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Dental caries remain a public health problem for many developing countries and for underprivileged populations in developed countries. This paper outlines the historical development of public health approaches to the use of fluoride and comments on their effectiveness. Early research and development was concerned with waterborne fluorides, both naturally occurring and added, and their effects on the prevalence and incidence of dental caries and dental fluorosis. In the latter half of the 20th century, the focus of research was on fluoride toothpastes and mouth rinses. More recently, systematic reviews summarizing these extensive databases have indicated that water fluoridation and fluoride toothpastes both substantially reduce the prevalence and incidence of dental caries. We present four case studies that illustrate the use of fluoride in modern public health practice, focusing on: recent water fluoridation schemes in California, USA; salt fluoridation in Jamaica; milk fluoridation in Chile; and the development of “affordable” fluoride toothpastes in Indonesia. Common themes are the concern to reduce demands for compliance with fluoride regimes that rely upon action by individuals and their families, and the issue of cost. We recommend that a community should use no more than one systemic fluoride (i.e. water or salt or milk fluoridation) combined with the use of fluoride toothpastes, and that the prevalence of dental fluorosis should be monitored in order to detect increases in or higher-than-acceptable levels.

The prevalence of dental fluorosis in the United States has increased during the last 30 years. In this study, we used a mathematical model commonly employed by the U.S. Environmental Protection Agency to estimate average daily intake of fluoride via all applicable exposure pathways contributing to fluorosis risk for infants and children living in hypothetical fluoridated and nonfluoridated communities. We also estimated hazard quotients for each exposure pathway and hazard indices for exposure conditions representative of central tendency exposure (CTE) and reasonable maximum exposure (RME) conditions. The exposure pathways considered were uptake of fluoride via fluoridated drinking water, beverages, cow’s milk, foods, and fluoride supplements for both age groups. Additionally, consumption of infant formula for infants and inadvertent swallowing of toothpaste while brushing and incidental ingestion of soil for children were also considered. The cumulative daily fluoride intake in fluoridated areas was estimated as 0.20 and 0.11 mg/kg-day for RME and CTE scenarios, respectively, for infants. On the other hand, the RME and CTE estimates for children were 0.23 and 0.06 mg/kg-day, respectively. In areas where municipal water is not fluoridated, our RME and CTE estimates for cumulative daily average intake were, respectively, 0.11 and 0.08 mg/kg-day for infants and 0.21 and 0.06 mg/kg-day for children. Our theoretical estimates are in good agreement with measurement-based estimates reported in the literature. Although CTE estimates were within the optimum range for dental caries prevention, the RME estimates were above the upper tolerable intake limit. This suggests that some children may be at risk for fluorosis.

The Nutrient Data Laboratory (NDL), Agriculture Research Service, USDA, coordinated the development of the USDA National Fluoride Database of Selected Beverages and Foods subsequently described as the National Fluoride Database–a critical element of the comprehensive multi-center National Fluoride Database and Intake Study
(NFDIAS).  This second release of the USDA National Fluoride Database includes a column with mean values reported in parts per million, some data changes, and some new data resulting from aggregations of the Jackson (Jackson et. al., 2002) data and new data from University of Minnesota(UMN), Nutrition Coordinating Center and University of Iowa (UIowa), College of Dentistry data (UMN-UIowa) along with data from other literature and unpublished sources.  These new aggregations have resulted in increases in the number of data points and in the number of studies resulting in tighter minimum to maximum values ranges, tighter lower and upper Error Bounds, and in some cases improved confidence codes.  The National Fluoride Database has been incorporated into a computer-based fluoride assessment tool being developed by the University of Minnesota, Nutrition Coordinating Center (NCC), as a module of the Nutrition Data System for Research (NDS-R) software.

Fluoride has long been known to influence the activity of various enzymes in vitro. Latterly it has been demonstrated that many effects primarily attributed to fluoride are caused by a synergistic action of fluoride plus aluminum. Fluorinated chemicals are of growing importance, with applications in medicine. Fluorine substitution has profound effects on the properties of organic compounds. The very high electronegativity of fluorine can modify electron distribution in the molecule, affecting its absorption, distribution and metabolism. Fluorine-containing drugs are used in medicine as anesthetics, antibiotics, anti-cancer and anti-inflammatory agents, psychopharmaceuticals, and in many other applications. The potential contribution of fluorinating pharmaceuticals to human fluoride exposure is discussed.