We compared published data collected during the 1930s by H. T. Dean1,2 and data from the 1986–1987 National Survey of School Children3,4 conducted by the National Institute of Dental Research, now the National Institute of Dental and Craniofacial Research, or NIDCR. Both of these data sets used the same diagnostic criteria to identify enamel fluorosis.
In the 1986–1987 NIDCR survey, a group of trained examiners identified enamel fluorosis using, in addition to Dean’s criteria, the Russell’s criteria to differentiate fluorosis vs. non-fluorotic lesions. Therefore, in our analysis we relied on the diagnosis made by others, and although there is room for misclassification, we believe both studies used sound methodologies in their efforts to obtain unbiased data.
We agree completely with Dr. Gilbert’s second comment. In fact, we discussed extensively that the fluorosis observed in 1986–1987 probably was produced by the combined exposure to fluoride from multiple sources, not just fluoride in the water.
We are not saying that water fluoridation in the optimal range (0.7 to 1.2 parts per million fluoride ions) is the sole cause of the fluorosis prevalence and severity observed in 1986–1987. The wide availability of fluorides, especially in dietary supplements, processed foods and toothpaste, in addition to the fluoride levels in the water, puts children at a higher risk of enamel fluorosis.
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