some water sources are naturally fluoridated and do not require artificial fluoridation. Others contain high quantities of fluoride and must have fluoride removed. In areas with no natural fluoride, some water systems are legally required to fluoridate the water, whereas others are not [6].

While the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and the American Dental Association (ADA) recommend universal water fluoridation, it is not available in all U.S. communities. As of 2010, approximately two-thirds (66%) of all Americans had access to fluoridated tap water. In about 10% of cases, lack of access to fluoridated water is due to the use of private or community wells. In the remaining one-quarter of the population, it is usually due to a local decision to forego water fluoridation [5].

WATER FLUORIDE LEVELS

For many years, the recommended content of fluoride in U.S. drinking water was 0.7–1.2 mg/L. In 2015, the U.S. Public Health Service (USPHS) simplified this recommendation to provide an "optimal" level for fluoride in water: 0.7 mg/L (or 1 part per million). This optimal level was identified as the fluoride concentration that would maximize dental health benefits while minimizing risks, such as dental fluorosis [7].

At the time of this announcement, it was estimated that most fluoridated water systems were providing fluoride concentrations of 0.8–1.2 mg/L. As a result, the new recommendations were expected to reduce overall fluoride exposure from water by about 25%. When dietary sources of fluoride are also considered, the new recommendation was expected to reduce overall exposure to fluoride by 14% [7].

It is important to understand that U.S. water systems maintain tight control on fluoride content, with a focus on achieving the optimal level set in 2015. In contrast, many low- and middle-income countries have water sources that naturally contain very high concentrations of fluoride, sometimes ranging far above 10 mg/L. Many of the health risks associated with fluoride exposure have been identified in communities with very high natural levels of fluoride and no systems for reducing these levels.

Bottled Water

In 2022, the U.S. Food and Drug Administration (FDA) adopted a recommendation for fluoride in bottled water. In a final rule titled Beverages: Bottled Water, the agency determined that the highest allowable level of added fluoride in bottled water should be 0.7 mg/L. Additionally, any bottled water containing added fluoride must declare this additive on the label [8].

This rule does not apply, however, to any natural fluoride found in bottled water. These products do not need to limit their fluoride content nor declare the presence of fluoride on the label [8].

3. FLUORIDE IN THE DIET

Although water often dominates discussions about fluoride exposure, it is not the only source of fluoride in a typical diet. Rather, fluoridated drinking water is thought to account for about 60% to 70% of all fluoride intake in the United States.

In many cases, the presence of fluoride in other components of the diet, particularly other drinks, stems from their manufacture in areas with fluoridated water. For example, carbonated soft drinks have been found to contain an average of 0.72 mg/L fluoride [9].9 Similarly, fruit juices or fruit-flavored beverages can contain higher quantities of fluoride if they are produced in areas with fluoridated water.

Brewed teas present the most significant sources of fluoride in the diet, even when the tea is brewed with non-fluoridated water. Depending on the type of tea and the source of the tea leaves, a cup of tea made with non-fluoridated water can contain between 0.3–6.5 mg/L of fluoride (or about 0.07–1.5 mg per cup of tea). Coffee can also provide a notable amount of fluoride, depending on how the beans were prepared and where they were grown; one cup of brewed coffee can provide around 0.22 mg fluoride [10].

Foods such as beans and oats, can also provide measurable amounts of fluoride, typically because they have been cooked with fluoridated water. Canned shellfish can also contain measurable quantities of fluoride. For example, 3 ounces of canned shrimp provides about 0.17 mg of fluoride [10].

TOLERABLE UPPER INTAKE LEVELS OF FLUORIDE

The Institute of Medicine has established a tolerable upper intake level (UL) for fluoride, based on age (Table 1). This level is intended to provide a daily dose above which fluoride would be expected to produce unwanted adverse effects over the long-term, as will be discussed later in this course [11].

Table 1: THE UL FOR FLUORIDE, BY AGE

Age

Tolerable Upper Limit (UL)

0–6 months

0.7 mg

7–12 months

0.9 mg

1–3 years

1.3 mg

4–8 years

2.2 mg

9 years and older

10 mg

Source: [11]

Based on these levels, an adult or child older than 9 years of age living in a community with artificially fluoridated water would need to consume 14 liters of water each day to reach the UL from water alone. Even if water is presumed to provide only 60% of daily fluoride intake, then this person would need to consume 8.5 liters of water per day to reach this level.

However, it is important to use caution when administering fluoride-containing products to children. For children younger than 3 years of age, the ADA recommends that caregivers brush the child's teeth with only a "smear" of toothpaste, or no more than a grain of rice. For children 3 to 6 years of age, provide no more than a pea-sized amount of toothpaste and supervise the child to ensure they are not swallowing while brushing [12].

Without appropriate precautions, formula-fed infants may be at risk of elevated fluoride exposure. The fluoride content of infant formula depends primarily on the water used for reconstitution. The CDC recommends that parents living in areas with fluoridated water consider using bottled water labeled as deionized, purified, demineralized, or distilled to reconstitute infant formula. Alternatively, ready-to-feed formulas contain only small quantities of fluoride [13].

MEASURING FLUORIDE INTAKE

For researchers to investigate a correlation between fluoride intake and any downstream health effects, fluoride intake must first be measured. Measurement techniques, each with pros and cons, take two main approaches:

- Assessing general fluoride intake to identify population-level changes via direct comparison of water fluoride concentrations or estimation of predicted water intake

- Obtaining granular, individualized data on fluoride intake to identify changes within a community via dietary surveys or measurement of urinary fluoride levels

Although these two options may unintentionally dismiss individual variability in water consumption and dietary fluoride intake, the next two can introduce confounding factors.

DIETARY SURVEYS

As with any self-reported tool, food and drink surveys suffer from subjective reporting discrepancies and recall bias. The accuracy of these surveys decreases the further back the survey reaches. For example, a 24-hour survey is more likely to provide relatively accurate information than a survey asking the participant to recall estimates of intake over an extended duration of time.

URINARY FLUORIDE LEVELS

Urinary fluoride levels, while popular in epidemiological research, are considered a potentially unreliable marker of fluoride intake. These levels can be altered by various factors, including individual variability in fluoride pharmacokinetics, lifestyle factors (e.g., smoking and alcohol consumption), and intermittently elevated intake from fluoride-containing dental products or high-fluoride foods [14]. Additionally, one study investigating the impact of diet on urinary fluoride levels during pregnancy identified variations between trimesters and between the pre- and postpartum states [15]. As a result, using urinary fluoride levels as a marker of typical and long-term fluoride intake may lead to inappropriate conclusions.

4. ASSESSING THE RISKS OF FLUORIDE

Water fluoridation has a long history of controversy that dates back to the very first fluoridation initiatives in the United States. In some conspiracy theories, fluoride is viewed as a source of governmental mind control, or a plot to compromise American health. For many people, however, there is simply a general unease with the knowledge that the government is adding a colorless, odorless chemical to their drinking water.

As with most chemicals and substances, fluoride does carry the potential for toxicity. But this toxicity is known to be dose-dependent. Many of the concerns that have been raised in relation to fluoride safety—such as its impact on the brain and thyroid—stem from studies conducted in regions with naturally high fluoride levels. Over time, studies evaluating the toxicity of fluoride have either been misconstrued, misinterpreted, or misapplied to communities with tightly controlled artificial water fluoridation programs.

FLUOROSIS

One exception to this rule is dental fluorosis. As the name may imply, fluorosis is a known and established risk with fluoride exposure, and dental fluorosis can occur in regions with fluoridated water. However, as with all other fluoride-related risks, fluorosis only occurs with elevated exposure, and the degree of severity is dose-dependent.

Dental Fluorosis

Dental fluorosis is caused by exposure to fluoride while the teeth are still developing, a period that typically ends around 8 years of age. Although the actual pathology of fluorosis is not fully understood, the uptake of large quantities of fluoride by the enamel can lead to the development of white streaks or spots on the teeth [16].

Population research suggests that dental fluorosis occurs when water concentrations of fluoride exceed 1.5 mg/L. However, the risk of developing dental fluorosis increases when the teeth are exposed to various other additional topical sources of fluoride, such as through toothpaste or fluoride treatments administered at the dentist's office [16].

Dental fluorosis is directly associated with cavity resistance, indicating that the anti-cavity effects of fluoride persist at these higher exposures. Most cases of dental fluorosis involve subtle changes to the color of the enamel, although some people may develop severe discoloration that can impact self-esteem and confidence. Although this may present a serious cosmetic concern for a small segment of those affected, it does not present a serious health concern [16].

Skeletal Fluorosis

In contrast, skeletal fluorosis is a serious condition that can cause severe and long-term complications. Skeletal fluorosis, which ultimately results in weakened bones, occurs after the long-term ingestion of large quantities of fluoride. Some people with this disorder develop joint stiffness and pain, muscle wasting, and—in cases where the vertebrae are impacted—neurological defects [17].

Most observational research suggests that skeletal fluorosis is most likely to occur in people who have been exposed to levels above the UL for more than 10 years [11]. Unlike dental fluorosis, fluoride must be ingested to contribute to skeletal fluorosis; topical fluoride treatments do not add to fluoride intake unless they are swallowed.

As noted previously, the intake of fluoride at this level would require consuming vast quantities of fluoridated water each day. In general, only communities with very high natural levels of water fluoride have been associated with an increased risk of skeletal fluorosis [17].

ONCOLOGIC CONCERNS

For many years, opponents of water fluoridation have cited its potential to cause cancer. However, decades of animal research and observational human research have failed to demonstrate an association between fluoride exposure and cancer.

Multiple committees and agencies, including the National Research Council (NRC), California's Carcinogen Identification Committee, the United Kingdom's National Health Service (NHS), and the USPHS, have conducted independent reviews that have all reached similar conclusions: There is no strong evidence of any link between water fluoridation and cancer [18].

More recent studies have also evaluated a potential correlation between fluoride exposure and a specific, rare form of bone cancer called osteosarcoma. However, these studies have failed to show a consistent relationship between osteosarcoma and fluoride exposure [18].

NEUROLOGICAL CONCERNS

Neurological effects—or more specifically, impacts on brain development—are another recurring concern with fluoride. Many of the studies that have identified such a relationship have evaluated children living in regions with very high natural levels of fluoride (up to 11.5 mg/L).

A meta-analysis of these observational studies found that once fluoride levels have exceeded 1 mg/L, there is an average 3-point decrement in IQ score for each 1 mg/L increase in water fluoride concentrations [19]. A separate meta-analysis that included many of the same studies ultimately determined that any inverse association between IQ score and water fluoride levels does not become significant until water fluoride levels exceed 1.5 mg/L [20]. For context, the current U.S. recommendation for water fluoride content is 0.7 mg/L.

In 2019, an observational study conducted in Canada sparked renewed concern in this area. This study, which utilized the Canadian Maternal-Infant Research on Environmental Chemicals (MIREC) cohort, reported a small inverse association between IQ score at 3.5 years of age and fluoride exposure during infancy, but not childhood. Exposures in these age groups were estimated, respectively, by predicted use of fluoridated water in formula and urinary fluoride levels. However, the impact on IQ score varied by biological sex and was only significant for certain test scores. Additionally, the authors of this study published an addendum that found that the findings were no longer significant after adjusting for multiple testing [21].

In direct conflict with these findings, two studies utilizing cohorts from Australia have found no association between water fluoridation and IQ score. One study utilized dental fluorosis as a marker of elevated fluoride exposure during childhood; at 16 to 26 years of age, there was no difference in IQ scores between people with and without dental fluorosis [22,23].

Concerns about the effect of fluoride exposure in utero have also been raised. However, studies attempting to assess such an association have yielded conflicting findings. Additionally, most of these studies have relied on the use of maternal urinary fluoride levels to approximate in utero exposure [24,25,26,27].

ENDOCRINE CONCERNS

Another recurring concern regarding fluoride exposure relates to thyroid function. However, the studies which have identified an association between thyroid function and fluoride exposure have been conducted in regions with very high natural levels of fluoride (up to 25.1 mg/L).

A meta-analysis of observational studies, mostly in children 6 to 18 years of age, has found that water fluoride is directly associated with thyroid stimulating hormone (TSH) levels only at fluoride levels above 2.5 mg/L. There were no consistent correlations between thyroid hormone levels (such as T3 and T4) and fluoride exposure [28].

5. PRACTICE PEARLS

Counsel your patients on the importance of topical fluoride for the prevention of cavities. Topical fluoride can be obtained via fluoridated water or other drinks, fluoridated toothpaste, or fluoride dental treatments.

If your patients express concern about fluoridated water in their communities, reassure them that the risks of exposure at these levels appear to be limited. If they are interested in reducing overall exposure, review their other sources of exposure (e.g., toothpastes, carbonated beverages, juices), and encourage them to discuss the risks and benefits of fluoride treatments with dental providers rather than solely obtaining information from unverified sources.

Conversely, if your patients are concerned about the lack of fluoride in their community water system, reassure them that dental health can be adequately maintained via other sources of fluoride. Encourage them to use fluoride-containing toothpastes and seek out fluoride treatments. It may also be helpful to educate them on the presence of fluoride in many bottled water products and other beverages.

6. CONCLUSION

Since its first implementation in 1945, water fluoridation has been associated with a widespread reduction in dental cavities. In the proceeding 80 years, however, fluoride has also become readily available through other means, including toothpaste and routine dental treatments. Although it is not clear whether water fluoridation continues to provide a strong benefit for people with access to these other options, it remains a universal assurance of fluoride exposure for all members of a community, regardless of socioeconomic status.

Based on the available research, the risks of artificial water fluoridation appear to be limited. Dental fluorosis remains the only established and confirmed risk associated with the levels of exposure that occur in communities with artificially fluoridated water. This primarily cosmetic concern can be avoided on an individual basis by limiting the number of topical fluoride sources during early childhood.

Other common fluoride-related safety concerns appear to be a true concern only in communities with high natural levels of fluoride in their water. Artificial water fluoridation programs in the United States proactively maintain a concentration of 0.7 mg/L; thyroid dysfunction and neurodevelopmental concerns appear to arise with water fluoride levels of 1.5–2.5 mg/L and become more pronounced as levels increase past this point. Skeletal fluorosis only occurs when fluoride intake exceeds the UL consistently for many years, a level that is not obtainable solely via consumption of artificially fluoridated water.

Although some observational studies have stoked concerns about the safety of artificially fluoridated water, these studies suffer from significant methodological limitations and are often in conflict with other research. Further research is required to determine the presence or absence of a causal relationship. More information is also needed to determine whether any purported effects may be related to other environmental exposures or lifestyle factors.

Works Cited

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2. Centers for Disease Control and Prevention. Community Water Fluoridation: One of the 10 Greatest Public Health Achievements of the 20th Century. Available at https://blogs.cdc.gov/pcd/2015/04/23/community-water-fluoridation-one-of-the-10-greatest-public-health-achievements-of-the-20th-century. Last accessed May 22, 2026.

3. Centers for Disease Control and Prevention. Timeline for Community Water Fluoridation. Available at https://www.cdc.gov/fluoridation/timeline-for-community-water-fluoridation/index.html. Last accessed May 22, 2026.

4. Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR. 2001;50(RR14):1-42.

5. Iheozor-Ejiofor Z, Worthington HV, Walsh T, et al. Water fluoridation for the prevention of dental caries. Cochrane Database Syst Rev. 2015;2015(6):CD010856.

6. Centers for Disease Control and Prevention. About Community Water Fluoridation. Available at https://www.cdc.gov/fluoridation/about/index.html. Last accessed May 22, 2026.

7. U.S. Department of Health and Human Services Federal Panel on Community Water Fluoridation. U.S. Public Health Service recommendation for fluoride concentration in drinking water for the prevention of dental caries. Public Health Rep Wash DC 1974. 2015;130(4):318-331.

8. U.S. Food and Drug Administration. FDA Releases Final Rule for Added Fluoride Levels in Bottled Water. Available at https://www.fda.gov/food/hfp-constituent-updates/fda-releases-final-rule-added-fluoride-levels-bottled-water. Last accessed May 22, 2026.

9. Heilman JR, Kiritsy MC, Levy SM, Wefel JS. Assessing fluoride levels of carbonated soft drinks. J Am Dent Assoc 1939. 1999;130(11): 1593-1599.

10. National Institutes of Health Office of Dietary Supplements. Fluoride: Fact Sheet for Health Professionals. Available at https://ods.od.nih.gov/factsheets/Fluoride-HealthProfessional. Last accessed May 22, 2026.

11. Institute of Medicine Standing Committee on the Scientific Evaluationof Dietary Reference Intakes. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC: National Academies Press; 1997.

12. American Dental Association Council on Scientific Affairs. Fluoride toothpaste use for young children. J Am Dent Assoc 1939. 2014;145(2):190-191.

13. Centers for Disease Control and Prevention. Community Water Fluoridation Frequently Asked Questions. Available at https://www.cdc.gov/fluoridation/faq/index.html. Last accessed May 22, 2026.

14. Levy SM. Caution needed in interpreting the evidence base on fluoride and IQ. JAMA Pediatr. 2025;179(3):231-234.

15. Castiblanco-Rubio GA, Muñoz-Rocha TV, Téllez-Rojo MM, et al. Dietary Influences on urinary fluoride over the course of pregnancy and at one-year postpartum. Biol Trace Elem Res. 2022;200(4):1568-1579.

16. Niazi FC, Pepper T. Dental fluorosis. In: StatPearls. StatPearls Publishing; 2025.

17. Joseph A, Rajan R, Paul J, et al. The continuing crippling challenge of skeletal fluorosis: case series and review of literature. J Clin Transl Endocrinol Case Rep. 2022;24:100114.

18. American Cancer Society. Water Fluoridation and Cancer Risk. Available at https://www.cancer.org/cancer/risk-prevention/chemicals/water-fluoridation-and-cancer-risk.html. Last accessed May 22, 2026.

19. Veneri F, Vinceti M, Generali L, et al. Fluoride exposure and cognitive neurodevelopment: systematic review and dose-response meta-analysis. Environ Res. 2023;221:115239.

20. Taylor KW, Eftim SE, Sibrizzi CA, et al. Fluoride exposure and children's IQ scores: a systematic review and meta-analysis. JAMA Pediatr. 2025;179(3):282-292.

21. Farmus L, Till C, Green R, et al. Critical windows of fluoride neurotoxicity in Canadian children. Environ Res. 2021;200:111315.

22. Do LG, Sawyer A, John Spencer A, et al. Early childhood exposures to fluorides and cognitive neurodevelopment: a population-based longitudinal study. J Dent Res. 2025;104(3):243-250.

23. Do LG, Spencer AJ, Sawyer A, et al. Early childhood exposures to fluorides and child behavioral development and executive function: a population-based longitudinal study. J Dent Res. 2023;102(1):28-36.

24. Green R, Lanphear B, Hornung R, et al. Association between maternal fluoride exposure during pregnancy and IQ scores in offspring in Canada. JAMA Pediatr. 2019;173(10):940-948.

25. Till C, Green R, Lanphear B. Association between maternal fluoride exposure and child IQ: reply. JAMA Pediatr. 2020;174(2):216-217.

26. Goodman CV, Hall M, Green R, et al. Iodine status modifies the association between fluoride exposure in pregnancy and preschool boys' intelligence. Nutrients. 2022;14(14):2920.

27. Grandjean P, Meddis A, Nielsen F, et al. Dose dependence of prenatal fluoride exposure associations with cognitive performance at school age in three prospective studies. Eur J Public Health. 2024;34(1):143-149.

28. Iamandii I, De Pasquale L, Giannone ME, et al. Does fluoride exposure affect thyroid function? A systematic review and dose-response meta-analysis. Environ Res. 2024;242:117759.