When I first learned that a critical medication for transplant patients — one that keeps them alive — had generic versions that might not be effective, I called a specialty pharmacist at a hospital in Virginia. Adam Cochrane had written a journal article about the problems with the generics. 

The drug is called tacrolimus, and it keeps a transplant patient’s body from rejecting a donated organ. I was surprised to hear that Cochrane had several patients he thought had died in part because their generic tacrolimus hadn’t worked right.

He told me about Hannah Goetz, though he didn’t divulge her name initially. She would become the focus of a story I published recently that’s part of a larger investigation into how the Food and Drug Administration has for years allowed risky drugs into your medicine cabinet. 

Hannah was 17 when she had a double lung transplant because of complications from cystic fibrosis, a genetic condition that fills the organs with mucus. She died in 2023 at just 21 years old, he said. And she had been taking one of the bad generics. 

He agreed to see if her mom would be willing to chat with me. When I met Holly Goetz at her home in Portsmouth, Virginia, she was open and personable. She was angry, too. Hannah had died too young. She welcomed the chance to tell her daughter’s story. “I was excited, because someone was going to research this issue,” Holly told me recently. “Possibly turn things around.” Before we’d met, she’d been told she didn’t have any legal recourse to sue over Hannah’s death despite the issue with the generic. Lawyers told Holly it was impossible to draw a straight line from Hannah’s death to a generic manufacturer.

I knew that in telling Hannah’s story in detail, I’d also be telling the larger story about tacrolimus, and larger still about the systemic failures at the FDA. ProPublica’s reporting typically focuses on exposing wrongdoing in the hopes of spurring change. I wasn’t sure whether our reporting would bring Holly the accountability she yearned for, at least not in a tangible way. I hoped Holly’s experience sharing an intimate, tragic part of her life wouldn’t end up being a disappointment.

Holly had been by Hannah’s side, advocating for her since she was diagnosed with cystic fibrosis and through the four-year journey after the transplant. Over several hours as the sky turned dark that February day, she took me through all that happened — from Hannah’s sudden need for a transplant where she almost died, to her doing well enough to take college courses and enjoy having her first (and only) real boyfriend, to her unexpected decline just three and half years after the successful transplant. 

“It was hard, because I was reliving everything over again,” Holly said of our first interview at her home. “Then again, I got to talk to someone else about Hannah, who she was, not just her in the hospital.” 

As she showed me Hannah’s peach bedroom that day, with its dozens of stuffed animals and the hair bows she wore every day when she was in school, Holly shared that when Hannah was a little girl she started sticking her tongue out in pictures. Holly laughed, saying she thought for sure Hannah would outgrow the habit, but it turned into her signature pose. Now, one of those pictures hangs from Holly’s rearview mirror in her car, one of many touchstones. There are photos and memorabilia of Hannah all over the house. I felt privileged to step into Holly’s own bedroom to see the pink urn with angel wings that holds Hannah’s ashes. 

During our conversation, I realized that my reporting had given me access to key details about Hannah’s death that Holly didn’t know. I didn’t relish being the messenger who informed her that Hannah had taken not just one but actually two different suspect generic versions of tacrolimus, that she had the misfortune of exclusively taking ones that doctors, pharmacists or the FDA had found problematic. Holly’s eyes widened. I had to share, too, that the FDA had revoked one version’s generic status just two months after Hannah had died. 

The two manufacturers of the generic medication Hannah was taking, companies named Accord and Dr. Reddy’s, both maintain that their tacrolimus is safe and effective. An Accord spokesperson said in a statement that the company cannot comment on individual cases but that it is “dedicated to patient safety, product quality and regulatory compliance.” Dr. Reddy’s said in a statement that it hasn’t received any complaints that “indicated any concerns in patient safety.” 

The next day as I made the three-hour drive back to Washington, D.C., where I live, I called one of ProPublica’s managing editors, Tracy Weber, whom I’ve known for years. I cried as I described my conversation with Holly. One unavoidable aspect of my job is that I’m often asking people about the worst things that have happened to them. In my two decades as a reporter — quite a few of those years spent covering the Iraq and Afghanistan wars — I’ve sat at many kitchen tables with grieving mothers. Talking with Holly, though, was the first time I’d done so as a mother myself. Her sorrow hit me differently. 

Over the next nine months, I’d be a constant presence in Holly’s life. We texted hundreds of times. She dug up old photos and videos and gave me access to Hannah’s private Instagram account. One of the hardest moments was listening to a recording Holly sent of the doctors telling Hannah shortly before she died that they couldn’t give her a second transplant.

The ask from an investigative reporter is never just, “Tell me about your loved one.” Our work requires meticulous detail and all the receipts. I had to recruit Holly to take considerable time to help with my reporting. 

There were four years of medical care I needed to comb through to write the story, which meant asking Holly to track down records from two hospitals and, crucially, the pharmacy where Hannah had gotten all her medications. It wasn’t a simple task. 

Hannah was an adult when she died, so Holly wasn’t automatically entitled to her records. Although Hannah had signed an advance directive giving Holly power of attorney before her death, including the ability to request records, Holly still couldn’t get access.

She had to recruit a lawyer friend and attend probate court to get Hannah’s hospital records for me. “What I had to go through to get them was ridiculous,” Holly said. I first asked about the records in February. It took until May for her to get appointed as executor of Hannah’s estate, and then several more months for the hospitals and pharmacy to fulfil Holly’s request and send her the records. We didn’t have them until July. 

There were upwards of 13,000 pages — all of which she shared with me. Sometimes, the records meant I had to ask uncomfortable questions of Holly. Why, for example, didn’t Hannah consistently take her medication for her pancreas? Did that mean she also didn’t take her tacrolimus? (Answers: She didn’t like how the pancreas drug made her feel, and Holly was so insistent on guaranteeing her daughter took her tacrolimus that she made her FaceTime when she took the pills away from home.) Holly was unfazed by even the most difficult questions. She and Hannah were alike that way: There was no shrinking from the world. Holly made my job a lot easier; she didn’t have to.

I hesitated each time I had to reach out, wondering if texting about Hannah in the middle of the day would be jarring. What was it like for Holly to check her phone on her break from teaching high schoolers and be greeted with a message that would take her back to Hannah’s final days in the hospital? To my relief, Holly told me later she looked forward to my texts or calls. “I like sharing everything about Hannah,” she said. 

Holly said she had agreed to talk to ProPublica because she thought speaking to me and the resulting story might bring her a sense of closure. Did it? I asked her. 

“Yes, because more people know now what really happened,” she said. “The real story.”

The post Her Daughter Died After Taking a Generic Version of a Lifesaving Drug. This Is What She Wants You to Know. appeared first on ProPublica.

When Ciji Graham visited a cardiologist on Nov. 14, 2023, her heart was pounding at 192 beats per minute, a rate healthy people her age usually reach during the peak of a sprint. She was having another episode of atrial fibrillation, a rapid, irregular heartbeat. The 34-year-old Greensboro, North Carolina, police officer was at risk of a stroke or heart failure. 

In the past, doctors had always been able to shock Graham’s heart back into rhythm with a procedure called a cardioversion. But this time, the treatment was just out of reach. After a pregnancy test came back positive, the cardiologist didn’t offer to shock her. Graham texted her friend from the appointment: “Said she can’t cardiovert being pregnant.”

The doctor told Graham to consult three other specialists and her primary care provider before returning in a week, according to medical records. Then she sent Graham home as her heart kept hammering.   

Like hundreds of thousands of women each year who enter pregnancy with chronic conditions, Graham was left to navigate care in a country where medical options have significantly narrowed.

As ProPublica has reported, doctors in states that ban abortion have repeatedly denied standard care to high-risk pregnant patients. The expert consensus is that cardioversion is safe during pregnancy, and ProPublica spoke with more than a dozen specialists who said they would have immediately admitted Graham to a hospital to get her heart rhythm under control. They found fault, too, with a second cardiologist she saw the following day, who did not perform an electrocardiogram and also sent her home. Although Graham’s family gave the doctors permission to speak with ProPublica, neither replied to ProPublica’s questions.

Graham came to believe that the best way to protect her health was to end her unexpected pregnancy. But because of new abortion restrictions in North Carolina and nearby states, finding a doctor who could quickly perform a procedure would prove difficult. Many physicians and hospitals now hesitate to discuss abortion, even when women ask about it. And abortion clinics are not set up to treat certain medically complicated cases. As a result, sick pregnant women like Graham are often on their own.

“I can’t feel like this for 9mo,” Graham wrote her friend. “I just can’t.” 

She wouldn’t. In a region that had legislated its commitment to life, she would spend her final days struggling to find anyone to save hers. 

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Graham hated feeling out of breath; her life demanded all her energy. Widely admired for her skills behind the wheel, she was often called upon to train fellow officers at the Greensboro Police Department. At home, she needed to chase her 2-year-old son, SJ, around the apartment. She was a natural with kids — she’d helped her single mom raise her nine younger siblings.

She thought her surprise pregnancy had caused the atrial fibrillation, also called A-fib. In addition to heart disease, she had a thyroid disorder; pregnancy could send the gland into overdrive, prompting dangerous heart rhythms. 

When Graham saw the first cardiologist, Dr. Sabina Custovic, the 192 heart rate recorded on an EKG should have been a clear cause for alarm. “I can’t think of any situation where I would feel comfortable sending anyone home with a heart rate of 192,” said Dr. Jenna Skowronski, a cardiologist at the University of North Carolina. A dozen cardiologists and maternal-fetal medicine specialists who reviewed Graham’s case for ProPublica agreed. The risk of death was low, but the fact that she was also reporting symptoms — severe palpitations, trouble breathing — meant the health dangers were significant. 

All the experts said they would have tried to treat Graham with IV medication in the hospital and, if that failed, an electrical shock. Cardioversion wouldn’t necessarily be simple — likely requiring an invasive ultrasound to check for blood clots beforehand — but it was crucial to slow down her heart. A leading global organization for arrhythmia professionals, the Heart Rhythm Society, has issued clear guidance that “cardioversion is safe and effective in pregnancy.”

Even if the procedure posed a small risk to the pregnancy, the risk of not treating Graham was far greater, said Rhode Island cardiologist Dr. Daniel Levine: “No mother, no baby.”

Custovic did not answer ProPublica’s questions about why the pregnancy made her hold off on the treatment or whether abortion restrictions affect her decision-making.  

The next day — as her heart continued to thump — Graham saw a second cardiologist, Dr. Will Camnitz, at Cone Health, one of the region’s largest health care systems. 

According to medical records, Graham’s pulse registered as normal when taken at Camnitz’s office, as it had at her appointment the previous day. Camnitz noted that the EKG from the day before showed she was in A-fib and prescribed a blood thinner to prepare for a cardioversion in three weeks — if by then she hadn’t returned to a regular heart rhythm on her own. 

Some of the experts who reviewed Graham’s care said that this was a reasonable plan if her pulse was, indeed, normal. But Camnitz, who specializes in the electrical activity of the heart, did not order another EKG to confirm that her heart rate had come down from 192, according to medical records. “He’s an electrophysiologist and he didn’t do that, which is insane,” said Dr. Kayle Shapero, a cardio-obstetrics specialist at Brown University. According to experts, a pulse measurement can underestimate the true heart rate of a patient in A-fib. Every cardiologist who reviewed Graham’s care for ProPublica said that a repeat EKG would be best practice. If Graham’s rate was still as high as it was the previous day, her heart could eventually stop delivering enough blood to major organs. Camnitz did not answer ProPublica’s questions about why he didn’t administer this test.

Three weeks was a long time to wait with a heart that Graham kept saying was practically leaping out of her chest.

Camnitz knew about Graham’s pregnancy but did not discuss whether she wanted to continue it or advise her on her options, according to medical records. That same day, though, Graham reached out to A Woman’s Choice, the sole abortion clinic in Greensboro. 

North Carolina bans abortion after 12 weeks; Graham was only about six weeks pregnant. Still, there was a long line ahead of her. Women were flooding the state from Tennessee, Georgia and South Carolina, where new abortion bans were even stricter. On top of that, a recent change in North Carolina law required an in-person consent visit three days before a termination. The same number of patients were now filling twice as many appointment slots. 

Graham would need to wait nearly two weeks for an abortion. 

It’s unclear if she explained her symptoms to the clinic; A Woman’s Choice spokesperson said it routinely discards appointment forms and no longer had a copy of Graham’s. But the spokesperson told ProPublica that a procedure at the clinic would not have been right for Graham; because of her high heart rate, she would have needed a hospital with more resources. 

Dr. Jessica Tarleton, an abortion provider who spent the past few years working in the Carolinas, said she frequently encountered pregnant women with chronic conditions who faced this kind of catch-22: Their risks were too high to be treated in a clinic, and it would be safest to get care at a hospital, but it could be very hard to find one willing to terminate a pregnancy. 

In states where abortions have been criminalized, many hospitals have shied away from sharing information about their policies on abortion. Cone Health, where Graham typically went for care, would not tell ProPublica whether its doctors perform abortions and under what circumstances; it said, “Cone Health provides personalized and individualized care to each patient based on their medical needs while complying with state and federal laws.” 

Graham never learned that she would need an abortion at a hospital rather than a clinic. Physicians at Duke University and the University of North Carolina, the premier academic medical centers in the state, said that she would have been able to get one at their hospitals — but that would have required a doctor to connect her or for Graham to have somehow known to show up.  

Had Graham lived in another country, she may not have faced this maze alone. 

In the United Kingdom, for example, a doctor trained in caring for pregnant women with risky medical conditions would have been assigned to oversee all of Graham’s care, ensuring it was appropriate, said Dr. Marian Knight, who leads the U.K.’s maternal mortality review program. Hospitals in the U.K. also must abide by standardized national protocols or face regulatory consequences. Researchers point to these factors, as well as a national review system, as key to the country’s success in lowering its rate of maternal death. The maternal mortality rate in the U.S. is more than double that of the U.K. and last on the list of wealthy countries.

Graham’s friend Shameka Jackson could tell that something was wrong. Graham didn’t seem like her usual “perky and silly” self, Jackson said. On the phone, she sounded weak, her voice barely louder than a whisper. 

When Jackson offered to come over, Graham said it would be a waste of time. “There’s nothing you can do but sit with me,” Jackson said she replied. “The doctors ain’t doing nothing.” 

Graham no longer cooked or played with her son after work, said her boyfriend, Shawn Scott. She stopped hoisting SJ up to let him dunk on the hoop on the closet door. Now, she headed straight for the couch and barely spoke, except to say that no one would shock her heart. 

“I hate feeling like this,” she texted Jackson. “Ain’t slept, chest hurts.” 

“All I can do is wait until the 28th,” Graham said, the date of her scheduled abortion. 

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On the morning of Nov. 19, Scott awoke to a rap on the front door of the apartment he and Graham shared. He’d been asleep on the couch after a night out with friends and thought that Graham had left for work. 

A police officer introduced himself and explained that Graham hadn’t shown up and wasn’t answering her phone. He knew she hadn’t been feeling well and wanted to check in. 

Most mornings, Graham was up around 5 a.m. to prepare for the day. With Scott, she would brush SJ’s teeth, braid his hair and dress him in stylish outfits, complete with Jordans or Chelsea boots. 

When Scott walked into their bedroom, Graham was face down in bed, her body cold when he touched her. The two men pulled her down to the floor to start CPR, but it was too late. SJ stood in his crib, silently watching as they realized. 

The medical examiner would list Graham’s cause of death as “cardiac arrhythmia due to atrial fibrillation in the setting of recent pregnancy.” There was no autopsy, which could have identified the specific complication that led to her death. 

High-risk pregnancy specialists and cardiologists who reviewed Graham’s case were taken aback by Custovic’s failure to act urgently. Many said her decisions reminded them of behaviors they’ve seen from other cardiologists when treating pregnant patients; they attribute this kind of hesitation to gaps in education. Although cardiovascular disease is the leading cause of death in pregnant women, a recent survey developed with the American College of Cardiology found that less than 30% of cardiologists reported formal training in managing heart conditions in pregnancy. “A large proportion of the cardiology workforce feels uncomfortable providing care to these patients,” the authors concluded in the Journal of the American Heart Association. The legal threats attached to abortion bans, many doctors have told ProPublica, have made some cardiologists even more conservative.

Custovic did not answer ProPublica’s questions about whether she felt she had adequate training. A spokesperson for Cone Health, where Camnitz works, said, “Cone Health’s treatment for pregnant women with underlying cardiac disease is consistent with accepted standards of care in our region.” Although Graham’s family gave the hospital permission to discuss Graham’s care with ProPublica, the hospital did not comment on specifics. 

Three doctors who have served on state maternal mortality review committees, which study the deaths of pregnant women, told ProPublica that Graham’s death was preventable. “There were so many points where they could have intervened,” said Dr. Amelia Huntsberger, a former member of Idaho’s panel.

Graham’s is the seventh case ProPublica has investigated in which a pregnant woman in a state that significantly restricted abortion died after she was unable to access standard care. 

The week after she died, Graham’s family held a candlelight ceremony outside of her high school, which drew friends and cops in uniform, and also Greensboro residents whose lives she had touched. One woman approached Graham’s sisters and explained Graham had interrupted her suicide attempt five years earlier and reassured her that her life had value; she had recently texted Graham, “If it wasn’t for you, I wouldn’t be here today, expecting my first child.”

As for Graham’s own son, no one explained to SJ that his mother had died. They didn’t know how to describe death to a toddler. Instead, his dad and grandmother and aunts and uncles told him that his mom had left Earth and gone to the moon. SJ now calls it the “Mommy moon.”

For the past two years, every night before bed, he asks to go outside, even on the coldest winter evenings. He points to the moon in the dark sky and tells his mother that he loves her.

The post A Pregnant Woman at Risk of Heart Failure Couldn’t Get Urgent Treatment. She Died Waiting for an Abortion. appeared first on ProPublica.

Last year, when Utah lawmakers passed the nation’s first statewide ban on community water fluoridation, they included a provision making it easier for people to get fluoride supplements without having to visit a dental provider.

This would make fluoride available through individual choice, rather than “mass public dosing,” as a Utah House of Representatives webpage put it — part of the rising rhetoric of skepticism that’s led to rollbacks of water fluoridation, a proven method to reduce tooth decay.

“It’s what I like to refer to as the win-win, right?” Speaker Mike Schultz said on a June episode of the “House Rules” podcast from the Utah House. “Those that want fluoride can now get fluoride easier, and those that don’t want fluoride in their drinking water don’t have to have that.”

But even as critics point to fluoride supplements as an alternative — along with fluoride toothpaste, rinses and varnishes — many are creating barriers to these same products.

Under U.S. Health and Human Services Secretary Robert F. Kennedy Jr.’s oversight, the Food and Drug Administration said it issued notices to four businesses about their ingestible fluoride supplements for children and also put out new guidance for health professionals.

In Texas, Attorney General Ken Paxton launched investigations into two large companies over their marketing of fluoride toothpaste to parents and children.

And changes to Medicaid in President Donald Trump’s so-called One Big Beautiful Bill Act threaten to make it harder than it already is for the most vulnerable people to access any oral health care at all, let alone fluoride treatments at a dentist’s office.

More than anything, experts say, alarmist language from high-profile officials is trickling down to the public, leading more people to question whether any form of fluoride — in drinking water or in other treatments — is a good idea.

Scott Tomar, a professor and associate dean at the University of Illinois Chicago College of Dentistry, is among those who have watched with dismay as the conversation about fluoride has been affected by arguments likely to scare people.

“I’m certain that the net result of all of this is going to be a greater reluctance on the part of parents and providers to prescribe fluoride supplements,” Tomar said.

Low, consistent exposure to fluoride is widely credited for dramatic declines in decaying teeth. But long-simmering skepticism about its use gained more influence in recent years, especially with Kennedy’s credibility and influence as the nation’s chief health officer.

“The evidence against fluoride is overwhelming,” he said as he stood alongside Utah lawmakers at a press conference in Salt Lake City last April.

Even though the science to support his conclusions is limited, he claimed that fluoride “causes IQ loss, profound IQ loss,” and he linked water fluoridation to ADHD, hypothyroidism, osteoarthritis, and kidney and liver issues.

Lee Zeldin, who leads the Environmental Protection Agency, spoke at the Utah event, too, crediting Kennedy for helping to spur the agency’s review of its standard for fluoride in drinking water. An EPA spokesperson, in a statement to ProPublica, said that the agency’s “next analysis of new scientific information on potential health risks of fluoride in drinking water was not due until 2030, but this agency is moving at Trump Speed.”

Meanwhile, the FDA is partnering with other federal agencies to develop what it called “a fluoride research agenda.” And, as part of a series of drastic cutbacks last spring, the Division of Oral Health at the Centers for Disease Control and Prevention was eliminated.

In a statement emailed to ProPublica, an HHS spokesperson argued that fluoride’s “predominant benefit to teeth comes from topical contact with the outside of the teeth, not from ingestion. There is no need, therefore, to ingest fluoride.”

Fluoride’s opponents cite a hotly debated “state of the science” report from the National Toxicology Program in 2024, saying that it shows an association between fluoride exposure and a lowered IQ in children.

But those findings are not widely embraced because of the review’s limitations. It analyzed studies conducted outside the U.S., with different water conditions, and involving fluoride levels at more than twice the standard for drinking water here. The report itself states, in bold type, that it does not address “whether the sole exposure to fluoride added to drinking water” at the recommended level in the United States and Canada “is associated with a measurable effect on IQ.”

In this atmosphere, as ProPublica has reported, there’s been widespread wavering on water fluoridation, even in Michigan, where the treatment debuted more than 80 years ago.

Florida joined Utah in banning fluoridation statewide. Bills to do the same were introduced in at least 19 other states last year, and that momentum is carrying forward, with statewide bans recently proposed in Arizona and South Carolina. Meanwhile, local debates over fluoridation are turning raucous.

Utah’s dental professionals are concerned about how to stave off an expected hit to oral health, as other communities experienced when they cut off fluoridation.

“We get heartburn over the situation,” said James Bekker, a pediatric dentist and past president of the Utah Dental Association.

Bekker and others are piecing together ways to provide other forms of fluoride treatment to Utahns. But he’s worried, he said, about “all these susceptible, vulnerable children in underserved populations that don’t have a choice and don’t have a voice, but they are going to suffer.”

Shortly after Utah banned fluoridation, the FDA took aim at the kind of supplements that lawmakers had presented as a key alternative. The agency announced that it was working to remove certain ingestible fluoride products for children from the market. Its press release described associations with changes to the gut microbiome, thyroid disorders, weight gain “and possibly decreased IQ.”

More than 4,600 public comments poured into the FDA, including many from people worried about losing access to supplements while simultaneously losing water fluoridation.

“Now that fluoride has been removed from much of Utah’s water, it is imperative to provide supplementation through other means,” one orthodontist wrote. A dentist in South Florida criticized the scare tactics and bad science leading states like hers to ban fluoridation and said that prescribing fluoride drops and lozenges is one of the few alternatives for pediatric patients.

On Oct. 31, the FDA announced efforts to “restrict the sale of unapproved ingestible fluoride prescription drug products for children.” The agency said it sent notices to four companies about marketing the supplements for children under 3 and older children with moderate or low risk for tooth decay. It also said it issued letters to health care professionals “warning about the risks associated with these products.”

Even though the FDA landed short of a ban, Stuart Cooper, executive director of the Fluoride Action Network, called the agency’s shift a “major victory.” He said he believes it’s just the start of federal action to limit the use of fluoride products that FAN has long campaigned against.

Fluoride supplements, which emerged in the 1940s alongside water fluoridation, never went through an FDA review. A decade ago, Cooper said, FAN submitted a citizens petition that called for the agency to pull ingestible fluoride supplements from the market. “What we’re seeing is that come to fruition,” he said, “because we finally have FDA employees who were willing to look at the issue.”

The FDA’s stance on supplements is now at odds with several health organizations, including the American Dental Association, the American Academy of Pediatric Dentistry and the American Academy of Pediatrics. Several of them jointly support a graduated fluoride supplementation schedule that starts at six months for high-risk children.

Johnny Johnson, a retired pediatric dentist in Florida, questions the FDA’s risk parameters. “If you don’t have fluoride at appropriate levels in your water, by definition, you are at high risk” of tooth decay, said Johnson, who heads the nonprofit American Fluoridation Society.

The FDA’s letter to health professionals recommends topical fluoride as an alternative, such as toothpaste. But even that method faces scrutiny. The Texas attorney general’s office launched investigations into Colgate-Palmolive and Procter & Gamble, which sell Colgate and Crest fluoride toothpastes.

Their marketing to parents and children is “misleading, deceptive and dangerous,” Paxton’s office said in a press release. Referencing the NTP report on fluoridation, the release said the investigation came “amid a growing body of scientific evidence demonstrating that excessive fluoride exposure is not safe for children.”

In September, Paxton’s office announced a “historic agreement” with Colgate-Palmolive. When its packaging and promotional material for children’s fluoride toothpaste shows the paste on a brush, the company will display a pea-sized amount, rather than the traditional swirl. This month, Paxton’s office reported a similar settlement with Procter & Gamble.

A representative from Colgate-Palmolive said in a statement to ProPubica that Paxton’s press release acknowledged that “we already provide directions on our packaging that complies with U.S. FDA requirements for how our children’s fluoride toothpastes should be used.” Procter & Gamble said in a statement that “the Texas Attorney General acknowledged in the settlement that our products comply with all laws and regulations regarding directions for use.”

Another tool for fluoride treatment is varnish applied during a dental checkup, which may be provided at free or reduced cost through insurance programs. But even with health coverage, there are barriers that often make it difficult to see the dentists and pediatricians providing such treatment. Recent research found that insurance denials for fluoride varnish applications can add another layer of complication for patients and providers.

Supplemental fluoride treatments are limited, compared with the effectiveness, reach and cost of fluoride in drinking water, said Johnson, the retired pediatric dentist, but “it is the only option that we have in Florida and in Utah.”

“Nothing replaces fluoridated water,” he added. “Nothing comes close.”

The post After Sowing Distrust in Fluoridated Water, Kennedy and Skeptics Turn to Obstructing Other Fluoride Sources appeared first on ProPublica.