Expecting Perfection, Accepting Mediocrity: Assessing Fluoride and Statins

Do you expect things to work? When you turn the key or push a button on your car’s ignition switch, do you anticipate that the vehicle will start? Most people do. What about your computer or smart phone? If you charged it, you assume the device will start up every time. Do you ever use a microwave? Don’t you insist that it heats food? If you answered yes to these queries, you may wonder why we seem to have such trouble assessing fluoride or statin-type cholesterol-lowering drugs. How effective are they in preventing tooth decay or heart attacks?

Why Do We Have Such Low Standards for Drugs?

Americans are demanding. If something stops working shortly after we buy it, we send it back for a replacement or want our money back. Why don’t people demand the same reliability from the health care system?

Most people assume that pharmaceuticals and other health interventions should work a bit like flipping a light switch. When they don’t, however, we rarely complain.

Assessing Fluoride Effectiveness in Water:

Most people believe that fluoridated tap water protects children and adults from cavities. It does, but the level of protection is surprisingly low.

Do you know how many teeth you have? If you still have your wisdom teeth and no other teeth have been pulled, you should have 32 teeth…16 in your upper jaw and 16 in your lower jaw. Even if you have had all 4 of your wisdom teeth extracted, you should still have 28 teeth.

We suspect that if you polled 1,000 people and asked them how many teeth are protected from cavities, they would answer that fluoridating water should protect at least 3 or 4 from cavities. Some might expect even better results.

What about you? I am asking you to right now to guess how many teeth are protected from cavities if you drink fluoridated water. Make a mental note please.

Assessing Fluoride Effectiveness Scientifically:

The Cochrane Collaboration consists of independent health care experts working as volunteers to assess the benefits and risks of health interventions. Last fall this respected organization took a whack at assessing fluoride usefulness. Here is Cochrane’s latest evaluation of community fluoridated water (CWF).

Researchers report on fluoride in the Cochrane Database of Systematic Reviews, Oct. 4, 2024):

“Based on contemporary evidence (after 1975), the initiation of CWF [community fluoridated water] may lead to a slightly greater change in dmft [decayed, missing or filled teeth] over time (mean difference (MD) 0.24, 2 studies, 2908 children; low‐certainty evidence). This equates to a difference in dmft of approximately one‐quarter of a tooth in favour of CWF; this effect estimate includes the possibility of benefit and no benefit.”

Conclusions:

“Contemporary studies indicate that initiation of CWF may lead to a slightly greater reduction in dmft and may lead to a slightly greater increase in the proportion of caries‐free children, but with smaller effect sizes than pre‐1975 studies. There is insufficient evidence to determine the effect of cessation of CWF on caries and whether water fluoridation results in a change in disparities in caries according to socioeconomic status. We found no eligible studies that report caries outcomes in adults.

“The implementation or cessation of CWF requires careful consideration of this current evidence, in the broader context of a population’s oral health, diet and consumption of tap water, movement or migration, and the availability and uptake of other caries‐prevention strategies.”

Interpreting Cochrane’s Efforts at Assessing Fluoride:

The scientific evaluation of fluoride effectiveness may be a bit stuffy for most folks to grasp. Here’s my interpretation.

• The authors use the words “may lead to a slightly greater reduction” in decayed, missing or filled teeth. Please note the word “may.” That suggests it is not guaranteed.
• In recent studies, community water system fluoridation “may” lead to ¼ fewer cavities in children. In other words, less than one tooth might be protected from decay on a population-wide level.
• There are no “eligible” studies to evaluate in adults. This suggests that no large, well-conducted water fluoridation studies in adults were available for Cochrane to analyze.

I suspect that most Americans believe fluoridated water is much more effective than Cochrane discovered. What number of teeth did you predict would be protected by fluoride in the water supply? How close were you to the Cochrane analysis? Please share your result in the comment section below.

The Downside of Fluoride:

In assessing fluoride, the Cochrane investigators looked into something called “dental fluorosis.” This is a discoloration of tooth enamel. It can show up as white spots on the teeth. When the condition is severe, there may be a mottled brownish look to the teeth.

According to Cochrane:

“…fluoridated water may be associated with dental fluorosis. With a fluoride level of 0.7 parts per million (ppm), approximately 12% of participants had fluorosis of aesthetic concern (40 studies, 59,630 participants), and approximately 40% had fluorosis of any level (90 studies, 180,530 participants).”

One More Thing…the IQ impact of Fluoridation:

A study published in JAMA Pediatrics (Jan. 6, 2025) revealed that early exposure to fluoride in drinking water might have a negative impact upon IQ. You can read all about this analysis of 74 studies at this link.

What About Statin Effectiveness?

In another arena, people with high cholesterol are often prescribed a statin-type cholesterol-lowering medication. The most popular is atorvastatin (Lipitor). At last count, about 28 million Americans were taking this drug. The expectation is that this drug will prevent a lot of heart attacks and save millions of lives.

Years ago, when Lipitor was a best-selling brand name drug, the manufacturer ran ads that stated:

“In patients with multiple risk factors for heart disease, Lipitor reduces risk of heart attack by 36%*.”

We suspect that many people took that to mean that 36 people out of 100 taking Lipitor would avoid a heart attack they would otherwise have suffered. What about you? If you read an advertisement that says a medication “reduces the risk of heart attack by 36%,” how would you interpret that statement?

A few readers might have checked the asterisk at the end of that sentence. Would that have been you?

In small print at the bottom of the page, the Lipitor ad stated:

“That means in a large clinical study, 3% of patients taking a sugar pill or placebo had a heart attack compared to 2% of patients taking Lipitor.”

That’s a lot less impressive.

These days most people over the age of 65 are urged to take a statin, regardless of their diet, exercise capability or family history. Should you wish to read more about statins, here is a link to an article titled:

Should Everyone Over 65 Take a Statin to Prevent a Heart Attack?

Final Words on Assessing Fluoride and Statin Effectiveness:

The take-home message of these two examples—assessing fluoride in water and relying upon statins to prevent first heart attacks—is to be better informed about the actual efficacy of anything you put in your body. Health care professionals have a responsibility to be completely transparent about both benefits and risks. Patients should request details that will help them make a realistic assessment of whether or not a particular therapy will help them stay healthy.

How can you do that? There are two ways. Always ask your doctor and your pharmacist what percentage of people get benefit from whatever is being recommended. Do not accept the relative risk reduction. In the case of the Lipitor ad, the relative risk reduction would have been 36%. Always ask for the absolute risk reduction. In the Lipitor ad that would have been 1%.

I do not think you would settle for a car, a smart phone or a microwave that only worked 1% of the time. I do not want to put words in your mouth, though. Please share your thoughts about fluoride, statins or any other treatment in the comment section below. And if you think you know someone who might appreciate our effort at assessing fluoride and statin effectiveness, please share this article with them. Thank you for supporting our work.