48 American Dental Association foods, dietary fluoride supplements and fluoride toothpaste. Estimated fluoride intake was noted during different time periods and cumulatively from birth to 15 years of age. The findings indicate that fluoride exposures at typical levels for most U.S. adolescents in fluoridated areas do not have significant effects on bone mineral measures. These findings are generally comparable with those from the analyses of this cohort at age 11 years.61 During the intervening 4 years, cohort members generally experienced a substantial increase in bone mass accrual. For example, mean whole-body bone mineral content showed mean increases of approximately 61% in females and 96% in males. Despite the acceleration of bone growth near puberty, the associations between fluoride intake and bone outcome measures remained weak and none was significant after adjustment for other variables.60 In one of the largest studies of its kind with nearly half a million subjects, Swedish researchers looked at residents’ chronic consumption of various levels of fluoride and the risk of hip fracture. All individuals born in Sweden between January 1, 1900 and December 31, 1919, alive and living in their municipality of birth at the time of the start of follow-up, were eligible for the study. Information on the study population was linked to the Swedish health registers. Estimated individual drinking water fluoride exposure was stratified into 4 categories: very low, 0.3 mg/L low, 0.3 to 0.69 mg/L medium, 0.7 to 1.49 mg/L and high, ≥ 1.5 mg/L. Published in 2013, the researchers found Swedish residents chronically exposed to various levels of fluoride in drinking water did not show any differences in rates of either hip fracture or low-trauma osteoporotic hip fracture due to fluoride exposure.62 A study published in 2005 evaluated the bone mineral density levels and rate of bone fracture of 1,300 women living in three separate communities. To be included in the study, the women had to be ambulatory. The ages of the women ranged from 20 years to 92 years. The size and demographics of the three communities were similar. One part of the study looked at whether fluoride was associated with adverse bone-related outcomes. The study measured fluoride serum levels, fluoride exposure, and bone metabolism as related to fluoride exposure and fluoride’s interaction with other important bone factors including age, menopause status and medications. The study concluded that long-term exposure to fluoride was not associated with adverse effects on bone health.63 A study published in 200164 examined the risk of bone fractures, including hip fractures associated with long-term exposure to fluoridated water in six Chinese populations. The water fluoride concentrations ranged from 0.25 to 7.97 mg/L. A total of 8,266 male and female subjects, all of whom were 50 years old or older participated in the study. The results showed an interesting and potentially important finding regarding overall bone fractures. Whereas there appeared to be a trend for higher fracture rates from 1.00 to 4.00 mg/L, the fracture rate in the 1.00 to 1.06 mg/L category was lower than the rate in the category with the lowest fluoride intake (0.25 to 0.34 mg/L). The study concluded that long-term fluoride exposure from drinking water containing 4.32 mg/L or more increases the risk of overall bone fracture, as well as hip fracture, while water fluoride levels of 1.0 to 1.06 mg/L decreased the risk of overall fractures relative to negligible fluoride in water.64 (Note that 4.32 mg/L is more than six times the fluoride level currently recommended for community water fluoridation in the United States). While a number of studies reported findings at a population level, both the Hillier and Phipps studies published in 2000, examined risk on an individual, rather than a community basis, taking into account other risk factors such as medications, age of menopause, alcohol consumption, smoking, dietary calcium intake and physical activity. Using these more rigorous study designs, these two studies reported no effect of the risk of hip fracture65 and no increase in the risk of hip fracture in those drinking fluoridated water,66 respectively. According to the best available science, drinking water that has been fluoridated at the recommended level does not have an adverse effect on bone health.