• These studies should focus on moderate and severe enamel fluorosis in relation to caries and in relation to psychological, behavioral, and social effects among affected children, their parents, and affected children after they become adults.

  • Methods should be developed and validated to objectively assess enamel fluorosis. Consideration should be given to distinguishing between staining or mottling of the anterior teeth and of the posterior teeth so that aesthetic consequences can be more easily assessed.

  • More research is needed on the relation between fluoride exposure and dentin fluorosis and delayed tooth eruption patterns.

  • Bone studies

    • A systematic study of clinical stage II and stage III skeletal fluorosis should be conducted to clarify the relationship between fluoride ingestion, fluoride concentration in bone, and clinical symptoms.

    • More studies of communities with drinking water containing fluoride at 2 mg/L or more are needed to assess potential bone fracture risk at these higher concentrations. Quantitative measures of fracture, such as radiologic assessment of vertebral body collapse, should be used instead of self-reported fractures or hospital records. Moreover, if possible, bone fluoride concentrations should be measured in long-term residents.

  • Other health effects

    • Carefully conducted studies of exposure to fluoride and emerging health parameters of interest (e.g., endocrine effects and brain function) should be performed in populations in the United States exposed to various concentrations of fluoride. It is important that exposures be appropriately documented.



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