22 l © 2025 American Dental Association
Section 1: Effectiveness and Benefits
Cuba: La Salud (Kunzel and Fischer, 2000)
In La Salud, Cuba, a study on tooth decay in children indicated that the rate of tooth decay did not
increase after fluoridation was stopped in 1990. However, at the time fluoridation was discontinued,
a new preventive fluoride program was initiated in which all children received fluoride mouthrinses
on a regular basis and children 2–5 years of age received fluoride varnish once or twice per year.118
Finland: Kuopio and Jyväskylä (Seppa et al., 2002)
In Finland, a longitudinal study in Kuopio (fluoridated from 1959–1992) and Jyväskylä (with low levels
of natural fluoride) showed little difference in decay rates between the two communities, which were
extremely similar in terms of ethnic background and social structure.119 That finding was attributed to
a number of factors. First, the dental programs provided intensive topical fluoride regimens and dental
sealant programs for Finnish children. In addition, nearly all children and adolescents in those cities
used the government-sponsored, comprehensive, free dental care. As a result, the net benefit of water
fluoridation appeared minimal. Because of this unique set of factors, the authors concluded that those
results would not be replicated in countries with less-intensive preventive dental care programs.119
(Former) East Germany: Chemniz and Plauen (Kunzel et al., 2000)
No significant decrease in tooth decay was seen after fluoridation was discontinued in 1990 in
Chemniz and Plauen, located in what was formerly East Germany.120 The intervening factors in those
communities included improvements in attitudes toward oral health behaviors, and broader availability
and increased use of other preventive measures, including fluoridated salt, fluoride toothpaste, and
dental sealants.120
Netherlands: Tiel and Culemborg (Kalsbeek et al., 1993)
A similar situation was reported from the Netherlands. A study conducted among 15-year-old children
in Tiel (fluoridated 1953–1973) and Culemborg (non-fluoridated) compared tooth decay rates in the
two cities from 1968 to 1988. The lower tooth decay rate in Tiel after the cessation of fluoridation
was attributed in part to the initiation of a dental health education program, free dietary fluoride
supplements, and a greater use of professionally applied topical fluorides.121
In the preceding examples, many communities that discontinued fluoridation found higher tooth
decay rates in their children. The absence of caries increases in some communities that discontinued
fluoridation likely was due to the availability and use of free dental services for all children or the
implementation of widespread decay prevention programs that require significant professional
and administrative support and are less cost-effective than fluoridation.
Section 1: Effectiveness and Benefits
Cuba: La Salud (Kunzel and Fischer, 2000)
In La Salud, Cuba, a study on tooth decay in children indicated that the rate of tooth decay did not
increase after fluoridation was stopped in 1990. However, at the time fluoridation was discontinued,
a new preventive fluoride program was initiated in which all children received fluoride mouthrinses
on a regular basis and children 2–5 years of age received fluoride varnish once or twice per year.118
Finland: Kuopio and Jyväskylä (Seppa et al., 2002)
In Finland, a longitudinal study in Kuopio (fluoridated from 1959–1992) and Jyväskylä (with low levels
of natural fluoride) showed little difference in decay rates between the two communities, which were
extremely similar in terms of ethnic background and social structure.119 That finding was attributed to
a number of factors. First, the dental programs provided intensive topical fluoride regimens and dental
sealant programs for Finnish children. In addition, nearly all children and adolescents in those cities
used the government-sponsored, comprehensive, free dental care. As a result, the net benefit of water
fluoridation appeared minimal. Because of this unique set of factors, the authors concluded that those
results would not be replicated in countries with less-intensive preventive dental care programs.119
(Former) East Germany: Chemniz and Plauen (Kunzel et al., 2000)
No significant decrease in tooth decay was seen after fluoridation was discontinued in 1990 in
Chemniz and Plauen, located in what was formerly East Germany.120 The intervening factors in those
communities included improvements in attitudes toward oral health behaviors, and broader availability
and increased use of other preventive measures, including fluoridated salt, fluoride toothpaste, and
dental sealants.120
Netherlands: Tiel and Culemborg (Kalsbeek et al., 1993)
A similar situation was reported from the Netherlands. A study conducted among 15-year-old children
in Tiel (fluoridated 1953–1973) and Culemborg (non-fluoridated) compared tooth decay rates in the
two cities from 1968 to 1988. The lower tooth decay rate in Tiel after the cessation of fluoridation
was attributed in part to the initiation of a dental health education program, free dietary fluoride
supplements, and a greater use of professionally applied topical fluorides.121
In the preceding examples, many communities that discontinued fluoridation found higher tooth
decay rates in their children. The absence of caries increases in some communities that discontinued
fluoridation likely was due to the availability and use of free dental services for all children or the
implementation of widespread decay prevention programs that require significant professional
and administrative support and are less cost-effective than fluoridation.
