Your indifference is based on some core assumptions that are false. In reality,
1) Fluoride in water works in addition to fluoride in toothpaste to protect our teeth - rather than two highly concentrated events of reminieralization, fluoriated water reminieralizes the teeth throughout the day.
2) There is a strong economic downside to ceasing fluoridation: Fluoridation saves millions of dollars that otherwise would be spent on dental bills by the public - https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2016.0... - shows cost savings ratio of twenty dollars for every.
dollar invested in reduced treament costs. This remains apt: https://pmc.ncbi.nlm.nih.gov/articles/PMC7164347/
3) The best way to preserve choice is to maintain fluoridation. People cannot choose to fluoridated their own water system - they can choose to live in unfluoridated areas, use filters that remove fluoride, or otherwise avoid the tap water.
4) Removing fluoridation means acces to fluoride becomes much more difficult and expensive. The reason fluoridation is so cost effective is that it is delivered through the public water system - a community resource. Bottled fluoridated water is more expensive than gasoline. It is also less regulated and less available in the U.S.A.
Tooth decay and the disease that comes with it is a multi-factorial disease - its not enough to simply eliminate "sugar" from the diet.
So, although I agree 100% that we need put systemic interventions to make those that promote a sugary diet accountable for the externalities they create, like hospitalizations, lower quality and length of life, lower incomes and educational attainment etc., We still need to focus on preventing cavities. Cavities are caused by all carbohydrates, including crackers, bread, etc. that have time on teeth allowing the bacteria that cause cavities to digest them and excrete acid on the tooth.
Eliminate enough risk factors and you will prevent the disease - in fact cavities are 100% preventable - with proper hygiene, enough fluoride, healthy diet and early prevention of the bacteria that spreads the disease from childcare provider to baby.
The Kumar study you cite has many limitations and alternate explanations - one, of which, isn't mentioned - that Medicaid fraud is rampant in New York State.
Kumar writes " one should be cautious in attributing this geographic variation solely to water fluoridation. Furthermore, the availability of fluoride in beverages and fluoride provided through organized programs, which distribute tablets and rinses in non-fluoridated communities, may underestimate [over over-estimate] the effect of fluoridation. A survey of third-grade children in less fluoridated communities in NYS showed that reportedly 20% to 80% of children had received fluoride tablets on a regular basis.34 About 100,000 school-aged children in non-fluoridated areas are targeted for participation in a weekly fluoride rinse program. In addition, toothpaste and processed beverages are the other sources of fluoride. Programs such as school-based sealant programs are also available in these areas."
The second link to a Calgary study concludes that tooth decay rates in Calgary, Alberta, have increased because of the city's decision to scrap its fluoridation program. But the study omits data showing that the spike in decay mostly occurred when fluoride was still in the water and used methods that a leading scientist says do "not provide a valid assessment," https://www.prnewswire.com/news-releases/calgary-fluoride-st...
Thanks for sharing that article. In reading it I noticed a few things: 1) the primary author is a well published structural engineer. The article was billed as review of the medical literature, so this is an odd match in regards to expertise and content. Their first co-author does have MD, MPH credentials, but they were fairly green having published only one other article. The journal itself seems legit and has been around for 100+ years.
In looking at the content 1) The methodology was essentially one paragraph and in execution it appears they cherry picked the literature and did not clearly indicate concentration of fluoride as they discussed certain postulated effects. 2) Often they reached conclusions based on single studies that do not seem to reflect the current body of evidence. For example, the reference to a Utah study on bone fracture in the elderly population. Many other studies have found opposite results and have been published prior to the publication of this study. 3) Their graphs that show a lack of association of water and salt fluoridation are used as evidence to make the declaration that there is no effect without discussion of causation for that difference.
In essence, this piece seems like a regurgitation of soundbites from US advocates opposed to fluoridation.
Chile continues its fluoridation program (70% of its population) and milk fluoridation for rural areas https://www.borrowfoundation.org/chile. The question over how to address cavities rates at the population level in rural areas where water fluoridation is not practical is a good one. And in looking at the evidence on milk fluoridation programs as I considered this article, there is room for further consideration and study there. However; this particular study is not enough to base such a policy discussion/ decision. The US does not currently offer or consider milk fluoridation in rural areas.
Fluoride works both topically and systemically to reduce tooth decay and is delivered through water, salt, milk, toothpaste, varnish, rinse depending on age, country of origin, income etc. For children ages 0-8 it is incorporated into the enamel of the teeth growing under the gums. After that, the mechanism is largely "topical" - however, that includes fluoride ions incorporated into the saliva and plaque in the process of ingesting it. Sipping water throughout the day bathes the teeth in fluoride each time and allows there to be a very small but impactful amount of fluoride in the mouth environment. This assists in the remineralizations of teeth enamel after acid attacks. The "topical vs. systemic" debate is a bit of a red herring. Its asking how does it work, not if it works. The evidence is clear that fluoridation does work to prevent tooth decay.https://fluorideexposed.org/fluoridescience/fluoride-mechani... additionally, a recent economic review of fluoridation found that the benefits in terms of reduced cavity rates and related dental costs outweigh the cost of implementing the strategy. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6171335/
The effect of fluoride is in addition to the effect of toothpaste and other fluoride delivery modalities (25%). Even if that were not the case, prior to the adoption of other fluoridation modalities, fluoridation reduced cavities by as much as 65%. Additionally, for urban centers it costs less than a tube of toothpaste per person per year. Finally, it works without requiring a behavioral intervention - people naturally drink and eat. It is not considered one of the top ten public health interventions of the 20th century for nothing.
Here is the CDC take on the products used in fluoridation. https://www.cdc.gov/fluoridation/engineering/wfadditives.htm...
They are all subject to NSF Standard 60 requirements for purity. "Some have suggested that pharmaceutical grade fluoride additives should be used for water fluoridation. Pharmaceutical grading standards used in formulating prescription drugs are not appropriate for water fluoridation additives. If applied, those standards could actually exceed the amount of impurities allowed by AWWA and NSF/ANSI in drinking water."
The reference the author uses to support his claim in this case referred to a review he co-authored that looked at high concentrations of fluoride. Her is one funded by the National Toxicology Program both relevant to community water fluoridation concentration levels of fluoride (low): https://link.springer.com/article/10.1007/s12640-018-9870-x#... - which found, for male Long-Evans Hooded Rats at least, " Drinking water exposure at these low levels was not found to alter motor performance or learning and memory in the test paradigms assessed. Low-level F− did not alter thyroid hormone levels and produce neuronal damage or glia reactivity in the hippocampus, or histological damage in the heart, kidney, or liver. The low-level F− diet did not show a significant effect on the behavioral endpoints examined."
