The Pros and Cons of Fluoridation

The Fluoride Debate: The Pros and Cons of Fluoridation
Antoine Aoun, corresponding author Farah Darwiche, Sibelle Al Hayek, and Jacqueline Doumit.

Fluoride is the ionic form of fluorine, the thirteenth most abundant element in the earth’s crust. It is released into the environment naturally in both water and air. Its concentration in water is variable. Water is the major dietary source of fluoride. The variability in water content explains much of the variability in total fluoride intake. Other important sources of fluoride are tea, seafood that contains edible bones or shells, medicinal supplements, and fluoridated toothpastes.

Fluoride compounds are also produced by some industrial processes that use the mineral apatite, a mixture of calcium phosphate compounds. Dietary fluoride is absorbed rapidly in the stomach and small intestine.

Fluoride works to control early dental caries in several ways. Due to its anticariogenic and antimicrobial properties, the fluoride ion (F−) has been widely used in the treatment of dental caries. The antibacterial action of fluoride is due to the acidification of the bacterial cytoplasm through the formation of hydrogen ion (H+) and F− from hydrogen fluoride and the disruption of the bacterial metabolism by inhibiting vital bacterial enzymes such as proton releasing adenosine triphosphatase and enolase.

Moreover, the use of fluoride lowers the pH. Bacteria will thus use more energy to maintain a neutral pH. Therefore, they will have less energy left to grow, reproduce and generate acid and polysaccharides.

The mechanisms of fluoride oral action suggested by Ullah et al. include the following:

  • reduction in de-mineralization of sound enamel by inhibiting microbial growth and metabolism,
  • enhancement of the remineralization and the recovery of demineralized enamel, and the formation of the fluorapatite mineral phase that provides more resistance to demineralization and acid dissolution following acid production by bacteria,
  • inhibition of enzymes such as reduction of immunoglobulin A protease synthesis; reduction in extracellular polysaccharide production which helps in decreasing bacterial adherence to dental hard tissues.

As fluoride concentrates in dental plaque, it inhibits the process by which cariogenic bacteria metabolize carbohydrates to produce acid and adhesive polysaccharides.

Dental caries is an infectious and multifactorial disease afflicting most people in industrialized and developing countries. Fluoride reduces the incidence of dental caries and slows or reverses the progression of existing lesions. Although pit and fissure sealants, meticulous oral hygiene, and appropriate dietary practices contribute to caries prevention and control, the most effective and widely used approaches include fluoride use.

Dental treatments are expensive throughout the world. The cost of dentistry has hardly been reduced, even in countries where the decline in caries began 30 years ago. Thus, extension of preventive dentistry is still indispensable for improving oral health. The absence of dental care and poor hygiene are still considered the main causes of dental decay.

Although multifactorial in origin, caries is a preventable disease, with fluoride as a preventive agent used worldwide. Several modes of fluoride use have evolved, each with its own recommended concentration, frequency of use, and dosage schedule. Concurrently, recent opposition has been growing worldwide against fluoridation, emphasizing the potential and serious risk of toxicity. Since the fluoride benefit is mainly topical, perhaps it is better to deliver fluoride directly to the tooth instead of ingesting it. Fluoride toothpaste, rinses and varnish applications have proven their effectiveness in some countries, but they are still not universally affordable.

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