Fluoride in drinking water is associated with impaired childhood cognition

Fluoride occurs naturally as fluoride ions in drinking water, but the concentrations are generally low in public water supplies. In some countries, such as the USA, Canada, Chile, Australia and Ireland, fluoride is commonly added to the municipal water supply at around 0.7 mg per litre to prevent caries.

“Given the concern about health risks, the addition of fluoride to drinking water is controversial and has been widely debated in the USA and Canada,” says Maria Kippler, associate professor at the Institute of Environmental Medicine, Karolinska Institutet. “Our results support the hypothesis that even relatively low concentrations of fluoride can impact children’s early development.”

500 mothers and children

The researchers followed 500 mothers and their children in rural Bangladesh, where fluoride occurs naturally in the drinking water, to investigate the association between early exposure to fluoride and children’s cognitive abilities. The concentrations are similar to those found in many other countries worldwide.

Trained psychologists evaluated the children’s cognitive abilities at five and ten years of age, using well-established tests. The exposure to fluoride in the mothers and children was determined by measuring the concentrations in urine samples, which reflects ongoing exposure to all sources, such as drinking water, food and dental care products.

“I’d like to stress that dental care products such as toothpaste are not normally a significant source of exposure since they are not intended for ingestion,” says Dr Kippler. “Fluoride in toothpaste is important for prevention of caries, but it’s important to encourage small children not to swallow the toothpaste during brushing.”

Decreased cognitive abilities

The median concentration of fluoride in urine of the pregnant Bangladeshi women was 0.63 mg/L. Increasing concentrations of fluoride in the pregnant women could be linked to decreasing cognitive abilities in their children at five and ten years of age.

Children that had more than 0.72 mg/L fluoride in their urine by the age of ten also had lower cognitive abilities than children with less fluoride in their urine, with most pronounced associations for verbal reasoning skills and the ability to interpret and process sensory input. The exposures that were associated with impaired cognitive development are lower than those obtained at the existing WHO and EU threshold for fluoride in drinking water, which is 1.5 mg/L.

The researchers found no statistically significant link between fluoride concentrations in the urine of the five-year-olds and their cognitive abilities.

“This may be due to the shorter exposure time,” Dr Kippler speculates, “but also to the fact that urinary fluoride concentrations aren’t as reliable in younger children owing to greater variations in how much fluoride is taken up and stored in the body, particularly in the bones.”

More studies needed

Since it was an observational study, no firm conclusions can be drawn about causalities. It is therefore important to assess the overall results of several similar longitudinal studies, according to the researchers. They will now investigate the associations in other populations and establish experimental models to determine the possible molecular mechanisms driving it.

“There is a need for more research to create a robust basis for reviewing fluoride health risks and thresholds for drinking water, foods, and dental care products, especially for children,” she continues. “Even small changes in cognition at a population level can have serious public health consequences.”

The study was mainly financed by national grants from the Swedish Research Council and the Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning. The researchers have declared no conflicts of interest.

Publication:

“Prenatal and childhood exposure to fluoride and cognitive development: findings from the longitudinal MINIMat cohort in rural Bangladesh”Taranbir Singh, Klara Gustin, Syed Moshfiqur Rahman, Shamima Shiraji, Fahmida Tofail, Marie Vahter, Mariza Kampouri, Maria Kippler, Environmental Health Perspectives, online 5 March 2025, doi: 10.1289/EHP14534.