Effectiveness Of Water Fluoridation Research Articles

A scoping review of the links between early childhood caries and clean water and sanitation: the Sustainable Development Goal 6

IntroductionThe United Nation’s Sustainable Development Goal (SDG) 6 calls for universal access to clean water, sanitation and hygiene (WASH), which are crucial elements of health and well-being and fundamental for a life in dignity. Early childhood caries (ECC) is a preventable disease affecting health and quality of life of millions of young children worldwide. This scoping review aims to explore the connection between ECC and access to clean water and sanitation.MethodsThis scoping review, registered on the Open Science Framework and following PRISMA-ScR guidelines, conducted a thorough search in databases (PubMed, Web of Science, Embase, Google Scholar, SciELO) and websites (via Google) in November 2023. The search, without date limitations, targeted studies in English and Spanish linking ECC to SDG6. Exclusions were made for studies solely focusing on ECC without a direct connection to clean water and sanitation. Descriptive statistics summarized the retrieved papers.ResultsThe initial search yielded 303 articles. After removing duplicates, 264 articles remained for title and abstract screening after which 244 were excluded and one report was added through citation searching. The 21 remaining articles underwent full text review. There were no studies on a direct association between access to clean water and sanitation and the prevalence of ECC. There were nine studies that showed indirect associations between ECC and access to clean water and sanitation through the links of: water and sanitation access as a marker for poverty (n = 1), water consumption as a feeding practice (n = 4), and the effectiveness of water fluoridation (n = 4). These were used to develop a conceptual model.ConclusionsWhile it is conceivable that a direct link exists between ECC and access to clean water and sanitation, the available body of research only offers evidence of indirect associations. The exploration of potential pathways connecting water access to ECC warrants further investigation in future research.

Effects of water fluoridation on early embryonic development of zebrafish

Fluoride has strong electronegativity and exposes diversely in nature. Water fluoridation is the most pervasive form of occurrence, representing a significant threat to human health. In this study, we investigate the morphometric and physiological alterations triggered by fluoride stimulation during the embryogenesis of zebrafish and reveal its putative effects of stage- and/or dose-dependent. Fluoride exhibits potent biological activity and can be extensively absorbed by the yolk sac, exerting significant effects on the development of multiple organs. This is primarily manifested as restricted nutrient utilization and elevated levels of lipid peroxidation, further leading to the accumulation of superoxide in the yolk sac, liver, and intestines. Moreover, pericardial edema exerts pressure on the brain and eye development, resulting in spinal curvature and reduced body length. Besides, acute fluoride exposure with varying concentrations has led to diverse teratogenic outcomes. A low dose of water fluoridation tends to induce abnormal development of the embryonic yolk sac, while vascular malformation is widely observed in all fluoride-treated groups. The effect of fluoride exposure on blood circulation is universally present, even in zebrafish larvae that do not exhibit obvious deformities. Their swimming behavior is also affected by water fluoridation, resulting in reduced activity and delayed reactions. In conclusion, this study provides valuable insights into the monitoring of environmental quality related to water fluoridation and disease prevention.

Effectiveness of water fluoridation in an upper-middle-income country: A systematic review and meta-analysis.

To summarize the information on the effectiveness of community water fluoridation (CWF) on the reduction of dental caries in the context of the wide use of fluoridated toothpaste in Brazil. A systematic review was conducted regarding the effect of CWF based on studies with Brazilian population groups using the following electronic databases: MEDLINE/PubMed, LILACS, SciELO, and SCOPUS. The literature search was conducted up to August 2019. Studies that compared caries experience in at least two areas, one fluoridated and the other non-fluoridated, by mean dmft/DMFT (decayed, missing, and filled teeth) index or caries prevalence (caries vs. caries-free) were included. Considering the beginning of widespread use of fluoride dentifrice and the time for producing dental caries decline, studies published before 1995 were excluded. Descriptive analysis and meta-analyses were carried out. The effect size was measured by mean difference for dmft and DMFT±SD and odds ratios on a logarithmic scale for caries prevalence. Of the 574 studies retrieved, 16 and 10 were included in the qualitative and quantitative analysis, respectively. Fluoridated areas exhibited lower mean dmft/DMFT than non-fluoridated areas did. The mean difference in the dmft between non-fluoridated and fluoridated areas was -2.28 (95% CI -3.26; -1.30) for children aged 5-8years and -1.12 (95% CI -1.93; -0.32) for those aged 3-12years; the mean difference in the DMFT was -0.61 (95% CI -0.80; -0.42) for the children aged between 7 and 12years. The caries prevalence was 1.4 times and 57% lower, respectively, at primary and permanent dentition in fluoridated areas. Heterogeneity was observed in all age groups, ranging from 77.6% to 98.2%. Community water fluoridation remains effective in preventing dental caries in children younger than 13years, even with the widespread use of fluoridated toothpaste.

Fluoretação da água de abastecimento público: uma revisão da literatura

INTRODUÇÃO: Os efeitos do flúor na prevenção da cárie dentária foram descobertos ainda na primeira metade do século XX. Atualmente a fluoretação da água de abastecimento público é uma das principais medidas para o controle da cárie em nível populacional. OBJETIVO: Este estudo tem como objetivo apresentar uma revisão da literatura narrativa sobre a fluoretação da água de abastecimento público e seu papel no controle e prevenção da cárie dentária em populações. MATERIAIS E MÉTODO: Para a realização desta revisão da literatura, foram pesquisados artigos científicos, teses e dissertações publicados nas bases de dados Scielo, LILACS, BBO e MEDLINE entre 2000 a 2018, em idioma português e inglês sobre a fluoretação da água de abastecimento, com foco no uso desta tecnologia no Brasil. Utilizou-se a combinação de palavras-chave: fluoretação da água, saúde bucal, cárie dentária e seus correspondentes em inglês: fluoridation of water, oral health, dental caries. RESULTADOS: A revisão da literatura baseou-se no desenvolvimento de aspectos importantes desta medida de saúde pública, tendo como foco o contexto brasileiro. Assim, foram elencados aspectos históricos a ela relacionados, assim como aspectos legais, técnicos, operacionais e éticos. Também foram evidenciados os principais mecanismos de ação do flúor no controle da cárie, relacionado sobretudo com o equilíbrio do processo de desmineralização-remineralização, e a efetividade da fluoretação da água neste controle verificada em estudos recentes. CONSIDERAÇÕES FINAIS: A fluoretação da água de abastecimento público é uma tecnologia de saúde bucal coletiva simples, de baixo custo e com efetividade comprovada cientificamente.

What are the effects of water fluoridation on dental caries and dental fluorosis in children?

What are the effects of water fluoridation on dental caries and dental fluorosis in children?

Effectiveness of water fluoridation in the prevention of dental caries across adult age groups.

Lifetime access to fluoridated water (FW) is associated with lower caries experience. However, assessing this association in adults is likely affected by age. Cohort stratification and categorization of per cent lifetime access to fluoridated water (% LAFW) within cohorts are current approaches to this assessment. These approaches require an examination of the % LAFW and caries experience variation within and across age groups and their association to inform future analyses. This secondary analysis aimed to examine the age group variation in % LAFW and caries experience; and the association of % LAFW with caries within and across age groups of adults. A secondary analysis was undertaken using the Australian National Survey of Adult Oral Health 2004-2006 data on 4090 persons aged 15-91 years randomly sampled by a stratified, multistage probability method. Study participants underwent an interview, an oral examination by trained and standardized dentists to determine decayed, missing or filled tooth surfaces (DMFS) and a mailed self-complete questionnaire which collected residential history to calculate % LAFW. Variations in % LAFW and DMFS across age groups (15-34; 35-44; 45-54; 55+) were examined. Multivariable regression log-link models were generated for DMFS score within each age group. The age groups varied in values and distribution of % LAFW. Caries experience was strongly associated with age. % LAFW was significantly associated with DMFS score in the two younger age groups, but not in the others. Multivariable regression models showed that the highest % LAFW quartile had significantly lower DMFS count than the lowest quartile in the two younger age groups (mean ratios: 0.67 and 0.78, respectively), controlling for other covariates. Access to FW was associated with caries experience in Australian adults. The magnitude of associations varied between age groups, dependent on the natural history of caries and its measurement by DMFS.

The effect of water fluoridation on dental health in India

This paper examines how fluoridation can prevent the occurrence of dental cavities. There is an overall increase in caries which is becoming a major health issue all over the world. Awareness for dental health is quite low in several parts of India. Besides brushing and rinsing the mouth one is not much concerned for caring for one's teeth. Modern techniques of consuming bottled water and from types of filters used for purifying water removes most of the fluoride and is thus one aspect for leading to caries in most children and adults. Moreover usage of non-fluoride toothpaste in several regions of India is also a cause for concern. This epidemiological study attempts to identify why so many children as well as adults suffer from dental caries, which seems to have no cure. India is a diverse land and this study explores the possible reasons for deteriorating oral health which could also be due to heavy concentration of fluoride in some areas due to climatic variations and soil conditions. This study attempts to add to the body of research in the area of caries and ill health. In light of changing living conditions and dietary habits, the incidence of dental caries will increase in many low income countries, can this be controlled is what this study will highlight'

Effectiveness of water fluoridation in caries reduction in a remote Indigenous community in Far North Queensland.

Children in remote Indigenous communities in Australia have levels of dental caries much greater than the national average. One such, the Northern Peninsula Area of Far North Queensland (NPA), had an oral health survey conducted in 2004, shortly before the introduction of fluoridated, reticular water. Children were again surveyed in 2012, following five years exposure. An oral examination was conducted on all consenting children enrolled in schools across the community, using WHO Basic Oral Health Survey methodology. Few teeth had restorations in both surveys. Age-weighted overall caries prevalence and severity declined from 2005 to 2012 by 37.3%. The effect was most marked in younger children, dmft decreasing by approximately 50% for ages 4-9 years; at age 6, mean decayed score decreased from 5.20 to 3.43. DMFT levels also decreased by almost half in 6-9 year olds. However, significant unmet treatment needs exist at all ages. There has been considerable improvement in child dental health in the NPA over the past 6-7 years. In light of continued poor diet and oral hygiene, water fluoridation is the most likely explanation. The cost-effectiveness for this small community remains an issue which, in the current climate of political antagonism to water fluoridation in many quarters, requires continued study.

Slaying sacred cows: is it time to pull the plug on water fluoridation?

Water fluoridation continues to be a contentious public health policy. Recent moves to introduce schemes in England raise important questions about the use of evidence in public policy. Of particular concern is how evidence is used for public health policy-making purposes. This article reviews some of the key debates about water fluoridation and examines the way evidence has been promoted and used. The background to water fluoridation is discussed and also key ideas about how evidence influences policy. While traditionally the problem of evidence is characterised as one where policy makers either accept or ignore evidence, a central concern of this article is where poor evidence is promoted by professionals and accepted by policy makers. The article then examines the evidence on the effects of water fluoridation. Drawing on the idea of the ‘Gold Effect’, the article shows how deeply held beliefs about public health actions shape not just policy but also the application of evidence itself by professionals and researchers.

A retrospective view on the viability of water fluoridation in South Africa to prevent dental caries

Despite a Commission of Inquiry into water fluoridation recommending the fluoridation of public water supplies to the optimal fluoride concentration of 0.7 ppm, as well as regulations for the introduction of water fluoridation which compel water providers to fluoridate public water supplies, no artificially fluoridated water scheme exists in South Africa. In view of concerns expressed by South African local authorities about cost and reports urging further investigation into the effectiveness of water fluoridation, the aim of this study was to determine whether water fluoridation is still a viable option to reduce dental caries in South Africa. A model based on a cost evaluation of 44 communities in Florida, United States, and applied to South Africa was used as the basis for this study. Twenty-three input variables were used to create a computerized model which was populated with 2006 and 2011 data. Per capita cost, cost-effectiveness ratio and cost-benefit ratio were calculated as economic outputs to facilitate decision making for projected caries reductions of 15%, 30% and 50%. The average per capita cost of water fluoridation for all category water providers combined is US$0.28 in 2006 and US$0.35 in 2011, an increase of 23.2% over this period. The average cost-effectiveness for all water providers combined varies from US$3.32 for a 50% to US$11.08 for a 15% caries reduction. Despite higher cost-effective values for some cities and towns, the cost per person per year to save one Decayed, Missing or Filled Tooth (DMFT) at a projected caries reduction of at least 15% as a result of the introduction of water fluoridation, is at least 48.4% less than the cost of a two surface restoration. The average cost-benefit for all water providers combined varies from 0.1 at a 50% to 0.34 at a 15% caries reduction. For both cost-effectiveness and cost-benefit ratio better results are achieved when the projected caries reduction increases. The results of this study show that water fluoridation is still a viable option to prevent dental caries in communities in South Africa along with the reduction in the prevalence of dental caries and increases in economically driven variables.

Lifetime fluoridation exposure and dental caries experience in a military population

While there is good evidence of caries-preventive benefits of fluoride in drinking water among children and adolescents, there is little information about effectiveness of water fluoridation among adults. To determine whether exposure to fluoride in drinking water is associated with caries experience in Australian Defence Force (ADF) personnel. Cross-sectional study of 876 deployable ADF personnel aged 17-56 years. At each person's mandatory annual dental examination, military dentists recorded the number of decayed, missing and filled teeth (DMFT) using visual, tactile and radiographic criteria. Participants also completed a questionnaire, listing residential locations in each year from 1964 to 2003. People were classified into four categories according to the percentage of their lifetime living in places with fluoridated water: <10%, 10% to <50%, 50% to <90% and > or =90%. Mean DMFT was compared among those categories of fluoridation exposure and the association was evaluated statistically using analysis of variance to adjust for age, sex, years of service and rank. Without adjustment for confounders, the mean DMFT (+/-95% confidence interval) was 6.3 +/- 0.8 for <10% fluoridation exposure, 7.8 +/- 0.8 for 10% to <50% exposure, 7.5 +/- 0.7 for 50% to <90% exposure and 4.6 +/- 0.6 for > or =90% exposure (P < 0.01). However, age was inversely associated with mean DMFT and in the <10% exposure group, 91% of people were aged <35 years. Service rank was also significantly associated with both fluoridation exposure and DMFT. After adjustment for all covariates, mean DMFT was 24% lower among people in the two groups with > or =50% exposure compared with the <10% exposure group. Degree of lifetime exposure to fluoridated drinking water was inversely associated with DMFT in a dose-response manner among this adult military population.

수돗물불소농도조정사업이 지역주민의 골밀도에 미치는 영향

Adjusted water fluoridation has been disputed because of its various effects on human health. Previous studies have been concerned with the difference in bone mineral density (BMD) between water fluoridated (WF) and none water fluoridated (NWF) districts. The aim of this study is to examine whether water fluoridation affects BMD. BMD was measured by dual energy X-ray absorptiometry (DXA). 386 adults(174 males and 212 females) in Ansan (WF) district and 399 adults (176 males and 223 females) in Sihwa (NWF) district, participated in this study. The Ansan and Sihwa districts are similar in residential environment and living class. The relationship between serum fluoride concentration and BMD was also examined by analysis of the serum fluoride concentrations from 402 inhabitants of the Ansan district. In females, the BMD of subjects living in Ansan (<TEX>$0.457{\pm}0.008$</TEX>) was a little higher than that of Sihwa subjects (<TEX>$0.446{\pm}0.008$</TEX>), although it is not significant, after adjusting for BMI, physical activity level, educational achievement, smoking volume, menopause status, and number of births. However, the BMD of Ansan subjects (<TEX>$0.532{\pm}0.020$</TEX>) in their forties was statistically higher than that of Sihwa (0.498{\pm}0.019). No relationship was found in males. In residential periods, there was significant difference (Ansan <TEX>$0.467{\pm}0.013$</TEX>, Sihwa <TEX>$0.434{\pm}0.012$</TEX>, p=0.0125) in the BMD between females of two districts, particularly in the group of over 6 year long-term inhabitants. On the contrary, there was no remarkable difference in males from the two districts. Serum fluoride concentrations in females were associated with BMD, especially in the age group of forties (p=0.0457). No relationship was observed in the male group. Analysis of adult BMD over the age of 20 in a water fluoridated and a none water fluoridated district, confirms more or less a higher BMD in the water fluoridated (WF) district, especially for females. It is assumed that the difference between two districts came somewhat from the effect of water fluoridation.

Systemic Benefits of Fluoride and Fluoridation

AbstractClinical trials, animal studies, and in vitro tests demonstrate effectiveness of exposure to topical (posteruptive) fluoride in caries prevention and reduction of enamel dissolution. However, careful analyses of human epidemiologic data on caries increments, following communal water fluoridation, show unquestionably that fluoride has an important preemptive effect on caries in permanent teeth, particularly on pit and fissure surfaces. These preemptive or systemic benefits also apply to the use of fluoride supplements or fluoridated salt when used continuously during the period of tooth formation. The role of systemic fluoride in caries prevention is neither “minimal” nor “of borderline significance.” On the contrary, it is a major factor in preventing pit and fissure caries, the most common site of tooth decay. Maximal caries‐preventive effects of water fluoridation are achieved by exposure to optimal fluoride levels both pre‐ and posteruptively.

Proximal caries in juvenile periodontitis patients.

Caries is recognized as the prevalent proximal dental disease in adolescents, while proximal bone loss is minimal to non-existent in this population. Adolescents demonstrating an inverse disease pattern, i.e., minimal caries and active periodontitis, could provide powerful clues with regard to both diseases. However, data are inconsistent. This study was designed to clarify this relationship by comparing proximal caries prevalence in a juvenile periodontitis (JP) group to a matched non-periodontally diseased control group. Two groups (cases [JPs] and control patients [CPs]) were matched for age, sex, and race and evaluated for decayed, missing, filled teeth and surfaces (DMFS) by radiographic analysis. Statistical analysis was performed by ANOVA and Student t test. The study consisted of four phases. Phase I was based on data from a previous study that failed to include race in the analysis. Thus, the original 23 JP patients (mostly African-Americans from New York City) were rematched for race as well as sex and age with CPs from Newark, NJ. The effect of water fluoridation (found in NYC) was evaluated in Phase II by matching the 23 original CPs (mostly Caucasian from NYC) with 23 CPs from NJ. Since differences were seen, we rematched our original JPs from NYC with a new set of race-matched CPs from NYC (Phase III). Finally, 13 JP patients from the University of Medicine and Dentistry of New Jersey (UMDNJ) were matched with CPs from NJ (Phase IV). Phase I and III indicated that JP patients had significantly less proximal caries than their matched CPs (P < or =0.05). Phase II confirmed the role of fluoride in caries reduction. Phase IV (NJ sample) supported our previous data and suggested that JP patients had less proximal caries than CPs (P < or =0.05). JP patients had significantly less proximal caries than their matched CPs when groups were balanced and radiographic evaluations were performed. In-depth studies of JP patients could provide important clues about both caries and periodontal disease etiology and pathogenesis.

The effect of water fluoridation and social deprivation on tooth decay

We examined the effect of both artificial and natural water fluoridation on tooth decay in 5-year-olds, after controlling for deprivation by the use of the Jarman Under Privileged Area score.Five-year-old children (n= 10,004) in electoral wards in three areas—naturally fluoridated Hartlepool, fluoridated Newcastle & North Tyneside and non-fluoridated Salford & Trafford—were dentally examined and statistically significant, positive correlations were demonstrated regardless of the level of water fluoridation between deprivation and tooth decay. Weighted multiple linear regression showed a statistically significant interaction between ward Jarman score, mean tooth decay and both types of water fluoridation, confirming that in more deprived areas there is a statistically greater reduction in tooth decay.At a Jarman score of zero (the English average) there was a predicted 44% reduction in decay in 5-year-olds in fluoridated areas, increasing to a 54% reduction in wards with a Jarman score of 40. In an area with natural fluoridation at a level of 1.2ppm the reduction was 66%, increasing to 74% in electoral wards with a Jarman score of 40.Tooth decay is associated with social deprivation and water fluoridation is more efficacious in deprived areas at an electoral ward level. The findings confirm that the implementation of water fluoridation, especially in areas of social deprivation, has been effective in halving tooth decay in 5-year-old children.

Fluoride supplements for young children: an analysis of the literature focusing on benefits and risks.

The use of fluoride supplements to prevent caries has been advised for more than 100 years, but serious promotion of this strategy occurred only after the effectiveness of water fluoridation was established, in the late 1950s and 1960s. Although the effectiveness of fluoride supplements was apparently endorsed by many small clinical studies, closer examination of the experimental conditions of these, their methods and the analysis of their results undermined confidence in their findings. It is likely that confounding resulted in spurious conclusions in many of them. More modern, well-conducted clinical trials of supplements suggest that today, in children also exposed to fluoride from other sources such as toothpaste, the marginal effect of fluoride supplements is very small. There is evidence that fluoride lozenges, designed to maximise any local effect, may have a small caries preventive effect, particularly in deciduous teeth. Overall, poor compliance makes fluoride supplements a poor public health measure. Supplement use by young children is associated with a substantial risk of dental fluorosis. Fluorosis is an issue about which the public is becoming concerned in several countries and this concern, if translated into opposition to all fluoride use, could jeopardise the most successful caries preventive aid we have. The potential for dental fluorosis, concern about the public's reaction to this, the poor effectiveness of supplements and the public's poor compliance with their use are persuasive arguments for a radical reduction in the use of supplements by young children. Recent changes in fluoride dosage schedules and deferment of the age of commencing the use of supplements, implemented in many countries, have followed from these concerns. Supplements formulated as lozenges maximise topical exposure of enamel to fluoride and such products may offer older children and some adults a way of maintaining an elevated fluoride level in saliva at times when toothbrushing is not practical.

The Effect of Water Fluoridation on the Bone Mineral Density of Young Women

Osteogenic effects of therapeutic fluoride have been reported; however, the impact of exposure to low level water fluoridation on bone density is not clear. We investigated the effect of long-term exposure to fluoridated water from growth to young adulthood on bone mineral density (BMD). BMD was measured in 24 healthy women from Regina (fluoride 0.1 mg/L) and 33 from Saskatoon (fluoride 1.0 mg/L), with no differences between groups for height, weight, lifestyle or dietary factors. Saskatoon women had significantly higher mean BMD at total anterior-posterior lumbar spine (APS) and estimated volumetric 1.3 (VLS), with no difference at total body (TB) or proximal femur (PF). Exposure to water fluoridation during the growing years may have a positive impact on axial spine bone density in young women.

Effect of water fluoridation on the bone mineral density of young women (The)

Effect of water fluoridation on the bone mineral density of young women (The)

Fluoride reduces bone strength in older rats.

In response to recent concerns about the effect of water fluoridation on hip fracture rates, we studied the influence of fluoride intake on bone strength. Four groups of rats were fed a low-fluoride diet ad libitum and received 0, 5, 15, or 50 ppm of fluoride in their drinking water. Animals were euthanized after 3, 6, 12, or 18 months of treatment. Mechanical strength of the right femur was measured by three-point bending. Fluoride content for the left femur was measured, and static histomorphometric measurements were made on a lumbar vertebra. Femoral failure load was not significantly decreased in rats treated for 3 and 6 months, but was decreased as much as 23% in rats treated 12 and 18 months at 50 ppm fluoride. Extrapolation from regression equations predicted that older rats lose 36% of femoral bone strength when bone fluoride content is increased from 0 to 10,000 ppm, while younger rats will lose only 15%. Thus, the decreased strength appeared to be due to the combined effects of fluoride intake and age on bone tissue and was not associated with a decrease in bone density or mineralization defects. There were only small effects of fluoride on bone histomorphometry. Fluoride intake at high levels had no negative effects on bone mineralization. Fluoride intake was associated with slight increases in trabecular bone volume and trabecular thickness, but these effects could not be demonstrated consistently. The mechanism by which large amounts of fluoride affect bone strength more severely in older animals is unknown.

Water fluoridation: current effectiveness and dental fluorosis

This paper reviewed the literature on the evidence for water fluoridation's effectiveness under current conditions of multiple fluoride use at recommended and at reduced concentrations, the extent of dental fluorosis at different fluoride concentrations, and the "halo" effect of water fluoridation. Using the relative difference in dental caries between communities with low and optimal water fluoride as an indicator, the effectiveness of water fluoridation has decreased over time as the use of other fluorides has increased. Thus the effectiveness of water fluoridation alone cannot now be determined. Compared to the early fluoridation studies, the differences in dental caries and fluorosis prevalence between fluoridated and non-fluoridated areas have markedly narrowed. Both the prevalence and severity of dental fluorosis have increased since 1945; however, the portion of fluorosis due to water fluoridation is now less (40%) than that attributed to other fluoride sources (60%). Research also suggests that the "halo" effect of community water fluoridation may result in a significantly greater intake of fluoride for people in non-fluoridated communities. This review recognized that since water fluoridation has unique advantages from the perspectives of distribution, equity, compliance and cost-effectiveness over other fluoride technologies, it remains as the fundamental base for caries prevention. The increasingly greater contribution that other sources of fluoride make to dental fluorosis suggests that these sources of fluoride, many of which are used on an elective basis, should be more closely examined for needed changes.