Fluoride confidence: why more facts alone fail to persuade hesitant caregivers

Fluoride has one of the most mature evidence bases in preventive medicine, yet the professionals who deliver it increasingly report that scientific maturity does not automatically translate into stable public confidence. In a Perspective paper published in Frontiers in Oral Health, Guglielmo Campus of Sahlgrenska University Hospital in Gothenburg, Marco Dettori of the University of Sassari and Peter Karl Lingström of Sahlgrenska argue that fluoride communication should be treated as an intervention requiring diagnosis, targeting and evaluation, rather than as the simple transmission of facts. Their argument responds to a practical challenge that has grown visible in dental practices: fluoride hesitancy, particularly toward topical fluoride, has emerged as a communication problem for oral-health professionals that cannot be solved by making more scientific information available.

The empirical signal behind this concern comes from two strands of research. Survey data have shown that dentists perceive caregiver fluoride refusal as a relevant and growing challenge, with a substantial proportion reporting discomfort when discussing fluoride with caregivers who refuse it. Qualitative research has further shown that oral-health professionals use heterogeneous approaches when managing fluoride-hesitant caregivers, including education, insistence, disengagement and shared engagement, and that these approaches are not consistently grounded in evidence-based communication principles. Taken together, these observations suggest that the problem is not the availability of evidence about efficacy, exposure and safety, which remains essential, but how that evidence is interpreted, by whom, in which context and with what consequences for behaviour. Decisions are also shaped by perceived control, trust in professionals and institutions, prior experiences, values, social narratives and the broader information environment.

A central conceptual move in the paper is the separation of attitudinal constructs that are often collapsed into a single category. The authors use fluoride confidence to refer broadly to the conditions that enable individuals and populations to make informed decisions about fluoride based on credible evidence, an appropriate understanding of benefits, risks and uncertainty, and trust in the sources and processes through which that evidence is communicated. Confidence, in this framework, is not simply the inverse of hesitancy, nor an expectation that everyone will reach the same decision. Hesitancy denotes uncertainty or ambivalence, whereas opposition refers to an explicitly negative stance toward fluoride use. These attitudes must also be distinguished from behavioural outcomes such as acceptance, delay or refusal, and from trust, which may influence confidence without being synonymous with it.

This distinction matters because the statement I do not want fluoride may conceal very different underlying concerns. A caregiver may believe fluoride is unnecessary, may wish to avoid substances perceived as chemicals, may fear harm, may be uncertain about the quality or completeness of the evidence, or may distrust the professional relationship and feel pressured. These positions are not minor variants of the same attitude; they represent different mechanisms and therefore imply different communication tasks. The authors identify additional fluoride-specific determinants that warrant empirical investigation, including perceptions of natural versus artificial interventions, commercial distrust related to dental products, previous dental experiences, differing understandings of caries as a disease process, and exposure to social-media narratives promoting non-fluoride alternatives.

The framework explicitly challenges the knowledge-deficit response, the assumption that reluctance is primarily caused by insufficient factual knowledge and that additional information should therefore reduce it. That response may be appropriate when the barrier is a correctable misunderstanding about benefit, dose or exposure. It is less plausible when the dominant barrier is distrust, perceived coercion, identity, loss of control or an unresolved uncertainty that the person regards as legitimate. In those circumstances, supplying more facts without addressing the actual mechanism may be ineffective and, in some circumstances, counterproductive. Observed refusal, the authors stress, is an endpoint rather than a diagnosis: the same behaviour may arise from different combinations of beliefs and circumstances, while similar concerns may produce different behaviours in different people. Communication research should therefore separate at least three levels: the underlying concern or determinant, the expressed stance such as hesitancy or opposition, and the behavioural outcome such as acceptance, delay or refusal.

To build the framework, the authors drew on a methodological precedent from vaccination research, which has progressed from describing hesitancy to measuring determinants, tailoring interventions and evaluating outcomes. Dentistry initially looked to that field for an empirical reason: in a study of 1,024 caregivers, immunisation refusal was associated with topical fluoride refusal, suggesting that preventive-care refusal behaviours can cluster within individuals or families. Subsequent evidence made the picture more nuanced. Carpiano and Chi found that analogous attitudes toward childhood vaccines and topical fluoride could be correlated across domains, while their adjusted associations with actual refusal differed, with some measures predicting vaccine refusal but none of the analogous measures predicting topical fluoride refusal. A later study found that caregiver opposition to topical fluoride was associated with opposition to COVID-19 vaccination, showing that the behavioural association persisted in a different vaccination context. The most important lesson, the authors conclude, is not that fluoride hesitancy is a dental form of vaccine hesitancy, but that similar preventive behaviours can have different patterns of determinants. Recent evidence illustrates this directly: caregiver political affiliation was associated with childhood vaccine hesitancy, whereas it was not significantly associated with opposition to topical fluoride or community water fluoridation. Vaccination research therefore provides a methodological roadmap, not a causal template.

Progress requires constructs that can be measured reproducibly, and the authors point to the Fluoride Hesitancy Identification Tool, or FHIT, developed as a 20-item psychometrically evaluated measure of five domains of caregiver topical fluoride hesitancy: perceived lack of necessity, concern about chemicals entering the child’s body, perceived harmfulness, uncertainty about topical fluoride science, and distrust or feeling pressured by dentists and their motives. The importance of the FHIT is not that it supplies a universal taxonomy, but that it converts an otherwise vague construct into dimensions that can be compared, tested and related to outcomes. The first empirical application in a U.S. caregiver sample of 1,042 caregivers clarified the construct further: 82.9 percent met the study definition of general hesitancy, while 39.1 percent expressed opposition to topical fluoride. Hesitancy was strongly associated with opposition, but the two constructs were not equivalent. Among hesitant caregivers, 45.9 percent expressed opposition, whereas 97.3 percent of those expressing opposition were hesitant. This asymmetry is conceptually important: hesitancy can exist without opposition, and therefore should not be treated as a proxy for refusal or an anti-fluoride identity. For communication practice, hesitancy may represent uncertainty, ambivalence or unresolved concerns rather than a fixed behavioural endpoint, creating an opportunity for tailored responses. The authors caution, however, that existing evidence is concentrated in specific populations and settings, that cross-cultural validity cannot be assumed, and that translation should involve more than language equivalence, since the salience, meaning and structure of hesitancy domains may differ across countries, health systems, cultures and patterns of fluoride exposure.

The diagnosis-driven framework that follows integrates fluoride-specific evidence with methodological principles from the WHO Behavioral and Social Drivers of Vaccination framework, the WHO and UNICEF human-centered design approach, and the ECDC social and behavioral science tools. These frameworks should not be imported wholesale into fluoride communication, the authors argue, but they establish a directly transferable principle: the intervention should follow diagnosis, not precede it. The framework is governed by two principles. First, structured measurement and social listening should operate continuously, because both the prevalence and the content of concerns may change; structured instruments measure what researchers already know to ask, while a changing information environment can generate new narratives, vocabulary, concerns and information voids before these are represented in a questionnaire. Second, a communication response should be selected only after six diagnostic dimensions have been specified: the relevant population, such as caregivers of young children rather than a generic public; the information and decision environment, such as a concern reinforced by social media before a dental visit; the level of action, whether individual, clinical, community-based, informational, organisational, public-health or policy-level; the credible messengers and necessary partners, including oral-health professionals, public-health authorities, behavioral scientists, communication specialists, professional organisations and communities; and the predefined endpoint, which may be knowledge, perceived benefit, risk perception, confidence, trust, intention, uptake or another measurable outcome. Diagnosis may even indicate that communication is not the appropriate intervention at all, since some barriers may require changes in clinical practice, service organization, institutional transparency or policy rather than changes in messaging.

When communication is indicated, the response enters an action cycle with four steps. The first is Match: the strategy, messenger and setting should correspond to the diagnosed barrier, since a perceived-benefit problem may require a different response from uncertainty, uncertainty requires a different response from distrust, and a specific misinformation narrative should not be treated as equivalent to general skepticism. The second is Test: the selected response should be evaluated prospectively rather than assumed to work because it is scientifically accurate or intuitively persuasive. The third is Evaluate: success must be judged against the outcome defined before the intervention, because increased knowledge is not synonymous with increased trust, reduced risk perception is not synonymous with uptake, and stated intention is not behaviour. The fourth is Adapt: ineffective components should be revised, effective components should be tested for transferability, and scaling decisions should consider context, feasibility and equity. The authors illustrate the cycle with a worked example in which structured measurement or social listening identifies concern about fluoride harmfulness or dose among caregivers; diagnosis then specifies the population, information setting and intended endpoint, such as risk perception or confidence; a matched response uses a trusted oral-health professional to explain dose and exposure, prospectively compared with standard information; evaluation focuses on the predefined endpoint rather than knowledge alone; and the response is adapted or scaled only if effectiveness, context and equity support it.

Two requirements apply across the entire cycle, and the authors are explicit that the framework itself remains conceptual and has not yet undergone prospective empirical validation. The first requirement is transparency: communication should distinguish established evidence, legitimate uncertainty and unsupported claims, rather than implying certainty where uncertainty remains or treating every question as misinformation. The second is equity: a strategy that works in a well-resourced clinical setting may fail where access, language, digital connectivity, health literacy or continuity of care differ, and evaluating average effectiveness without examining distributional effects can conceal widening inequalities. Social listening, described in WHO guidance as a method for understanding conversations and concerns to inform proportionate and effective public-health responses, is proposed as a complement to structured measurement, analyzing questions, narratives, attitudes and uncertainties across health-system data, traditional media and user-generated digital content. In fluoride communication this function is particularly relevant because concerns may circulate across clinical encounters, peer networks, search engines, social platforms and, increasingly, AI-mediated interfaces, where potential risks include amplification of inaccurate information, false certainty and opaque sourcing, while potential opportunities include improving access to understandable information and directing users toward reliable sources. The authors stress that the role of AI-mediated information environments should be treated as an empirical research question rather than assumed, and that listening approaches should be ethical, privacy-conscious and proportionate, with the task not to surveil disagreement but to identify what people are asking, what remains unanswered and which narratives are gaining salience.

The research agenda that follows is deliberately comparative and multicountry. Current measures and findings should be tested across countries, languages, cultures and fluoride-delivery settings, with cross-cultural validation examining whether the same hesitancy domains retain their meaning and measurement properties and whether additional context-specific domains emerge. The framework should also be operationalized differently across delivery contexts: professionally applied topical fluoride involves an individual clinical decision within a direct patient-professional or caregiver-professional interaction, where communication may focus on perceived need, dose, safety, autonomy and trust in the clinician, whereas community water fluoridation operates at a population and policy level, where concerns may center on collective exposure, perceived control, institutional trust, equity, governance and the legitimacy of public-health decision-making. The same diagnostic framework can be retained, but the relevant population, actors, setting, barriers, intervention level and outcomes will differ. Research should move beyond prevalence estimates toward explanatory models that distinguish profiles of hesitancy and their relationships with opposition and behaviour, and comparative studies are needed to determine whether dose-and-exposure explanations, uncertainty communication, autonomy-supportive dialogue, prebunking or messenger changes work for different profiles rather than assuming a universally effective approach. No single data source can capture the full phenomenon, so structured surveys, qualitative research, clinical interaction studies, social listening, longitudinal designs and intervention trials should be deliberately combined. The objective, the authors conclude, is not to persuade everyone to hold the same view about fluoride or to dismiss legitimate uncertainty as misinformation, but to replace generic and reactive communication with transparent and evidence-based approaches, making communication itself an object of scientific inquiry so that the next challenge can be determined: what works, for whom, and under which conditions.

Subject of Research: Editorial: Fluoride across the world: innovations, access, outcomes and controversies

Article Title: Editorial: Fluoride across the world: innovations, access, outcomes and controversies

Article References: Dettori, M., Lingström, P., & Campus, G. (2026). Editorial: Fluoride across the world: innovations, access, outcomes and controversies. Frontiers in Oral Health, 7, Article 2005477. https://doi.org/10.3389/froh.2026.2005477

Image Credits: AI Generated

DOI: 10.3389/froh.2026.2005477

Keywords: Editorial, Fluoride, across, world, innovations, access, outcomes, controversies, scientific research