Dr. Craig Clayton (00:26)
Welcome to dentistry disrupted my friend. Today we are going to deep dive on fluoride, especially the new research that just came out, weighing the pros and cons of fluoride, exploring the history and alternatives to prevent cavities.
So we'll talk about the difference between fluoride and drinking water, toothpaste and fluoride varnish and why that matters, why each form of fluoride matters and the risk of each. And I am so stoked to be talking with Dr. Ryan Nolan today, a dentist and scientist and chemist and researcher and all the stuff who studies cavities. And that is his passion in life is studying.
what causes cavities and then figuring out what to do about it to stop the disease process. So, Dr. Nolan, thank you for being on the podcast with us today.
Dr nolan (01:20)
thank you, man. I appreciate you having me here and look forward to discussing all this. There's a lot to unpack.
Dr. Craig Clayton (01:27)
There it is, so much to unpack. So we'll try to keep this episode out of the weeds the best we can. And so we'll try to keep it of an overview, but we are gonna do two podcasts, one for...
One for patients and one geared at health professionals. So if you're a health professional listening to this, know that there's another podcast coming that has more in-depth information.
I'm going to start by sharing my experience learning about fluoride as a dental student and when my thinking started to shift. So Dr. Nolan, I wonder if you had a similar experience, but in dental school, fluoride was touted as the cure-all. You know, it's floss, brush your teeth, don't eat sugar, get your teeth clean, go to the dentist and use fluoride at any time.
I I opened up a lecture the other day from my geriatric dentistry class. Just, I found it on my desktop, like, eh, look at, you know, look it over. And so I skimmed through it and just talking about risk factors that are common in older populations, like less saliva and it's difficult to remove plaque, stuff like that. But the takeaway, after going through all these risk factors, the takeaway was,
we need to help these people brush their teeth better and floss. And we should prescribe them high strength fluoride varnish and high strength fluoride toothpaste. And that was like, it didn't talk about how to mitigate all these 15 risks. It just talked about just use fluoride. And so that was the knowledge that I left dental school with as far as how to manage caries disease that causes cavities. Do you have a?
similar experience.
Dr nolan (03:14)
Same thing, and to be honest, being that my first degree is in chemistry, I remember talking to one of my professors at the time and kind of asking some, should I say more in-depth questions about, hey man, isn't there anything else besides this? This seems like a very monochromatic view of prevention. And I felt like I just got slapped. Like, what do you mean? What else do we need? This is a...
It basically painted to be the one size fits all solution for everything, right? And so the more you do digging on it, the more you're like, wait a second, this isn't the only thing, nor is it probably the most beneficial thing that you could do for all of your patients, right? Everybody is not the same size t-shirt. So it's just one of those things where like,
It depends on what the patient's risk factors are. again, I didn't love the monochromatic viewpoint that I got from dental school, which was very black and white about this subject.
Dr. Craig Clayton (04:22)
Yeah, very few things are truly black and white. And that especially is not pertinent to oral health or systemic health. We don't just have a, use this and you won't get cavities. You won't have an issue. It's like, it just seems so, it's so far from the mark. It's so far. And it's just,
It's wild that that's how it's still taught. that's why it's frustrating, I know, with a lot of our listeners and those that follow us on social media or wherever they have come across our content is that there's not a lot of good information out there as to history, risks, benefits.
And as a result, there's a lot of shaming that naturally results in our profession of, well, this is your fault. You haven't been giving your kids fluoride. And so it's really, it causes a lot of dissonance in people because...
Dr nolan (05:15)
Mm-hmm.
Dr. Craig Clayton (05:30)
you know, people are becoming more educated and more and more people are aware of the dangers of fluoride and but to receive both these messages is hard. So that's what we're going to do today is try to demystify this and go through some of the basics about fluoride and talk about this new research
What would you like to refer to it as?
Dr nolan (05:52)
review of research regarding fluoride exposure and the potential risks associated with various levels of exposure. I think that's probably a good way of summarizing what it is.
Dr. Craig Clayton (06:07)
this is a big document, it's 80 pages long. so, Dr. Nolan consumes a lot of scientific literature. How many papers a week for the last 10 years? It's like...
Dr nolan (06:12)
So.
at least 15 a week. Not all dentistry all the time because that gets boring sometimes, but a lot of dentistry. So read a lot of scientific articles.
Dr. Craig Clayton (06:23)
Please 15 a week, so do the math.
So that is why I feel so fortunate to call Dr. Nolan, my friend and rub shoulders with them. So I've learned so much from him, which then I pass on to you listeners, followers, those that rely on our resources to learn about caries disease. I've worked so much with Dr. Nolan Because of his extensive.
training and interest in the topic. So, okay, well let's jump into the basics of fluoride. So Dr. Nolan, what is fluoride? In its most simple explanation.
Dr nolan (07:03)
Yeah, so fluoride is the ionic derivative of fluorine. basically it's an ion that has the unique property of being attracted to calcified tissues and calcified areas specifically.
In our case, we talk a lot about tooth enamel. And one of the things that it can do is it can actually make the crystal, the outside part that contacts the inside of your mouth, so like the outer part of the enamel, which by the way is the hardest part of your body in case you wanted to know, harder and more resistant to acid. So for very long time,
fluoride has been incorporated into multiple products, into the drinking water, into topicals, all kinds of different potential applications as a result of this unique property. So that's kind of the history of what it is and how it works in terms of a mechanism.
Dr. Craig Clayton (08:03)
so what I'm understanding is that that fluoride from fluorine likes to, likes to hang out with calcified structures like bone and teeth. And that's when it associates with the teeth that makes them more resistant to the acid in the mouth. And as you say, sugar doesn't cause cavities, acid does.
That's our mantra. So the traditional stance is that fluoride is necessary, essential in preventing tooth decay and backed by decades of research. Can you flesh this out a little bit? I know this in dental school, was touted that adding fluoride to the water was one of the biggest public health accomplishments of the 20th century. But then there's
Dr nolan (08:48)
Sure.
Dr. Craig Clayton (08:59)
some pretty damning studies that say, hold on there, is it really?
Dr nolan (09:05)
So the more that I kind of got into this, right? just to give you guys an idea, the last water fluoridation clinical trial in the United States was like 1969 or 1970, somewhere in that zone. So that's 50 plus years ago. So one of the things I started looking at was I started looking at standards, controls, outcomes.
things that they're looking for, how they're comparing it. And the first thing that you'll notice when you start going down these quote unquote decades of research is that, hey, there's a lot of factors that weren't necessarily controlled for. There's areas where they're not doing a great job in some of these studies, but so be it. I mean, they did a lot of studies on it. So they seem very confident. But what we're finding is that as time has gone on,
You know, the one that I point to, which I feel like is the, the nail in the coffin for this is the 2015 Cochrane review, which if you're not familiar with the Cochrane group, They do very high level, kind of summaries of, for evidence base of, of like different things. Okay. So in this case, what they did is they looked at a summary of a number of different
studies and things that basically where they looked at a lot of different countries and they looked at countries that did fluoridate, used to fluoridate, or still continue to fluoridate. And they took an outcome-based approach of how many of these people living in these countries, whether it's fluoridated, used to be fluoridated, or is still fluoridated, what is their
Dr. Craig Clayton (10:40)
and fluoridated is adding fluoride to the water.
Dr nolan (10:43)
Yes, yeah, exactly. How many of them still got cavities? And they measured it in terms of how many surfaces on the tooth based on how many cavities people were getting. And what they found after looking at a wide range of different countries, different populations, different subsets of people, is that the rate of cavities was identical. And that is a big problem.
Because if the rate of cavities that people are getting is identical, then that means the impact that you have with water fluoridation is
Dr. Craig Clayton | Restoration Dentistry AI (11:17)
is questionable.
Dr nolan (11:19)
at best. And that's an efficacy concern. That doesn't even get into some of the other stuff we're going to talk about, which is the toxicological concerns. But basically what I'm saying to you is it starts to open the door of
How reliable was that research from 50 years ago? And at what level does that benefit stack and what level does it not? And is there too much exposure or potentially are there areas where we're not really getting a benefit for what we're doing? If that kind of makes sense.
Dr. Craig Clayton (11:52)
Yeah. Yeah. And so it's fluoride for 50 years has been touted as this magic bullet for cavity prevention. And those studies are extremely concerning, especially because considering the risk of fluoride. what are the main risks of ingesting too much fluoride? Whether that be a little or a lot, where is that? Where's that danger point? We talked a little bit about this.
or a lot about this before we started recording, to summarize, what are the main risks of ingesting too much fluoride and what is too much?
Dr nolan (12:28)
Sure, so like the way that you look at this is you can look at it in a couple of different like aspects. Anytime you have a drug or anything that you're evaluating for safety, you want to look at what we call therapeutic window or therapeutic benefit. So basically we're evaluating something based on what we think it's capable of benefiting most people.
And there's also a risk association or risk factors for that therapeutic window. And we don't measure everything identically, but to give you guys an idea, like there's safety windows we want to meet in terms of the benefit,
Dr. Craig Clayton | Restoration Dentistry AI (13:08)
So basically.
Dr. Craig Clayton | Restoration Dentistry AI (13:09)
The safety has to be within a certain range in order for the therapeutic benefit to matter.
Dr nolan (13:14)
to matter. And what we're essentially seeing is
potential issues with where the current levels of water fluoridation are and the safety window for adverse events or effects. like for example, prior to all this information coming out from this report, primarily the concern was above four milligrams per liter or it was, so it's four parts per million.
the drinking water. That was considered like the top end that you could have before you start getting considerably adverse events in effect.
Dr. Craig Clayton (13:50)
And that's small, I mean four parts per million, it's a really small amount.
Dr nolan (13:54)
very small, very small, very small. So, you know, obviously I'm sure people are aware of pleurosis and some of these other things.
Dr. Craig Clayton (14:03)
but just in case they're not
so fluorosis is caused by having too much fluoride when the teeth are developing, which then affects the development of the tooth tissue.
Dr nolan (14:16)
Yeah. So it makes the enamel more model. There can be staining. can be areas that maybe are more prone to developing cavities as a result, but mainly it's modeling and just ineffective enamel growth essentially is what one of the main things that we look at. And it's not so much something that a lot of people, like a lot of people are affected by it, but it's mainly very minor. So it's not something that a lot of people really consider like a
big, big issue. But let's say it's a side effect potentially that we look at, right? I think the thing is, when you were doing a traditional evaluation of fluoride safety, and I'll just keep it to the water so everybody's on the same page.
Some of these things that we're discussing were not on the window of evaluation because they weren't known adverse effects. Meaning like, again, and I made this kind of funny analogy to Dr. Clayton, but it's like, okay, if I find out that if I drink 11 coffees and my kidney fails, then I know the safety window is like, all right, well, can't have more than 10, right? But what if I found out that
four coffees or five coffees that gosh, you know, I'm starting to have trouble seeing or my liver starts having issues. Maybe it's not to the point where it's as bad as my kidney failing, but it wasn't a known effect until recently because I've been drinking a lot of coffee apparently and now I care. The point is though, is this information is new and as a result of it coming out, we have to reevaluate our stances on
Dr. Craig Clayton (15:47)
Hahaha.
Dr nolan (15:57)
what we consider the ethos or the correct ethos to view or correct standpoint scientifically to view the risk associated with
Dr. Craig Clayton (16:07)
Okay, and I know the most common concern that is discussed among our community
can be boiled down to one word which is neurotoxic.
And at what level is fluoride neurotoxic? When does this become a concern? And how does that relate to fluoride exposure? For example, what are some of the main ways we're exposed to fluoride? When does the neurotoxicity become a concern? And then what can we do to minimize our exposure to fluoride?
Dr nolan (16:47)
Yeah, sure.
Assume that we get no fluoride exposure from any other source, which by the way, that's a very ideal assumption. But let's just take everything else off the table for a second. The amount that we're getting in our drinking water, the set amount should be 0.7 milligrams per liter, which is 0.7 ppm. But realistically, depending on where you live, in the United States even, it can vary greatly.
So if I go down somewhere, you know, maybe I go to Phoenix and maybe it's 1.2. Maybe it's 1.3 in Arkansas. Maybe it's 0.5 in Vermont. Maybe it's 0.7. The point is, is it's very precise or accurate as to how much you're getting. But let's, let's even take that out of the situation and just say it's 0.7. Is that enough?
to pose a reasonable risk to the population, even at 0.7. And the answer that the court kind of rolled on, right, is yes. And the reason is because they found in the NTP review, which is the toxicology folks that reviewed this, that at 1.5 ppm or 1.5 milligrams per liter, there were substantial deficits to IQ.
in children and it was enough to consider the fact that even at point seven that number or that amount needs to be reevaluated for safety. So that was kind of where this whole thing went down this road and here we are looking at all this stuff and now we're really having to dig deep and say okay well
Now I don't have to consider just water. What if I added water, food, products, potentially other sources of contamination or toothpaste or topicals, whatever. Now I have to take that whole bundle in knowing that it's never going to be just 0.7. So now as dentists, we're like kind of
Dr. Craig Clayton (18:57)
Mm-hmm.
Dr nolan (19:01)
semi-panicking a bit, right? Because now it's like this new information that we have in front of us poses a bit of a problem and that means, alright, well now we have to have a very stern conversation about risk versus benefit.
Dr. Craig Clayton (19:16)
I mean, is this even including the exposure from oral care products like toothpaste? Or is this just considering drinking water and then adding in food and you're saying even with drinking water and food, we're in that danger zone of being too much and now we look at fluoride in oral care products.
Dr nolan (19:21)
No. This is just water fluoridation. Yep.
Yes.
Yeah, that is like a pickle, right? Like it's like, here we are even trying to, even if in an ideal scenario, we separate it out the water by itself and we got no exposure other than the water, it's still a pickle. And now we have like three pickles, right? Because we have the water, we have the food and then other drinks that, or other natural substances that have fluoride. And then we also have the products that have fluoride and the professional product that.
So like we're going down a water slide and it's getting muddier and muddier. it's like, all right, like when is this going to get, like, when's this going to get better? I need to get off this ride. Like this is, this is bad. And so when we have these conversations, right. I think as a community, it's important to address these things instead of shying away from it or trying to double down on certain things that don't make a lot of sense or potentially have.
risks associated with them. And this is kind of where I differ with some of my colleagues is I feel as though it's not being handled properly. Meaning it's being framed as some fear-mongering thing and da da da da, with no context being given to the fact that the NTP, which is the National Toxpology Program, which is a very legitimate government program, released this report for the benefit of us.
and it's being framed as if it's like some anti-fluoride group, but it's not. And so here we are, we're sitting on new information, and we just have to do the best with that information that we can.
Dr. Craig Clayton (21:16)
Yeah, yeah, and it's we were talking before we started recording we were talking about the fact that We have to do the best we can with the information we have But the most important thing to do is to be willing to be wrong, which is it which is a hard thing it's no one likes to be wrong, but especially When people are taught a certain way and we get in this process
Dr nolan (21:26)
right.
Yeah, that's tough. It's tough.
Dr. Craig Clayton (21:41)
especially as dentists, think we're prone to this if we get in this process of this is just how it's done. And so it can be, these big changes can be scary because, know, myself included looking back at when we used to use a little bit of fluoridated toothpaste with our kids when they were younger, as well as not filtering our drinking water. Like this is, this is a significant,
concern now and I've been thinking a lot about this since we first, I mean, since we first started talking about the issue of now what can I do to help reduce the risk or the exposure of my family, my kids especially that are developing rapidly and their brains, little brains are growing. And it's interesting because this is something that wasn't on the radar like
Dr nolan (22:28)
Mm-hmm.
Dr. Craig Clayton (22:35)
My understanding with fluoride in the water was not so much the neurotoxicity as it was just the...
Well, yes, no toxicity, but more so that it was ineffective. So why have it in there? Like it doesn't make a difference. So why are we consuming it in our water rather than just using a varnish or?
Dr nolan (22:46)
Yeah, and we've had multiple.
Right. So
the point is, is we try and look at things and evaluate not just their toxicology, but their usefulness and what effects they have positive or negative, right?
Dr. Craig Clayton (23:05)
Yeah, man, there's always a lot to unpack. But moving through, let's do a rapid fire yes or no.
A couple of questions on what is safe and recommended or is it not safe or recommended? So first fluoride and drinking water, I think that's a pretty easy answer, which is a big no.
Dr nolan (23:25)
It's a pretty easy no. Yeah, it's a no for me. Yeah.
Dr. Craig Clayton (23:29)
about fluoride and daily toothpaste.
Dr nolan (23:31)
I feel like for me it's a no, I'm a bit biased about that, but I do think that now there's better alternatives. So I'm not saying a hundred percent no, but leaning towards a no.
Dr. Craig Clayton (23:44)
Okay, I like that. And then follow up question with that.
Say there is some indication maybe in a high-carries risk patient or person that's getting tons of cavities to get that little bit of benefit of stronger enamel. I mean, is this a high-strength prescription used occasionally or an over-the-counter fluoride toothpaste that's used once a week or is that just too hard to nail down?
Dr nolan (24:07)
It so depends on the individual patient because the other thing I don't want people doing is throwing away what's helping them. But at the same time, I think it depends on their age, it depends on how much they're consuming, it depends on their risks. So again, I think personally that there's better stuff.
But again, it's kind of like debating what's the lesser of all the evils, right? Like who knows? Right. But yeah, I, I, I still think, like I said, discovering and doing a little more research for individuals to find better brands and, and real science that's alternatives, is what I think people should be doing instead of just settling for whatever they're given. So yeah.
Dr. Craig Clayton (24:55)
Yeah.
so now with the review of the research and more information coming to light, we've talked about fluoride varnishes in the past, especially for kids that have a high rate of cavities, but fluoride varnish is very, very concentrated. So how do you feel about fluoride varnish now as far as
Dr nolan (25:19)
I still think
Dr. Craig Clayton (25:21)
high carries risk or just too much of a risk now.
Dr nolan (25:24)
I still think that fluoride varnish is useful because the thing is, is you're going to have patients where, keep in mind, they're getting this exposure, what, twice a year? That's really in the scheme of things. Not a lot of exposure. It is a higher dose, but I feel like you're going to get more saturation, more benefit from that than a daily exposure below a certain threshold. That being said though,
It should now be done more on a case by case basis than it used to be. Meaning it's not a blanket prescription that should be prescribed to everybody like it used to be. Because now that we have more data now, and I'm sure that you feel the same way about this. It's like, no, I have a two year old. How can I limit their floor and exposure is the first thing that I'm thinking. Right. And so, and I'm not fear mongering. What I'm saying is, is gosh, you know,
Dr. Craig Clayton (26:12)
Yeah, yeah, me too.
Dr nolan (26:18)
It's not really going to matter so much for me as an adult whose brain is fully developed, if you're hurt with it. And so it's one of those things where you almost as a parent initially your knee jerk reaction is, okay, well, what do I do for my kid? Right? So anyways, it's something to consider.
Dr. Craig Clayton (26:40)
it's too convoluted and I think this is what people need to hear is that there are multiple sides to some of these issues. Like fluoride in drinking water, yeah, hard no. Fluoride in daily toothpaste, know, better alternatives. Fluoride varnish twice a year, once a year.
Dr nolan (26:55)
I don't know if I'm ready to cut that yet, but like I said, I'm being more selective of who I'm using it on instead of just saying everybody gets it. Like, because for many years and I'm sure you're the same way, it's like everybody gets it. Now it's like, well, do they really? Yeah. Do they really need it? Because I think they're fine and they don't have the same level of risk and the benefit, the risk to benefit is now different because we know
Dr. Craig Clayton (26:59)
Yeah.
Yes.
Yeah, that's what we were taught.
Dr nolan (27:23)
alternative adverse effects that we didn't know of before. And so you have to weigh it a bit differently, right? So it's like, it's, not necessarily a bad thing. It's just a matter of, okay, like how much risk am I willing?
Dr. Craig Clayton (27:28)
Yeah.
Dr nolan (27:40)
I like the hard science, the factual information or the most accurate information I can get. And I just try and base decisions for each individual person based on this. Like, like, and again, with as clinicians, we can only treat what's in front of us with what we have right now.
I could be working on something magical and 10 years from now might be released, right? Or a team of scientists might release something awesome, but you and I have to act now with what we have in our hands. And so that's the other limiting factor is like, you, I don't want people to go blame their clinicians for what they're doing the best they can. That's not what this is about. This is about looking at everything as a whole and trying to make better decisions, like as an individual, right?
Because I don't want to sit here and blame people for doing the best they can with the knowledge they have. Right?
Dr. Craig Clayton (28:33)
so this really big review that's been done by the NCP is about regular daily exposure over a long period of time. So with a fluoride varnish that's once or twice a year that's a higher amount, do we know what effect that has right now? Because it is, we do have research that in those situations for that,
medication that it is effective and helpful. And I've only been recommending this to patients that have rampant decay, that have lots of teeth that are decayed or potential lesions. But in this case, that higher dose once or twice a year, we have that dangerous threshold of the neurotoxicity.
Do you get what I'm trying to ask is, is that single dose like, my gosh, my kid's gonna have like this terrible event or is it compounding?
Dr nolan (29:28)
Yeah, yeah, yeah, I think you're looking at this.
I don't think so. don't think anybody should know. It's compounding. So the way that you have to look at this is it's based on the amount of exposure you're getting daily. And if you're getting something that's higher exposure twice a year that could prevent stuff, I'm not ready to give that tool up yet. But I am wary that the net amount of what I'm getting is potentially cumulative and it could
be an issue if there's too much. So again, it's kind of a double edged sword, but at this point, I don't think it makes sense for a good chunk of patients to stop doing that. I'm not ready to make that change over yet, specifically on the varnishes, because I think they're the biggest bang for your buck.
And like I said, you know, every patient's going to be their own, you know, you're to have to talk to your provider and, kind of make a code decision, right?
Dr. Craig Clayton (30:31)
That's helpful. And this is what I appreciate about Dr. Nolan is this relying on the research, making reasonable decisions, and weighing risks and benefits. my father-in-law is a physician, and something he says is that a medication is always a poison first. And he says, I don't care if it's Advil, if it's naproxen, if it's
whatever the medication, he says, it's always the poison first and that's how it should be treated. And then after that, we rate the risks, benefits and say, okay, well, is it going to help the situation though? So I appreciate that approach because there is a lot of fear mongering of just black and white like, no, that is not how we roll.
Dr nolan (31:12)
And we're not like that and never have been. I understand that sometimes people will see a reel or a post and maybe they'll glance at it or they'll skim it and they really only see what they want to see. The reality is how much can we really give somebody on 140 words, Like it's just not like whatever the word count is, But the point is, there's such a limitation as to
spreading the information. so, you know, we've talked about the guides and some other things. And so there's a lot more like information in those things that are going to be beneficial for the average consumer. And that's, you know, you're not going to get off one Instagram or, or Twitter post or whatever. anybody who has things that are strictly black and white, like it's this or that those people are generally wrong.
there's always nuance in everything and nobody's perfect, right? So just like how this information wasn't available until recently, you know, I messaged Dr. Clayton, I was like, let's have a discussion about this because this is, this definitely changes the landscape a bit, right? And so it's important to always look at new evidence and reweigh and kind of have an open discussion without feeling judgmental about it, right? Just.
Dr. Craig Clayton (32:23)
Mm-hmm.
Dr nolan (32:31)
trying to understand where we're at and what we can do or what we need to change. We're looking at our protocols, right?
Dr. Craig Clayton (32:39)
and that's what we're all about is looking at the research and teaching evidence-based truth, science. So that's what we love.
Well, Dr. Nolan, thank you so much for taking the time to meet with me and discuss the science and the research that has been released about fluoride and why we should be concerned and what to do about it
And so and hang tight, everyone.
Dr. Craig Clayton | Restoration Dentistry AI (33:07)
We'll also have a part two of this podcast
Dr. Craig Clayton | Restoration Dentistry AI (33:09)
where we'll dive into our favorite products.
Dr. Craig Clayton (33:12)
But thank you so much, Dr. Nolan, for
being here, this has been fun.
Dr nolan (33:16)
Yeah, anytime man, thanks for having me. Let's hop on again soon.
