A meeting on Wednesday in the administration of food and medicines on fluoride supplements became, at a time, a return controversy over whether the ingrelated tablets damage children’s microbiomas or play a vital role to help them protect them from tooth decay.
Pediatric dentists consider chewable tablets, available only by recipe, as particularly important for families living in areas without fluoride in drinking water, which do not have dental insurance or that cannot pay regular visits to dentists.
However, under Commissioner Marty Makary, the FDA has been taking measures to eliminate market fluoride supplements. A final decision is not expected until October, although defenders and critics at the meeting did not agree on basic scientific methods or even responsible dental practices.
During the public meeting held at Silver Spring, Maryland, dental experts described the careful balance of obtaining the correct amount of fluoride to their patients. Very little can cause weakened dental enamel, said Dr. James Bekker, a member of the Utah Dental Association. Too much can cause fluorosis, a condition that leaves white or brown spots on the teeth.
“There are areas where we have community water fluoration. We do not need supplements in those areas,” said Bekker, who was invited to speak at Wednesday’s meeting. “But there are many areas of our country where we do not have community water fluoration or we do not naturally fluoride. In those places, supplements are the key to achieving that balance.”
A panelist, Dr. Bill Osmunson, a retired dentist who now works for the fluoride action network, an antifluoride group, Bekker splashed on how it determines if a child needs fluoride supplements.
“Where do you live?” Osmunson asked. “Do you ask where they go to school?”
Bekker explained how comprehensive evaluations of his young patients perform, including reviewing dietary problems and if they use other supplements, before prescribing fluorine tablets or falls.
“Actually, do you ask all those questions?” Osmunson said.
“I bet,” said Bekker.
The “Inquisition of Dr. Bekker of Osmunson was a tactic to try to make it look incompetent,” said Dr. Johnny Johnson, president of the American Fluoridation Society. “That type of exchange is understood as a popularity contest.” Johnson spoke in favor of the supplement during a public comment session.
Osmunson and other critics were based on data that did not necessarily prove their criticisms of the products.
For example, Makary, the FDA Commissioner, has said that the fluoride ingested alters the intestinal microbiome. His statement seems to depend on a 2023 review of the research of scientists in Ireland.
This analysis pointed out that animal studies suggested that eating fluoride affected the microbiome, but that none of the studies examined fluoride and human microbiome. The researchers concluded that any possible effect of fluoride in the microbioma is “even in their early days, and the studies that investigate the impact of fluoride on human microbiome have only begun to appear in the literature.”
One of the authors of that study also spoke at Wednesday’s meeting. “The consumption of fluoride at levels that we consider good to maintain good oral health probably has a limited impact on oral and intestinal microbiomes,” said Gary Moran of Trinity College Dublin in Ireland. But, he added, “we certainly need more studies.”
There was no vote for or against fluoride supplements.
Dr. David Krol, representative of the American Academy of Pediatrics, spoke in favor of fluoride supplements as one of the many tools that doctors need to ensure that the teeth of their patients are as strong as possible.
“Fluoride supplementation, as well as diet conversations and conversations about hygiene, are the types of things that take place between pediatricians and patients,” Krol said. “We have to have the opportunity to continue these conversations and have those multifactorial tools to address this disease.”
Although Medicaid covers oral health for children, less than half went to the dentist at least once a year.
The cavities that explode in the mouths of these children get worse if they are not treated, and can cause generalized damage. The decline “eats the bone” around the tooth and sometimes gets into the bloodstream, said Dr. Steven Levy, a professor of preventive and community dentistry at the University of Iowa.
“This is more than a simple experience in the middle class of the middle class with a cavity,” he said.
The main public health groups, including the American Academy of Pediatrics and the United States Preventive Services Working Group, recommend prescribing supplements for children from 6 months if the water supply is not fluored.
Fluoride supplements are often given to children from 5 years until they have their permanent teeth, around 13 or 14 years, Bekker said in an interview before the meeting. Babies receive drops until they are old enough to chew tablets. They are generally economical.
Vitamins and free sale supplements do not contain fluoride. The fluoride is available on the counter only in toothpaste and mouthwash.
Makary also opposes fluoride supplements because they are not approved by the FDA. Because the supplements had been in use for decades before Congress ordered that medication manufacturers show that their products were not only safe but also effective, they were never required to go through the approval process. For almost the time that supplements have been prescribed, critics have worried about the lack of rigorous data that show their possible health effects and how children’s teeth protect.
“I think we really need to understand the benefits,” said Linda Birnbaum, toxicologist and former director of the National Institute of Environmental Health and the National Toxicology Program. Birnbaum also spoke during the FDA meeting.
Dr. Brett Kessler, of the American Dental Association, acknowledged that prescription fluoride supplements must be administered only after a “reflexive decision” based on conversations between doctors and families.
“I hope we can all breathe, filter all the noise and not give in to anti-fluoride hysteria,” he said during the meeting.
