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Evidence found and GRADE certainty

164 questions · 214 findings · 22 reviews · All outcomes

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No studies found 3 · 1.4%GRADE not reported 161 · 75.2%Very low 25 · 11.7%Low 15 · 7%Moderate 8 · 3.7%High 2 · 0.9%

Higher drinking-water fluoride exposure vs Null / lowest drinking-water fluoride exposure (reference)

Fracture · general population

Non-linear positive dose-response: little change in overall fracture risk below ~1.5 mg/L drinking-water fluoride, with risk increasing above that threshold (RR 1.06, 1.19, 1.35 at 2.0, 3.0, 4.0 mg/L vs null); ungraded (4 studies).

4 findings from 1 review
Show 1 more finding

Higher drinking-water fluoride exposure vs Null / lowest drinking-water fluoride exposure (reference)

Risk of femoral fractures · general population

Femoral-fracture risk was mildly U-shaped: RR 0.86 at 0.5 mg/L rising to 1.06 at 1.8 mg/L drinking-water fluoride vs null; risk mostly below null across the range; ungraded.

2 findings from 1 review
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Drinking-water fluoride 1.8 mg/L vs null
    RR 1.06 [0.67, 1.69]
    Studies not reported
    GRADE not reported
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Drinking-water fluoride 0.5 mg/L vs null
    RR 0.86 [0.71, 1.05]
    Studies not reported
    GRADE not reported

Higher drinking-water fluoride exposure vs Null / lowest drinking-water fluoride exposure (reference)

Risk of fragility fractures · Male participants

In males (7 studies), fragility-fracture risk generally decreased with increasing fluoride: RR 0.83 (95% CI 0.72-0.97) at 0.57 mg/L to 0.87 (0.48-1.58) at 1.8 mg/L vs null; ungraded.

2 findings from 1 review
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Males: drinking-water fluoride 1.8 mg/L vs null
    RR 0.87 [0.48, 1.58]
    7 studies
    GRADE not reported
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Males: drinking-water fluoride 0.57 mg/L vs null
    RR 0.83 [0.72, 0.97]
    7 studies
    GRADE not reported

Higher drinking-water fluoride exposure vs Null / lowest drinking-water fluoride exposure (reference)

Risk of fragility fractures · general population

Fragility-fracture risk overall was slightly U-shaped: RR 0.93 up to 0.9 mg/L, ~1.00 at 1.48 mg/L, 1.05 at 1.8 mg/L drinking-water fluoride vs null; ungraded.

5 findings from 1 review
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Drinking-water fluoride up to 0.9 mg/L vs null
    RR 0.93 [0.84, 1.02]
    Studies not reported
    GRADE not reported
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Drinking-water fluoride 1.8 mg/L vs null
    RR 1.05 [0.82, 1.35]
    Studies not reported
    GRADE not reported
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Sensitivity (excluding high risk-of-bias studies): 0.8-1.5 mg/L vs null
    RR 0.93 [0.72, 1.21]
    Studies not reported
    GRADE not reported
Show 2 more findings
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Drinking-water fluoride 1.48 mg/L vs null
    RR 1.00 [0.82, 1.21]
    Studies not reported
    GRADE not reported
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Sensitivity (excluding high risk-of-bias studies): 1.8 mg/L vs null
    RR 0.95 [0.70, 1.29]
    Studies not reported
    GRADE not reported

Higher drinking-water fluoride exposure vs Null / lowest drinking-water fluoride exposure (reference)

Lumbar spine bone mineral density (BMD) · general population

Spine BMD showed an inverted U-shaped association with fluoride (peak ~0.6 mg/L); excluding high risk-of-bias studies gave small positive MDs (e.g., 0.05 g/cm2, 95% CI 0.01-0.10, up to 2.27 mg/L); ungraded.

4 findings from 1 review
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Sensitivity (excluding high risk-of-bias studies): 1.27 to 2.27 mg/L vs null
    MD 0.05 [0.01, 0.10]
    Studies not reported
    GRADE not reported
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Sensitivity (excluding high risk-of-bias studies): 0.60 mg/L vs null
    MD 0.06 [-0.02, 0.13]
    Studies not reported
    GRADE not reported
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Both sexes, main dose-response
    Inverted U-shaped association in both males and females, highest value around 0.6 mg/L (no numeric MD reported in text for main analysis)
    Studies not reported
    GRADE not reported
Show 1 more finding
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Sensitivity (excluding high risk-of-bias studies): above 2.27 mg/L vs null
    MD 0.04 [-0.21, 0.30]
    Studies not reported
    GRADE not reported

Higher drinking-water fluoride exposure vs Null / lowest drinking-water fluoride exposure (reference)

Risk of fragility fractures · Females (all ages)

In females, fragility-fracture risk was U-shaped: lowest ~0.4 mg/L, rising above 0.9 mg/L (RR 0.84 at 0.34, 1.00 at 0.9, 1.13 at 1.1 mg/L vs null); ungraded.

3 findings from 1 review
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Females: drinking-water fluoride 1.1 mg/L vs null
    RR 1.13 [0.93, 1.37]
    Studies not reported
    GRADE not reported
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Females: drinking-water fluoride 0.34 mg/L vs null
    RR 0.84 [0.67, 1.07]
    Studies not reported
    GRADE not reported
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Females: drinking-water fluoride 0.9 mg/L vs null
    RR 1.00 [0.79, 1.27]
    Studies not reported
    GRADE not reported

Higher drinking-water fluoride exposure vs Null / lowest drinking-water fluoride exposure (reference)

Lumbar spine bone mineral density (BMD) · Females (all ages)

In females (low-to-moderate risk-of-bias studies), spine BMD rose then plateaued ~0.5 mg/L: MD 0.02 g/cm2 (95% CI -0.02-0.07) at 0.20 mg/L and 0.06 (-0.01-0.12) across 0.7-2.35 mg/L vs null; ungraded.

2 findings from 1 review
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Females, low-to-moderate risk-of-bias studies: 0.7-2.35 mg/L vs null
    MD 0.06 [-0.01, 0.12]
    Studies not reported
    GRADE not reported
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Females, low-to-moderate risk-of-bias studies: 0.20 mg/L vs null
    MD 0.02 [-0.02, 0.07]
    Studies not reported
    GRADE not reported

Higher drinking-water fluoride exposure vs Null / lowest drinking-water fluoride exposure (reference)

Risk of fragility fractures · Females aged over 50 years

In females over 50, fragility-fracture risk rose steeply from ~0.5 mg/L: RR 0.98 at 0.25, 1.00 at 0.45, and 1.26 (95% CI 1.10-1.46) at 1.0 mg/L drinking-water fluoride vs null; ungraded.

3 findings from 1 review
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Females over 50 years: drinking-water fluoride 0.45 mg/L vs null
    RR 1.00 [0.80, 1.24]
    Studies not reported
    GRADE not reported
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Females over 50 years: drinking-water fluoride 0.25 mg/L vs null
    RR 0.98 [0.83, 1.14]
    Studies not reported
    GRADE not reported
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Females over 50 years: drinking-water fluoride 1.0 mg/L vs null
    RR 1.26 [1.10, 1.46]
    Studies not reported
    GRADE not reported

Higher drinking-water fluoride exposure vs Null / lowest drinking-water fluoride exposure (reference)

Hip/femoral bone mineral density (BMD) · general population

Hip BMD increased with fluoride in both sexes (linearly in males, non-linearly above ~1.2 mg/L in females); no numeric MD reported in text for the main analysis; ungraded.

1 finding from 1 review
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Both sexes, main dose-response
    Hip BMD increased in both sexes, linearly in males and non-linearly (starting above 1.2 mg/L) in females (no numeric MD reported in text for main analysis)
    Studies not reported
    GRADE not reported

Higher drinking-water fluoride exposure vs Null / lowest drinking-water fluoride exposure (reference)

Hip/femoral bone mineral density (BMD) · Females (all ages)

In females (low-to-moderate risk-of-bias studies), hip BMD rose monotonically above ~0.9 mg/L: MD 0.04 g/cm2 (95% CI -0.03-0.12) up to ~2.3 mg/L and 0.09 (-0.09-0.27) at 4.0 mg/L vs null; ungraded.

2 findings from 1 review
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Females, low-to-moderate risk-of-bias studies: up to ~2.3 mg/L vs null
    MD 0.04 [-0.03, 0.12]
    Studies not reported
    GRADE not reported
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Females, low-to-moderate risk-of-bias studies: 4.0 mg/L vs null
    MD 0.09 [-0.09, 0.27]
    Studies not reported
    GRADE not reported

Higher drinking-water fluoride exposure vs Null / lowest drinking-water fluoride exposure (reference)

Wrist fractures · general population

Wrist-fracture risk declined nearly linearly with increasing fluoride: RR 1.00 at 0.01 mg/L to 0.84 at 1.5 mg/L drinking-water fluoride vs null; ungraded.

2 findings from 1 review
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Drinking-water fluoride 1.5 mg/L vs null
    RR 0.84 [0.43, 1.65]
    Studies not reported
    GRADE not reported
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Drinking-water fluoride 0.01 mg/L vs null
    RR 1.00 [0.99, 1.01]
    Studies not reported
    GRADE not reported

Higher drinking-water fluoride exposure vs Null / lowest drinking-water fluoride exposure (reference)

Hip Fracture · general population

Overall hip-fracture risk showed little association with drinking-water fluoride and a nearly flat dose-response curve (narrow CI); no numeric RR reported in text; ungraded.

1 finding from 1 review
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Overall dose-response (0 to highest exposure)
    Curve indicated little association and was nearly flat, with a comparatively narrow 95% confidence band (no numeric RR reported in text)
    Studies not reported
    GRADE not reported

Higher drinking-water fluoride exposure vs Null / lowest drinking-water fluoride exposure (reference)

Lumbar spine bone mineral density (BMD) · Females aged over 50 years

In females over 50, spine BMD showed an inverted U-shaped curve with a downward trend beginning at lower fluoride concentrations than in the overall analysis; no numeric MD reported in text; ungraded.

1 finding from 1 review
  • The association of fluoride exposure with bone density and fracture risk: a dose-response meta-analysis. 2025 All outcomes
    Long-term / lifetime fluoride exposure · General population; 37 observational studies (1944-2024), predominantly North America (USA, Canada) and Northern Europe (Finland, Sweden), plus UK, Poland, Italy, Germany, China, Taiwan, South Korea, Ethiopia; exposure mainly community drinking-water fluoride · Females >50, spine BMD dose-response
    Inverted U-shaped curve with a downward trend starting at lower fluoride concentrations than the overall analysis (no numeric MD reported in text)
    Studies not reported
    GRADE not reported

Restricted partial pulpotomy (pulp removal 2-3 mm from exposure site only) vs Extended partial pulpotomy (pulp removal 2-3 mm from entire pulp chamber with complete deroofing)

Overall success (composite of clinical and radiographic success) · Adults (18-45 y) with mature permanent molars, carious exposure and symptomatic irreversible pulpitis

Restricting the lateral extent of partial pulpotomy gives success equivalent to more extensive amputation (97.6% vs 97.5%, p>0.05; ungraded, single trial).

1 finding from 1 review

Restricted partial pulpotomy (pulp removal 2-3 mm from exposure site only) vs Extended partial pulpotomy (pulp removal 2-3 mm from entire pulp chamber with complete deroofing)

Postoperative pain and analgesic intake · Adults (18-45 y) with mature permanent molars, carious exposure and symptomatic irreversible pulpitis

Restricted partial pulpotomy causes less early postoperative pain and analgesic use than extended amputation (p<0.05; ungraded, single trial).

1 finding from 1 review

Postnatal passive tobacco exposure (secondhand/household smoke in infancy) vs No passive tobacco exposure (non-exposed children)

Caries presence in primary teeth · Young children with primary (deciduous) dentition (aged 1 to 6 years at study start)

Postnatal (infancy) tobacco exposure is associated with higher odds of caries in primary dentition (pooled OR 1.72, 95% CI 1.45 to 2.05; 13 studies; high heterogeneity I2=83%); certainty not graded.

1 finding from 1 review

Postnatal passive tobacco exposure (secondhand/household smoke in infancy) vs No passive tobacco exposure (non-exposed children)

Dental caries in permanent teeth · Children and adolescents with permanent dentition

Postnatal (infancy) tobacco exposure is associated with higher odds of caries in permanent dentition (pooled OR 1.30, 95% CI 1.25 to 1.34; 9 studies; no heterogeneity); certainty not graded.

1 finding from 1 review

Prenatal passive tobacco exposure (maternal smoking during pregnancy / in the womb) vs No passive tobacco exposure (non-exposed children)

Dental caries in permanent teeth · Children and adolescents with permanent dentition

No eligible studies examined prenatal tobacco exposure and caries in permanent dentition.

1 finding from 1 review

Prenatal passive tobacco exposure (maternal smoking during pregnancy / in the womb) vs No passive tobacco exposure (non-exposed children)

Caries presence in primary teeth · Young children with primary (deciduous) dentition (aged 1 to 6 years at study start)

Prenatal (in-womb) tobacco exposure is associated with higher odds of caries in primary dentition (pooled OR 1.46, 95% CI 1.41 to 1.52; 4 studies; no heterogeneity); certainty not graded.

1 finding from 1 review

Passive tobacco exposure (prenatal maternal smoking or postnatal secondhand/household smoke) vs No passive tobacco exposure (non-exposed children)

Dental caries · Children and adolescents (general population, aged under 20 years)

In children and adolescents, passive tobacco exposure (prenatal or postnatal) is associated with higher odds of dental caries (pooled OR 1.53, 95% CI 1.39 to 1.68; 21 studies), though heterogeneity was high (I2=86.5%); certainty of evidence not graded.

1 finding from 1 review