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In2015, AJPH published two articles on issues related to community water fluoridation (CWF). CWF consists in feeding a fl uoride compound into the water supply of a community up to a desired concentration, usually one milligram per liter, so that everyone who drinks tap water gets some fluoride. The idea appeared last century with the purpose of mass prevention of dental caries. Fluoride protects the teeth probably by interfering with the metabolism of bacteria causing caries. CWF is used by millions of people worldwide and in 1992 reached 144 millionpeopleintheUnited States.1 I have not found more recent statistics.
When millions of people are exposed to some preventive measure, the immediate reaction of the public health professional is to wonder if the benefit is worth the risk because even a small risk applied to so many people could have dramatic consequences.
Assessing the impact of a small risk requires epidemiological comparisons. And here is where the situation gets complicated. The consensus about the protective effect of fluoride on tooth carries and its lack of toxicity at optimal concentrations is such that fluoride has been very widely prescribed to children as pills and can be found in many toothpastes. Pure comparisons of people exposed to CWF over sufficiently long periods of time and at crucial ages with people not exposed to fluoride have become impossible.
The impossibility of observing clear-cut evidence in one direction or the other has created an ideal situation for intricate controversies. People who believe that fluoride is dangerous for children's health disseminate imaginary suspicions against CWF, and look for every weakness in epidemiological studies contradicting their views to denigrate the evidence. On the other side, the advocates for CWF, who rely on the extensive evidence of the beneficial effects and lack of harm of CWF, have been so scolded by the anti-CWF propaganda that they tend to see enemies in everyone who does not adhere entirely to their defense line. In the process, AJPH becomes the ring in which some of these fights take place. When AJPH publishes an article supporting CWF, letters pour in from the antifluoridation camp criticizing it. When AJPH publishes an article that does...