EP50: Everything You Need to Know About Fluoride

Can fluoride lower your IQ?

Will fluoride cause Alzheimer’s Disease or interfere with my thyroid?

In this episode of the Double Your Production Podcast, Wendy Briggs, RDH is answering all these burning questions. She’s even going a step further and sharing tips for explaining the efficacy and need for fluoride to patients. With her tips, you won’t ever be caught off guard by another question about this preventive procedure.

Listen now:

[music] Welcome to the Double Your Production podcast with the Team Training Institute. The one place designed for dentists and their staff who want to grow their practices by following in the footsteps of those that have done it, who are in the trenches, who know exactly what you're going through. And now your leaders, the stars of the podcast, Dr. John Meis and Wendy Briggs.

Hello, everybody. It's Wendy Briggs here with a Double Your Production podcast on a relatively interesting topic. Today, I'm going to be answering frequently asked questions or objections that we've been hearing from patients about fluoride treatment. There's a lot of buzz in the media about fluoride, and I know this isn't necessarily about growing your practice, but in a roundabout sort of way, it is, right? In the Ultimate Guide book, Dr. John and I wrote about optimizing hygiene, and fluoride is one of those services on our preventives menu that many patients desperately need. I think fluoride gets a bad rap in the media, and you hear a lot of sensationalized stories about why fluoride is not a good thing for patients. What we want to be able to do is counter those negative stories in the media with true scientific studies. So that's what I'm going to be talking about on today's podcast, and again, having your hygiene team listen to this would be helpful for them as they're the ones usually in the trenches, on the front lines, handling patient objections when it comes to this valuable service. So I'm going to answer some of those questions here as we go on the podcast today.

The first article that's gotten a lot of buzz here in recent weeks was a publication that was somewhat, in my opinion, a questionable study but one that was published. It got a lot of press. Washington Post. All over the news. Can maternal fluoride consumption during pregnancy lower children's IQ? And what the study suggested is that fluoride consumed by pregnant women can decrease the IQ of children, especially males. So let's talk about that. Obviously, decay in children is the number one child disease. It's a worldwide global problem. It's been considered a pandemic by the World Health Organization. And if we have all of our patients start declining fluoride, especially pregnant women who desperately need this valuable service, because of misinformation, we're going to take a huge step backwards as a profession, as an industry, rather than taking a step forward and really helping solve this issue. And of course, it's not just children that struggle with decay. It's a big problem for many adults as well as in our society we have a lot of high risk factors that are just part of our everyday lives.So let's talk about this study. It's really kind of an interesting thing. So when we look at this study and what the claims were, it was a study done of more than 500 Canadian women and their babies, and it focused really on six cities in Toronto where they add fluoride to the drinking water, and the other half were cities where they do not add fluoride to the drinking water. So there was about 500 women as a part of this study. And the scientists assessed fluoride exposure two ways. They measured fluoride in women's urine samples during pregnancy, and then they also calculated fluoride consumption based on how much is in a city's water supply and how much women recalled drinking. So the team reported in the Journal of the American Medical Association Pediatrics that it appears that higher level of fluoride can lead to lower IQs in the children, but only boys were affected when they looked at the urinary fluorides, okay? So the difference was typically a couple of IQ points, but the study, although it was funded by the Canadian government and the US National Institute of Environmental Health Science, had some pretty serious flaws. So let's kind of talk about what those flaws are. One of the biggest challenges that I saw with the study is that although they measured the urine levels in 512 pregnant women, they didn't actually look at the fluoride intake of the children. They only looked at the fluoride intake of the women, okay? So when we look at the results, we know that there's thousands of articles pointing to the safety and efficacy of water fluoridation. So how are we going to respond to this as a community? There was no significant impact for the girls.

So I've recently read a comprehensive study by the Centers for Disease Control on the recommendations for using fluoride to prevent and control dental caries in the United States, and this paper was put together-- a report with an incredible amount of experts and scientists in the field. And they put together a fluoride recommendations work group, and then they, again, had it reviewed by 23 specialists. So they looked at all of the studies regarding fluoride water but also utilizing fluoride in the office. And of course, they talk about some of the things that we've already mentioned, the threat of decay to public health, and what they put together in this report was the comprehensive recommendations on the use of fluoride to prevent and control dental caries in the United States. And again, these recommendations were developed by a work group of 11 specialists in fluoride research that were convened by the Centers for Disease Control and reviewed by an additional 23 specialists. So although the recommendations were developed specifically for the United States, aspects of this report certainly are relevant for other countries.

So I want to share with you some of the highlights on this that kind of help patients understand why fluoride is so important for them. We know that fluoride works to control early decay in several ways, right? Fluoride that's concentrated in plaque and saliva inhibits demineralization of enamel and enhances the remineralization of enamel that's already been demineralized. Obviously, it's important as well because as the cariogenic bacteria metabolize carbohydrates and produce acid, fluoride is released from dental plaque in response to low pH at the tooth-plaque interface, okay? So the released fluoride and the fluoride present in saliva are then taken up along with calcium and phosphate by that demineralized enamel, and it establishes an improved enamel crystal structure. So again, fluoride helps to inhibit caries by remineralizing the enamel but also by affecting the activity of the cariogenic bacteria. And of course, we know saliva can be a major carrier of topical fluoride, so that's an important thing. And applying fluoride gel or a varnish containing a high concentration of fluoride leaves a temporary layer of calcium-fluoride-like material on the surface, and the fluoride in this material is released when the pH drops, right? So we talk a lot about pH and the impact that pH can have on chronic disease and chronic infection.

So we all know the benefits, right? So I want to share with you just some responses to maybe common questions that you're getting about adults and should adults really have fluoride and when is fluoride beneficial in the office. Isn't it just for kids? Right? We got that question a few short weeks ago. So it's important that we have a way to answer these questions and combat these objections. Let's look to the experts on this, Dr. [Braun?] and Aparna Bole, who both are professors of pediatrics at Case Western Reserve University School of Medicine, and one serves as the chair of the AAP Council on Environmental Health executive committee. They said the results of the study are difficult to interpret given that the IQ difference was small, and then one group appeared only in boys, right? We mentioned that before. In a group where an association was seen for boys and girls, the fluoride intake was self-reported, which is less reliable.

So again, as I mentioned before, the study did not look at children's fluoride intake, only that of the pregnant women. So the academy still continues to recommend children use age-appropriate amounts of fluoride toothpaste, drink fluoridated water, and of course, have fluoride applied when they come and see us in the dental practice. And the reason for that, as I mentioned, is that the burden of caries is enormous in our patients. It's a big burden in pregnant women, and there's so much overwhelming evidence about the efficacy of fluoridation in reducing that burden of caries, right? So the ADA also agreed. Their statement's saying that they remain committed to fluoridation of public water supplies as the single most effective public health measure to help prevent tooth decay. The ADA said they obviously welcome the new study. Scientific inquiry is always welcome. But they want to make sure and see if the findings can be replicated with methods that demonstrate more conclusive evidence and of course, don't include self-reported usage, right? That's very difficult to measure and monitor and control.

So the American College of OBs, Obstetricians and Gynecologists, still also stresses the importance of good health during pregnancy and continues to recommend that women use fluoridated toothpaste and will consider any new evidence next time it reviews its guidelines, okay? So in the meantime, parents that are still concerned about the IQ of their children might want to consider that decay and dental disease cause children across the country to miss more than 50 million hours of school every year. And I would suggest that that probably has a bigger impact on their IQ than a nonscientific report that's fairly limited in scope and size on the impact of fluoride on an IQ. Very, very difficult, especially because there's so much range in IQ variations to begin with.

Okay. So that was the first question, the first study that we wanted to answer about fluoride. Another question that I've gotten from members is that they're having patients decline fluoride because they're afraid it's been linked to Alzheimer's disease. And as I looked at that and was trying to find some scientific evidence to back that up, what I found was actually to the contrary. I found a research publication published in 1992 in the Journal of Public Health that talks about aluminum fluoride [and?] the prevention of Alzheimer's disease. It says that the evidence regarding the link between aluminum and Alzheimer's disease was summarized in this report, and the evidence strongly suggests that aluminum is one of the contributing factors in the occurrence of Alzheimer's disease.

However, the study suggested that relatively high fluoride in drinking water plays a preventive role in Alzheimer's disease. So the rationale for the evidence is that aluminum and fluoride compete for absorption in the gut, and there was really no firm conclusion that could be drawn from this, and further investigation of fluoride in drinking water as a preventive measure for Alzheimer's disease should receive high priority. That was the findings of this study. So again, I think people are conflating the issue. Aluminum has been found to be harmful, but fluoride actually shows a preventive mechanism to help prevent Alzheimer's disease. So that's important for us to know as we're talking with patients that may have read someone's opinion or not a very scientific report on fluoride and Alzheimer's disease links.

Another question we commonly get is what about the fluoride exposure and the impact on the thyroid? There is a lot of speculation out there that the two may be linked. And here I found this study published in 2017 about fluoride exposure and indicators of thyroid functioning and implications for community water fluoridation. And the background states that there's concerns that altered thyroid functioning could be the result of ingesting too much fluoride. So they used highly scientific methods, and they found that there was no evidence of a relationship between fluoride exposure from both urine and tap water that was tested and the diagnosis of a thyroid condition. No statistically significant association between fluoride exposure and abnormal or low thyroid levels either. So basically, the conclusion suggests that at the population level, fluoride exposure is not associated with impaired thyroid functioning, even in a time and place where multiple sources of fluoride exposure occurred.

So again, as we're talking with patients and we're combating all of this research about fluoride and when it's effective and when it should be used, I think it's important for us to keep in mind that there's a lot of information out on the internet, but not all of it is true, right? And I would encourage you to look for scientific research, actual studies that use good scientific methods and are broad in spectrum that can illustrate that point. So again, if you have patients that are opposed to fluoride because of these concerns, I think the best defense really is to arm them with truly scientific studies that show the efficacy and the safety of ingesting fluoride in the water, but also we need to compare and draw the contrast between water fluoridation and topically applied fluoride.

So now let's spend just a few minutes going over the latest compelling research regarding fluoride and when it's recommended in the office. And whether it's for children and adults, if you've listened to our podcast very long or if you know much about our program and what we teach, we totally recommend fluoride on all patients, especially high-risk patients, be applied in the chair every time patients have their teeth polished. And for some practices, they've been around a while. You may have patients say, "Well, gosh. I thought fluoride was just for kids." And in the next part of this conversation, I want to equip you with the latest compelling research about fluoride so that you can have high-level conversations with these patients and help them understand why we feel so strongly that they deserve the opportunity to choose fluoride.

Another interesting finding in this CDC report is that fluoride toothpaste reduces caries experienced among children by a median of 15 to 30 percent. So that result is fairly modest compared with fluoride application in the office. So one of the things that they say is regular lifetime use of fluoride toothpaste likely provides ongoing benefits that might approach those of fluoridated water. So they're even saying, "We've got to make sure." New studies were evaluated that looked at the effectiveness of toothpaste, gel rinse, and varnish among adult populations as well. So child populations typically have been used for studies on caries prevention because of perceived increased [to?] caries susceptibility. However, teeth do remain susceptible to decay throughout life, and we know that, right, especially our high-risk adult patients. So this report looked specifically at topically applied fluorides with adults in addition. So studies were conducted all over the place. They have some that they reference from Canada, some from Europe, and these studies report that fluoride varnish is efficacious in preventing decay in children.

Some researchers advocate application of fluoride varnish as many as four times a year to achieve maximum effect. And this is what we often say, right? On high-risk individuals, children and adults alike, we want application as many as four times a year because of the higher benefits. Other studies show that three applications amongst several weeks once per year is also very effective. So this is what we teach when we talk about a fluoride intervention, right? When we see white spot lesions or children-- a good example here are kids that have just gotten braces off and they've got demineralization throughout their mouth. And we talk about a fluoride intervention where we place the fluoride and then they come back. Maybe two weeks from now we place another one. Two weeks from now we place another one. Those studies have shown much more effectiveness in regards to preventing decalcification and minimizing already existing decalcification and demineralization. So European studies also reported that fluoride varnish prevents decalcification beneath ortho bands - I just mentioned the kid that just got the braces off - and slows the progression of existing enamel lesions. So varnish is becoming a really valuable tool for us in this battle.

So let's continue on and look at some more research. Interestingly enough, people often say, "What about prescription-strength toothpastes?" Well, toothpastes that contain 4,000 to 20,000 parts per million of fluoride certainly are helpful in restoring the concentration of fluoride in the surface layer of enamel that can be removed by polishing, but this report specifically states it is not an adequate substitute for a fluoride gel or varnish when treating patients at high risk for decay. So fluoride paste is not accepted by the FDA or ADA as an efficacious way to prevent caries. That's important for us to note too, okay? So a variety of studies saying that various combinations of these fluoride modalities have generally reported their effectiveness in preventing dental caries as partially additive. So what it means is if we combine modalities, patients receive a higher benefit, and we suggest that as well, right? We talk about having a high-risk bundle or a fluoride bundle of some sort where they are given the opportunity to do a varnish but then also their take-home products are less expensive for them. So again, when we make these decisions, we've got to consider patient's risk. So as healthcare providers, we need to differentiate patients that are high risk and provide more intensive interventions as needed. More intensive interventions as these patients need.

The report also states that a risk category can change over time, right? So the type and frequency of preventive interventions can be adjusted accordingly as that risk category does change. So this is why we're so focused on providing risk assessments as we go. Now, it was thought in early years that fluoride really didn't provide much benefit after teeth had erupted, right? But those studies have in recent years been proven to have some serious flaws, so we need to continue our knowledge and our research. Things don't become static, right? So we want to make sure that we are always staying ahead of the latest research. So when we look at the latest information that we have, we know that in the CDC report it states that when used appropriately, fluoride is a safe and effective agent that can be used to prevent and control caries, and fluoride is needed regularly throughout life to protect teeth against tooth decay. So not just fluoride varnish in the office. But again, this report summarized an overwhelming amount of data that shows a combination of modalities actually provides our patients with the highest benefit. So the summary of this report basically said, "Adoption of these and other recommendations in this report could lead to considerable savings in public and private resources without compromising fluoride's substantial benefit on improved dental health."

So again, for those of you that have questions from patients, is this something I should really invest in? The use of fluoride varnish combined with at-home parts per million combined with other resources, mouth rinses, xylitol products, all of these provide a cumulative impact on the patient's reduction of caries. So again, I think we can say with confidence that what we teach in regards to risk assessment and then coming up with incredible solutions, fluoride in the office, fluoride at home, maybe xylitol three to five times a day-- by combining some of these solutions, we really are doing the right thing for the patients, and isn't that what it's all about? We strive to do the right thing for the right reasons every time when we're taking care of patients, and this is what we're all about. We also say production isn't the goal. Production is the result that comes when we do the right thing.

It's interesting when we look at practices who literally have doubled their production. We call this the Double Your Production podcast, but we've had quite a few of our recent members in a few short months literally double their previous production in hygiene. And what's exciting about this, again, is that they're doing it by taking better care of their patient. And that's why I thought it was important to record this quick podcast for you today so that you could be armed with the most current science and research about why fluoride is such a beneficial strategy and is needed in dental practices of today. Our patients desperately need fluoride. So if you have some patients that have objections, that need more information, I wanted to equip you with information that you can share with them. And certainly, we also teach a structure where we have an all-natural fluoride alternative for those who are holistically minded who just don't want to move forward with the fluoride.

And what we typically do here is we will go ahead and use an MI paste in the chair. That's what we polish their teeth with. And then our go-to product that we recommend at this point is a mouth rinse called Essential Smiles. Now, full disclosure statement; I was involved in helping create this product. We're super proud of it though. It has a therapeutic dose of xylitol in it. It neutralizes the pH in the oral environment. And for patients who are opposed to fluoride on principle, I find this is the best way to meet them in the middle, if you will. The xylitol helps reduce the caries, and they love the essential oils and the all-natural formula that's involved in Essential Smiles. So that is our go-to strategy for all-natural fluoride alternative. We polish with MI paste, and then we crack open a bottle of Essential Smiles, have them rinse chairside, and they take the bottle home.

So again, when you're dealing with patients that have questions about fluoride, hopefully, this podcast will have helped you learn what to say and how to say it and how to overcome some of those objections so that our high-risk patients really are able to get the care they desperately need. So I hope you found this podcast helpful, and this is Wendy Briggs. Thanks for listening.

Thanks for tuning in tonight to our Double Your Production podcast. I wanted to let you know that at our website, that www.theteamtraininginstitute.com/podcast, we do have references to the CDC article that Wendy mentioned in our episode tonight. So head that direction if you want access to that science as well as the transcripts and to get more info on the Team Training Institute. Again, thanks so much for listening in, and we'll see you next week. [music]

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