Understanding Fluoride Hesitancy: A Qualitative Scoping Review

Abstract

Fluoride is widely regarded within dentistry and public health as a safe and effective measure for preventing dental caries. Public ambivalence toward fluoride has intensified in recent years, reflected in ongoing disputes over water fluoridation. This scoping review synthesizes qualitative evidence on how fluoride hesitancy is constructed and expressed across social and clinical contexts. Qualitative studies examining perceptions, beliefs, and decision-making related to fluoride use were identified through searches of PubMed, Scopus, Embase, and CINAHL to April 2025. Twelve studies met the inclusion criteria. Data were extracted using a standardized charting approach and synthesized through an inductive, grounded theory–informed thematic analysis supported by constant comparison and reflexive memoing. Five interconnected domains of hesitancy were identified: (1) perceptions of fluoride as harmful or toxic; (2) uncertainty about benefits or necessity; (3) mistrust of scientific, professional, or governmental institutions; (4) ethical concerns regarding autonomy, consent, and environmental integrity; and (5) discomfort with specific delivery modalities paired with preferences for alternatives. Hesitancy was shaped not only by information but also by emotional responses, lived experience, parenting norms, online discourse, and interpretations of institutional credibility. Across studies, decisions about fluoride reflected broader efforts to navigate uncertainty, protect children, and maintain control over health choices. Fluoride hesitancy is a multifaceted interpretive process rather than a simple knowledge deficit. Addressing it requires approaches that pair clear scientific communication with attention to trust, autonomy, and the social contexts in which preventive recommendations are received. Strategies that acknowledge experiential perspectives and increase transparency around policy decisions may enhance the credibility and uptake of fluoride guidance, but some degree of hesitancy is likely to persist given wider environments of uneven trust and contested information.

Keywords

dental caries pediatric dentistry preventive dentistry qualitative research topical fluorides treatment refusal

Introduction

Fluoride is widely presented as an effective measure for preventing dental caries, with global policy frameworks endorsing its safety and efficacy (Petersen and Lennon 2004; Whelton et al 2019). Despite this long-standing scientific consensus, public unease regarding fluoride has intensified in recent years. Communities across multiple countries have engaged in recurrent debates over water fluoridation (Chikte 1997; Griffin et al 2008; Quiñonez and Locker 2009; Knox et al 2017), and dental professionals increasingly report encounters with caregivers who hesitate or decline professionally applied fluoride treatments (Chi et al 2023; Cruz et al 2024b). Fluoride hesitancy is defined as a delay in acceptance, thoughts of refusal, or refusal of fluoride despite availability (Ko and Chi 2023). This emerging ambivalence corresponds to a broader family of behaviors known as health hesitancies, driven by a broader shift in how individuals engage with health information, interpret risk, and place trust in scientific, professional, and governmental institutions (Bowen et al 2025).

Fluoride hesitancy shares features with other forms of contemporary health hesitancies in terms of the broader structural and cultural factors but remains distinct (Carpiano and Chi 2018). Unlike vaccine hesitancy that arises during discrete clinical encounters, fluoride-related choices permeate daily routines: brushing a child’s teeth, attending dental checkups, or drinking tap water (Ko and Chi 2023). These repeated exposures shape attitudes before clinical encounters (Burgette et al 2022), drawing on personal experience, parenting expectations, notions of “naturalness,” online discourse, and broader beliefs about autonomy and institutional trust. Understanding how these influences come together requires approaches attentive to lived experience and meaning, rather than solely to behaviors or outcomes.

Despite its growing relevance, qualitative evidence on fluoride hesitancy remains dispersed across settings, populations, and treatment modalities. Studies have examined parental refusal of topical fluoride in clinical settings (Hendaus et al 2016; Koh et al 2024), community resistance to water fluoridation (Quiñonez and Locker 2009), online promotion of fluoride-free lifestyles (Milne et al 2017), and culturally-specific narratives among minority groups (Scherzer et al 2010; Barker et al 2016). However, these perspectives have not been synthesized to explain how individuals construct meaning around fluoride such as how they interpret risk, weigh competing information, or justify refusal. Without such synthesis, the field lacks a coherent and empirically grounded understanding of fluoride hesitancy.

This scoping review addresses the gap by mapping the perspectives, motivations, and social processes that underpin fluoride hesitancy. Through a grounded, inductive analysis of qualitative studies across diverse contexts, this review develops a conceptual framework that illustrates how fluoride hesitancy emerges and is sustained.

Methods

Protocol and Registration

This review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology (Peters et al 2020). The reporting of the methodology and results was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (Tricco et al 2018). The review protocol was prospectively registered on the Open Science Framework (10.17605/OSF.IO/VNCPD).

Eligibility Criteria

The inclusion criteria followed the JBI Population–Concept–Context framework:

Population: Studies involving members of the public, dental patients, parents or caregivers, dental professionals, or other stakeholders whose perceptions, beliefs, or behaviors regarding fluoride use were explored.

Concept: Studies examining fluoride hesitancy or factors contributing to hesitancy, including beliefs, perceptions, risk interpretations, or decision-making related to fluoride or fluoridation, including fluoride toothpaste, varnish, supplements, and community water fluoridation.

Context: Studies conducted in any setting (community, clinical, educational, or public health) and in any geographical location.

Only qualitative studies using methods such as interviews, focus groups, or qualitative surveys were included. Qualitative components embedded within broader study designs (eg, mixed–methods or trial-based process evaluations) were also eligible. Quantitative studies, reviews, commentaries, conference abstracts, and non–peer-reviewed publications were excluded. Only studies published in English were considered, with no restriction on publication year.

Literature Search, Screening, and Selection

The search strategy was developed in accordance with the JBI methodology for scoping reviews. An initial search of PubMed and Scopus informed the final search terms, which were then applied to PubMed, Scopus, Embase, and CINAHL (Appendix Table 1). Reference lists of included studies were also screened. Searches were conducted up to April 10, 2025. Records were de-duplicated in EndNote and screened in ASReview Lab v2.0, with potentially relevant reports retrieved for full-text assessment against eligibility criteria by 2 reviewers; disagreements were resolved by consensus with a third reviewer when needed. Reasons for full-text exclusions were documented (Appendix Table 2). Additional details on ASReview screening, calibration, and interrater reliability are provided in the Appendix Methods.

Data Extraction

Data extraction used a standardized charting form capturing key study characteristics and findings relevant to fluoride hesitancy. The reviewers piloted the charting form on 3 studies to ensure clarity, consistency, and completeness. Minor revisions were made following this pilot phase. Two reviewers (S.M.S.C. and Y.J.O.) independently extracted data from each included study and compared the results for consistency. Discrepancies were resolved through consensus, with a third reviewer (J.R.H.T.) consulted when necessary. Extracted data included bibliographic details (author, year, country, journal), study aims, participant characteristics and recruitment context, qualitative methodology and data collection approaches, funding sources, conflict-of-interest statements, key themes and subthemes, and illustrative quotations reported in each study.

Quality Assessment

Following guidance for qualitative evidence synthesis, the methodological quality of included studies was appraised using the JBI Critical Appraisal Tool (Lockwood et al 2015). Two reviewers (A.H.C.T. and Y.J.O.) independently assessed each study, with any disagreements resolved through discussion. Where necessary, a third reviewer (J.R.H.T.) was consulted.

Data Synthesis

Qualitative findings from the included studies were synthesized using an inductive, grounded theory–informed thematic analysis, guided by the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) framework (Tong et al 2012). Consistent with grounded theory, the synthesis drew on the constant comparative method, allowing patterns and theoretical insights to emerge from the data.

Open coding was first conducted independently, concurrent with data extraction, examining data line by line to generate initial concepts and preliminary codes. These codes directed further data extraction and sampling and were iteratively compared, refined, and regrouped into higher-order categories capturing relationships among concepts across studies. Throughout this process, memo writing was used to document emerging ideas, conceptual links, and evolving interpretations. The study team also considered how their positions as dental clinicians and researchers within fluoride-endorsing health care systems might shape interpretation. Reflexive memoing and regular team discussions supported the identification of underlying assumptions, helping to ensure that interpretations remained anchored in the perspectives reported in the primary studies.

Themes were developed through continuous comparison of data within and between studies, with team discussions used to achieve interpretive coherence and consensus. Coding and thematic refinement continued until no further conceptual insights emerged. The resulting themes offer a conceptually grounded account of the factors shaping fluoride hesitancy, supported by illustrative quotes and interpretations from the included qualitative studies.

Results

Study Characteristics

A total of 1,036 records were identified. After screening and full-text assessment of 109 records, 12 studies met the inclusion criteria (Fig 1). Three studies examined water fluoridation as a municipal public health intervention. None focused on perceptions of naturally occurring fluoride in groundwater. One study assessed salt fluoridation, and the remaining studies focused on topical fluoride in clinical contexts or broader fluoride-related beliefs. Studies were conducted across North America, Europe, Australia, and the Caribbean. There was only 1 study in an upper-middle-income country (Tayhan and Çetinkaya 2024), and all other studies were in high-income contexts. When disclosed, reported funding sources were public or governmental (Appendix Table 3).

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart.

Study aims centered on public perceptions of fluoride, drivers of hesitancy, and decision-making surrounding fluoridated products or programs. Participants included parents, community members, dental patients, and online forum users recruited through clinical settings, community outreach, household surveys, and digital platforms. Across 9 studies reporting individual qualitative interview participants, 394 participants contributed to the evidence base (range 10–66 per study). One study used focus group discussions and 2 analyzed nonparticipant online data. Included studies were published between 2008 and 2024, with 7 published from 2022 onward. Data collection methods comprised interviews, focus groups, ethnography, online discourse analysis, and mixed-methods surveys (Table 1).

Table 1.

Study Characteristics of Included Studies.

Author	Year	Country of Origin	Study Aim	Participant Characteristics and Recruitment Context	Data Collection Approach	Analytic Approach/Framework
Barker et al	2016	United States	To explore and evaluate whether fluoridated salt would be acceptable to a low-income rural migrant Latino community in the United States and how domestic salt use, cultural beliefs, and experiences would help shape and influence acceptability	61 Latino parents (87% female, mostly Spanish speaking, low-income, farmworker families) in California’s Central Valley (does not add fluoride to its water supply) with children younger than 10 years old	Ethnographic interviews and focus groups in Spanish; field observations	Social constructivist approach; constant comparative method
Knox et al	2017	Australia	To investigate reasons behind strong opposition to water fluoridation in regional NSW and to make recommendations to improve community engagement	10 adult participants (90% female) with strong antifluoridation views, recruited via purposive and snowball sampling	Semi-structured interviews	Inductive and deductive qualitative thematic analysis (Braun and Clarke)
Milne et al	2017	Canada	To explore how parents engage with and reinterpret expert information on child dental health, particularly fluoride, in online forums	479 discussion threads; public BabyCenter Canada forum (publicly available online parenting forum in Canada); parents of young children	Extraction of public online parenting forum threads using keyword searches (related to caries and fluoride)	Iterative qualitative content analysis with hierarchical coding; critical content analysis informed by sociologist Sarah Netleton’s Focauldian theory of dental authority/power; critical social science lens
Ko and Chi	2023	United States	To determine associations between professionally applied topical fluoride varnish, fluoridated water, and fluoridated toothpaste hesitancy among a group of caregivers who self-reported hesitancy about topical fluoride varnish To investigate whether there was differential decision-making by caregivers among the forms of fluoride and if caregivers preferred one form of fluoride over another	56 caregivers of children ≤18 years old with self-reported hesitancy about topical fluoride; recruited from pediatric dental clinics in Seattle	Semi-structured interviews and survey; mixed-methods design with quantitative and qualitative analysis	Inductive content analysis
Griffin et al	2008	Multiple European countries	To understand European citizens’ opinions on water fluoridation, as part of research on their attitudes to the tensions between private and public interest	68 focus group discussions; adult citizens from several EU countries; recruited across multiple countries by market research companies for public opinion study (individuals who were self-proclaimed fluoride hesitant were excluded)	Structured and semi-structured questionnaires/interviews on attitudes to fluoride and water fluoridation	Inductive thematic analysis and descriptive comparison of attitudes across countries
Chi et al	2023	United States	To develop a conceptual model explaining why caregivers are hesitant or refuse topical fluoride for their children	56 caregivers of children ≤18 years old who had refused or thought about refusing topical fluoride; recruited from pediatric dental clinics (where billing records showed no fluoride) and community networks (social media, snowball sampling, dental and naturopathic practices)	In-depth semi-structured telephone interviews	Deductive and inductive content analysis; constant comparative method; development of a 6-domain, 21-category model
Leung et al	2023	United States	To assess how extended parallel process model (EPPM) and health belief model (HBM) constructs explain caregivers’ topical fluoride decision-making	56 fluoride-hesitant or fluoride-refusing caregivers recruited from a university-based and a community-based pediatric dental clinic plus community outreach	Semi-structured telephone interviews based on EPPM and HBM constructs	Deductive thematic analysis using EPPM (threat, efficacy) and HBM (benefits, barriers) constructs
Lotto et al	2023	Canada	To analyze the topics and trends of “fluoride-free” tweets over time as a window into antifluoride beliefs and misinformation	21,169 English-language tweets containing the term “fluoride-free” (May 2016 to May 2022)	Automated collection of tweets via Twitter API; preprocessing and text mining	Latent Dirichlet allocation topic modeling; intertopic distance mapping; descriptive temporal trend analysis
Cruz et al	2024a	United States	To test whether an existing conceptual model of topical fluoride hesitancy applies to Latino parents and whether applicability differs by language (Spanish vs English)	50 non-Latino English-speaking parents, 8 Spanish-speaking Latino parents, and 8 English-speaking Latino parents with a history of fluoride hesitancy/refusal	Semi-structured one-on-one telephone interviews conducted in English or Spanish	Deductive coding against the 6-domain, 21-category conceptual model; comparative content analysis by ethnicity and language group
Koh et al	2024	United States	To compare topical fluoride beliefs and refusal behaviors between caregivers of children with special health care needs (SHCN) and caregivers of healthy children To evaluate the association between special SHCN status and topical fluoride refusal To determine whether the reasons for topical fluoride refusal were different by SHCN status	520 caregivers completed a survey; 87 had a child with SHCN; 56 caregivers (12 with SHCN children) completed qualitative interviews	Online and clinic-based surveys plus follow-up semi-structured interviews with a subset of fluoride-hesitant or refusing caregivers	Deductive qualitative coding using the 6-domain topical fluoride hesitancy model
Tayhan and Çetinkaya	2024	Turkey	To develop a scale to determine parents’ attitudes and beliefs about fluoride varnish application in school health programs	810 parents of children between 6 and 11 years old in Turkey where school fluoride varnish programmes are implemented; aimed to reach all parents in selected schools using convenience sampling; 15 parents were selected for qualitative interviews Schools identified had 50% acceptance and 50% refusal rate of fluoride varnish	Qualitative interviews to generate items, followed by large cross-sectional survey using draft scale; online data collection via school WhatsApp groups and Google Forms	Inductive content analysis for item generation; exploratory factor analysis and confirmatory factor analysis; assessment of reliability and validity (Cronbach’s alpha, test–retest)
Naidu et al	2012	Trinidad and Tobago	To explore parents’ and caregivers’ experiences and beliefs about oral health care for preschool children and how these shape oral health attitudes and behaviors	18 parents and caregivers (mostly mothers) of preschool-aged children from 3 preschools in central Trinidad with diverse ethnic and socioeconomic backgrounds	Three focus groups using semi-structured topic guide	Thematic content analysis; iterative coding and comparison; reviewed by academic anthropologist for reflexivity and interpretive validity

API, application programming interface; EU, European Union; NSW, New South Wales.

Quality Appraisal

Overall, the studies demonstrated coherence between philosophical perspectives, methodologies, and methods, with most providing ethical approval and data-aligned conclusions. A consistent limitation across the evidence base was the lack of reporting on researcher positioning and reflexivity, with nearly all studies providing insufficient or unclear detail (Appendix Table 4).

Thematic Analysis

Across the included studies, a coherent picture of fluoride hesitancy emerged, spanning reluctance or refusal toward fluoride in community water supplies, professionally applied interventions, and home-use dental products (Appendix Table 5). Five overarching domains were identified (Table 2) and illustrated by representative quotes (Table 3).

1. Fluoride is harmful: Perceiving fluoride as a health and toxicity risk

Table 2.

Themes, Subthemes, and Definitions.

Theme	Definition	Subthemes	Notes
1. Fluoride is harmful: Perceiving fluoride as a health and toxicity risk	Concerns that fluoride is harmful, toxic, or biologically unnatural, often grounded in fears of chemical exposure or potential health effects	1a) Toxicity fears 1b) Fluoride as “unnatural” or a “chemical” 1c) Fear of overexposure and unknown long-term effects	Linked to broader mistrust but centered on bodily or toxicologic concerns
2. Uncertain benefits: Gaps in knowledge and doubts about fluoride’s necessity	Perceptions that fluoride offers limited benefit or is unnecessary, including uncertainty about its role in preventing caries	2a) Low perceived susceptibility to caries 2b) Perceived limited effectiveness of fluoride 2c) Limited knowledge or uncertainty about fluoride	Reflects uncertainty about relevance, effectiveness, or necessity
3. Losing faith: Erosion of trust in institutions and science	Skepticism toward institutional motives, scientific processes, or the credibility of experts and official sources	3a) Distrust in government 3b) Distrust in companies 3c) Distrust in health care professionals 3d) Distrust of scientific data	Acts as a central factor shaping other themes
4. “Not that way”: Discomfort with delivery and preference for alternatives	Objections related to specific fluoride delivery modalities or a preference for alternative approaches to oral health	4a) Opposition to water fluoridation 4b) Discomfort with topical fluoride 4c) Preference for nonfluoride alternatives	Often reflects modality-specific objections or a preference for alternative approaches (“not anti-fluoride, but opposed to certain delivery methods”)
5. Ethics of choice: Autonomy and environmental responsibility	Moral or political concerns centered on autonomy, consent, and environmental stewardship	5a) Autonomy and the right to choose 5b) Environmental and ecological concerns	Ethical concerns rooted in values rather than assessments of safety or efficacy

Table 3.

Representative Quotations Illustrating Subthemes.

Subtheme	Representative Quotation	Study
Toxicity fears	“Fluoride is toxic & I personally will make sure non [sic] is ingested by my LO [little one]. There are many studies proving that it causes neurological damage. . . . Dentists are taught to push that stuff & insist its safe, I’m not buying it!”	Milne et al (2017)
Fluoride as “unnatural” or a “chemical”	“I am often weary of doing things with chemicals [topical fluoride].”	Chi et al (2023)
Fear of overexposure and unknown long-term effects	“I am taking fluoride supplements, tooth paste enriched with fluoride. And on top of that, drinking water! I will be totally fluoridated.”	Griffin, Shickle and Moran, 2008
Low perceived susceptibility to caries	“I don’t really see the purpose of getting [topical] fluoride if they [my children] don’t have cavities.”	Chi et al (2023)
Perceived limited effectiveness of fluoride	“[My child] just continued to have bad teeth . . . I didn’t feel like it [topical fluoride] was giving positive results to continue using it because it didn’t seem to be making a difference.”	Chi et al (2023)
Limited knowledge or uncertainty about fluoride	“Well, if I was better informed I would take it, that’s why I’m used to taking what I already know.”	Barker et al (2016)
Distrust in government	“There was a survey done by the Department of Health. It was very leading . . . the whole questionnaire was really leading.”	Knox et al (2017)
Distrust in companies	“When large corporations start to twist arms of bureaucrats to pushing their own agendas onto communities . . . once science is being manipulated by corporations to get what they want, through governments, that’s it.”	Knox et al (2017)
Distrust in health care professionals	“The dentists are touting about how great it [topical fluoride] is but it’s just something extra for them to charge for.”	Chi et al (2023)
Distrust of scientific evidence	“As far as I know, no large-scale double-blind study has ever been done which goes over many years . . . it’s the only thing I would trust.”	Knox et al (2017)
Opposition to water fluoridation	“Tomorrow we put fluoride in it, the day after we put something else in it, where does it stop.”	Griffin, Shickle and Moran, 2008
Discomfort with topical fluoride	“She [my child] threw up after it [topical fluoride] and wet her pants at the same time . . . I don’t want her to go through the emotional duress.”	Leung et al (2023)
Preference for nonfluoride alternatives	“I have been making my own toothpaste for years. Essentially the 3 ingredients are: baking soda, coconut oil, salt.”	Milne et al (2017)
Autonomy and the right to choose	“I shouldn’t have to be pressured into it and I feel like fluoride is at times pushed onto parents.”	Cruz et al (2024a)
Environmental and ecological concerns	“. . . every human needs to be fighting to preserve our clean water and what’s under us.”	Knox et al (2017)

Across settings, participants frequently characterized fluoride added to water or dental products as an unnatural chemical additive, contrasting with the growing preference for “chemical-free” lifestyles and natural products (Griffin et al 2008; Chi et al 2023; Ko and Chi 2023; Leung et al 2023; Lotto et al 2023; Cruz et al 2024a; Koh et al 2024; Tayhan and Çetinkaya 2024). Fluoride was often described as artificial and potentially toxic, and these interpretations contributed to expressions of hesitancy (Griffin et al 2008; Naidu et al 2012; Barker et al 2016; Milne et al 2017; Chi et al 2023; Ko and Chi 2023; Leung et al 2023; Lotto et al 2023; Cruz et al 2024a; Koh et al 2024; Tayhan and Çetinkaya 2024). Fluoride was commonly regarded as a chemical contaminant and less as a preventive measure. Emotional reactions to the term “fluoride,” such as fear, anxiety, aversion, or disgust, further reinforced these views.

These risk perceptions persisted regardless of the information provided during these encounters, suggesting that concerns were grounded equally in emotional and experiential factors as in informational ones. Among caregivers, particularly parents of young children or those with special health care needs, avoidance was often described as a precautionary measure to protect the child (Chi et al 2023; Leung et al 2023; Cruz et al 2024a; Koh et al 2024). Biological or toxicological worries were frequently cited, but these accounts also intersected with wider concerns, including varying levels of trust in institutions and differing views on whether fluoride is necessary.

2. Uncertain benefits: Gaps in knowledge and doubts about fluoride’s necessity

Many participants also questioned whether fluoride was necessary, expressing uncertainty and skepticism about its effectiveness. For some, this uncertainty stemmed from limited knowledge or awareness rather than deliberate opposition (Barker et al 2016; Milne et al 2017; Chi et al 2023; Ko and Chi 2023; Cruz et al 2024a; Koh et al 2024; Tayhan and Çetinkaya 2024). Several caregivers of children and adolescents reported not knowing whether professionally applied fluoride or community water fluoridation provided additional benefits beyond routine oral hygiene. In situations in which explanations from health professionals were perceived as unclear or inconsistent, uncertainty tended to lead to hesitation rather than outright refusal. Other participants believed that good oral hygiene and regular toothbrushing were sufficient, reducing their perceived need for fluoride exposure (Griffin et al 2008; Milne et al 2017; Chi et al 2023; Ko and Chi 2023; Leung et al 2023; Cruz et al 2024a; Tayhan and Çetinkaya 2024). Some also expressed low confidence in fluoride’s effectiveness, questioning whether water fluoridation or topical applications provided the level of protection presented in public health messaging (Knox et al 2017; Chi et al 2023; Leung et al 2023; Cruz et al 2024a; Koh et al 2024; Tayhan and Çetinkaya 2024). These doubts extended to the credibility and relevance of scientific evidence, with fluoridation viewed by some as outdated or overstated. Overall, low perceived benefit often intersected with varying levels of trust in institutions. When the purpose of fluoride was unclear or uncertain, concerns about perceived risks became more prominent in decision-making.

3. Losing faith: Erosion of trust in institutions and science

Mistrust was a recurring influence on hesitancy. Participants frequently expressed skepticism toward government agencies, health authorities, dental professionals, and scientific institutions (Griffin et al 2008; Knox et al 2017; Milne et al 2017; Chi et al 2023; Ko and Chi 2023; Cruz et al 2024a; Tayhan and Çetinkaya 2024). In several studies, fluoridation initiatives were interpreted as politically or commercially motivated, rather than oriented toward public health. Perceived inconsistencies or a lack of clarity in public health messaging sometimes led participants to seek information from alternative sources, such as online communities and personal networks, which were viewed as more relatable or trustworthy.

4. “Not that way”: Discomfort with delivery and preference for alternatives

Participants generally did not oppose fluoride itself; rather, their concerns centered on how it was delivered. Community water fluoridation was perceived by some as a broad, population-level intervention that might be suitable for large groups but not tailored to individual needs (Griffin et al 2008; Knox et al 2017; Ko and Chi 2023; Lotto et al 2023; Cruz et al 2024a). Individual modalities, such as fluoridated toothpastes, dietary measures, or professionally applied products, were often preferred (Griffin et al 2008; Cruz et al 2024a). Among parents and caregivers, especially those caring for children with special health care needs, practical and sensory considerations further shaped these choices. Topically applied fluoride was frequently described as uncomfortable or distressing for children due to taste and texture sensitivity (Chi et al 2023; Leung et al 2023; Cruz et al 2024a; Koh et al 2024). Avoidance in these instances was often framed as a rejection of the mode of delivery to protect the child’s comfort and well-being, despite recognition by caregivers of the potential preventive benefits of fluoride.

5. Ethics of choice: Autonomy and environmental responsibility

Ethical and rights-based concerns featured across studies, particularly in relation to community water fluoridation (Griffin et al 2008; Knox et al 2017; Ko and Chi 2023; Lotto et al 2023; Cruz et al 2024a). Participants frequently described fluoridation as limiting personal autonomy, with some characterizing it as a form of “forced medication,” or as a public health measure implemented without individual consent (Griffin et al 2008; Knox et al 2017; Chi et al 2023; Ko and Chi 2023; Cruz et al 2024a; Koh et al 2024). Informed consent was viewed as a moral principle that should apply not only in clinical settings but also to population-level interventions. Beyond individual autonomy, some participants raised broader ethical and environmental concerns (Knox et al 2017). These included questions about the collective right to alter natural water systems and potential ecological consequences, such as the effects on aquatic ecosystems or water purity. In these accounts, hesitancy extended beyond bodily considerations to ideas about environmental integrity and resistance to perceived human-made modification of natural resources.

Ethical considerations therefore centered on issues of consent, choice, and the role of government in influencing health-related behavior. These concerns often intersected with broader patterns of trust and mistrust, with participants who doubted governmental motives being more likely to express reservations about the legitimacy of fluoridation policies. Social context added further complexity. Some individuals felt encouraged by professionals or peers to accept fluoride, while others found their doubts reinforced within personal networks or online communities that promoted “natural” or fluoride-free lifestyles (Ko and Chi 2023; Tayhan and Çetinkaya 2024). Thus, autonomy concerns interacted with social identity, moral values, and environmental perspectives.

Discussion

This review indicates that fluoride hesitancy is a multidimensional process shaped by emotional responses, interpretations of risk and benefit, trust in institutions, ethical commitments, and the practicalities of everyday care. Rather than a simple matter of “for” or “against” fluoride, the findings suggest a continuum of positions in which people negotiate uncertainty, responsibility, and control across different social and clinical contexts.

Across the themes, concerns about harm and toxicity were often expressed in vividly emotional terms. This pattern is consistent with broader work in risk psychology showing that affective reactions often precede and shape risk judgments. The “affect heuristic” and “risk-as-feelings” models propose that intuitive, emotion-based appraisals can dominate over more deliberative assessments when individuals evaluate hazards in health and environmental domains (Loewenstein et al 2001; Slovic et al 2007). Research on vaccine decision-making similarly demonstrates that people rely on heuristic cues such as the behavior of trusted persons, perceived experts, or the majority when navigating uncertainty, with social signals serving as practical means of resolving ambiguity (Xu et al 2024). Within this perspective, hesitancy is not simply a knowledge deficit but a response to uncertainty. Persistent concerns about fluoride safety, even in the presence of additional information, can therefore be understood as part of a broader process of making sense of risk, responsibility, and protection in everyday life.

In several studies, fluoride concerns related as much to the institutions promoting it as to fluoride itself. Healthcare operates as a social institution sustained by trust, cooperation, and perceptions of fairness (Gilson 2003). When communication from authorities was experienced as opaque, one sided, or inattentive to individual concerns, people often sought information from sources that felt more responsive to their own experiences. Similar patterns have been observed in the vaccine confidence literature, where declining trust in governments, industry, and scientific institutions has created space for competing explanations (Larson et al 2018). Social media can amplify this shift by strengthening trust in peer communities, elevating lay expertise, and making personal stories appear more credible than institutional messages (Nicholls et al 2024). A clear dichotomy emerged when comparing studies on water fluoridation, where the underlying institution was the government and utility infrastructure against studies on topical fluoridation, where the underlying institution was the healthcare system mediated by the specific healthcare providers. In water fluoridation, in which decisions were made by government and utility infrastructure rather than face to face, participants framed their concerns in terms of coercion, lack of choice, and suspicion of political or corporate agendas. For professionally applied topical fluoride, hesitancy was more often centered on children’s vulnerability, previous negative experiences, and perceived pressure or inadequate explanation from dental teams. Only 1 study examined fluoride toothpaste hesitancy, with the qualitative literature instead emphasizing community water fluoridation, likely because it is a collective, nonoptional intervention. Caregivers in several studies expressed uncertainty about its evidence and wanted more clarity about how safety and effectiveness were established. Across both contexts, institutional advice was interpreted alongside information drawn from peers, social media, and alternative health networks. The resulting doubts typically related to wider questions of trust and credibility rather than to specific disputes about toxicology or caries-prevention data (Griffin et al 2008; Knox et al 2017).

Conceptual Framework: Anthropological Model on Fluoride Hesitancy

Medical anthropology offers a useful lens for understanding fluoride hesitancy because it positions health decisions within wider cultural and political contexts rather than treating them solely as responses to clinical risk information (Singer and Clair 2003; Janes and Corbett 2009). As reflected in the conceptual framework (Fig 2), fluoride hesitancy emerges through the interaction of macro-level political and informational environments, meso-level social and cultural systems, and micro-level embodied experiences. Concerns about fluoride or preferences for “fluoride-free” products can be understood as part of broader patterns of self-care and identity, resonating with the idea of the “mindful body,” in which health practices reflect personal values and social expectations (Lock and Scheper-Hughes 1987).

Figure 2.

Conceptual framework of fluoride hesitancy.

Research on parenting and health behaviour shows that refusals of preventive interventions often stem from perceived efforts to be vigilant and protective, rather than from disagreement with clinical recommendations. These decisions are also shaped by parents’ social environments, including peer networks and moral expectations about responsible caregiving (Reich 2020): caregivers frequently grounded decisions in children’s sensory experiences, previous distress, or a desire to retain control over what enters the child’s body. These are shaped and reinforced by meso-level social environments such as peer networks and online communities.

Fluoride hesitancy also reflects interpretations of the legitimacy of institutions. Concerns about water fluoridation often centered on the role of government, perceived transparency of decision-making, and whether population-level measures respected community values. In contrast, hesitancy around topical fluoride tended to arise within everyday clinical encounters, shaped by communication style, perceived pressure, or how well parents felt their concerns were acknowledged. Attending to these social and institutional dimensions does not detract from the strength of the evidence for fluoride’s effectiveness; rather, it highlights where communication and engagement efforts can be strengthened so that preventive guidance feels credible, relevant, and responsive to the communities it aims to serve.

The findings also suggest that participants often approach fluoride from social, ethical, and experiential perspectives that differ from professional framing of fluoride as a routine preventive measure. While professional discourse tends to frame fluoride as a well-established preventive measure, members of the public may interpret it through alternative understandings of safety, autonomy, or past experiences with institutions. Recognizing these differing ways of making sense of fluoride can facilitate more productive dialogue and improve the credibility of preventive recommendations within the lived contexts in which individuals and families make decisions.

Strengths and Limitations of the Study

This review adhered to methodological and reporting standards, including JBI guidance, PRISMA-ScR, and ENTREQ. A quality assessment of the included studies was conducted, strengthening the transparency of the synthesis. Inductive and grounded analysis, drawing on constant comparison, allowed findings to be synthesized into a coherent, conceptually informed account of how fluoride hesitancy is constructed. However, the study is not without limitations. Studies were mostly from high-income settings, which may reflect varying cultural perceptions of risk, autonomy, and health responsibility that may not generalise to contexts in which dental caries burden, water infrastructure, or trust in public institutions differ. In such settings, fluoride hesitancy may also be shaped by affluence, as the ability to opt out of fluoride exposure (eg, through bottled water, filtration, or specialty products) may also be unevenly distributed by socioeconomic resources. None of the included studies explicitly examined the role of fluoridated bottled water or how commercial alternatives may mediate fluoride exposure and decision-making. As an interpretive synthesis, it offers a map of documented perspectives and underlying patterns not accessible through quantitative approaches. Formal patient and public involvement consultation was not undertaken in this scoping review. This may have limited the incorporation of lived experience, and future reviews would benefit from integrating patient and public involvement to enhance relevance and interpretation of findings.

Implications for Practice and Policy

Future research should use anthropological, ethnographic, and participatory approaches to examine how fluoride hesitancy develops in everyday life. Such approaches can inform communication strategies that prioritise dialogue rather than downstream messaging, while experiments testing informational cues and adapted trust-framework measures can clarify when hesitancy increases and what predicts it (Schwarzinger et al 2021; Bowen et al 2025).

The findings also highlight a broader misalignment between how clinicians and policymakers frame prevention and how members of the public make sense of fluoride. Professional guidance is often presented through epidemiological and risk–benefit logics, whereas patients draw on experiential, moral, and relational frameworks shaped by daily life (Dein 2003; Buus et al 2012). The evidence base was also dominated by public, caregiver, and community perspectives, with minimal representation of dental professional, policymaker, or implementer viewpoints. Future qualitative research incorporating these perspectives may support more comprehensive and context-sensitive engagement strategies. Addressing fluoride hesitancy requires strategies that extend beyond information provision. Clinically, this involves making space for questions, acknowledging uncertainty where appropriate, and explaining decisions clearly. At the policy level, clearer communication about how fluoridation decisions are made, why specific concentrations are used, and how safety is monitored may help strengthen trust. Treating experiential and scientific knowledge as complementary can help ensure that fluoride guidance is both trusted and used. However, in environments characterised by uneven trust and conflicting information, some hesitancy will be expected to remain.

Conclusion

Fluoride hesitancy reflects a combination of emotional, ethical, social, and experiential influences rather than a single concern. These dynamics influence how individuals interpret risk, benefit, and the trustworthiness of recommendations in relation to water fluoridation, professionally applied topical fluoride, and fluoride use at home. Recognising hesitancy as an interpretive process rather than a knowledge deficit provides a foundation for clinical and policy approaches that are more responsive to lived experience, more attentive to autonomy and trust, and ultimately more effective in supporting preventive oral health.

Author Contributions

S.M.S. Chen, Y.J. Ong, contributed to design, data acquisition, analysis, and interpretation, drafted and critically revised the manuscript; L.Y. Soh, contributed to design, data acquisition, analysis, and interpretation, critically revised manuscript; A.H.C. Tay, D.Y. Chow, contributed to design, data analysis and interpretation, critically revised the manuscript; J.R.H. Tay, contributed to conception and design, data acquisition, analysis, and interpretation, drafted and critically revised manuscript. All authors gave final approval and agree to be accountable for all aspects of the work.

Supplemental Material

sj-docx-1-jdr-10.1177_00220345261428043 – Supplemental material for Understanding Fluoride Hesitancy: A Qualitative Scoping Review

Supplemental material, sj-docx-1-jdr-10.1177_00220345261428043 for Understanding Fluoride Hesitancy: A Qualitative Scoping Review by S.M.S. Chen, Y.J. Ong, L.Y. Soh, A.H.C. Tay, D.Y. Chow and J.R.H. Tay in Journal of Dental Research

Footnotes

Acknowledgements

None.

A supplemental appendix to this article is available online.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

S.M.S. Chen

Y.J. Ong

L.Y. Soh

A.H.C. Tay

D.Y. Chow

J.R.H. Tay

Data Availability

The data supporting the findings of this study are provided in the Appendix. Detailed descriptions of the literature-screening process, calibration procedures, and interrater reliability are provided in the Appendix Methods. The complete search strategies and database counts are in Appendix Table 1, the list of full‑text exclusions with reasons is in Appendix Table 2, the reported funding sources and conflict of interest statements from included studies are in Appendix Table 3, the qualitative critical appraisal outcomes for included studies are in Appendix Table 4, and the thematic synthesis mapping of studies to themes and subthemes is in Appendix Table 5. As this review synthesized published qualitative studies, no original interview transcripts were generated; illustrative quotes were drawn from the included publications and cited in the text.

Registration Number

10.17605/OSF.IO/VNCPD

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