Fluoridation by country

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Artificial fluoridation of water, salt, and milk varies from country to country. Water fluoridation has been introduced to varying degrees in many countries, including Australia, Brazil, Canada, Chile, Ireland, Malaysia, the U.S., and Vietnam,[1] and is used by 5.7% of people worldwide.[2] Continental Europe largely does not fluoridate water, although some of its countries fluoridate salt; locations have discontinued water fluoridation in Germany, the Netherlands, and other countries.[2] Although health and dental organizations support water fluoridation in the countries that practice water fluoridation,[3] there has been considerable opposition to water fluoridation whenever it is proposed.[citation needed]

Africa[edit]

Egypt[edit]

Egypt does not fluoridate water, although a pilot study commenced in Alexandria.[4]

Nigeria[edit]

Only a fraction of Nigerians receive water from waterworks, so water fluoridation would affect only a few people. A 2009 study found that about 21% of water sources are naturally fluoridated to the recommended range of 0.3–0.6 ppm, about 62% have fluoride below this range, and the remainder are above this range.[5]

South Africa[edit]

South Africa's Health Department recommends adding fluoridation chemicals to drinking water in some areas. It also advises removal of fluoride from drinking water (defluoridation) where the fluoride content is too high.[6][7]

Legislation around mandatory fluoridation was introduced in 2002, but has been on hold since then pending further research after opposition from water companies, municipalities and the public.[8]

Asia[edit]

China[edit]

In China, water fluoridation began in 1965 in the urban area of Guangzhou. It was interrupted during 1976–1978 due to the shortage of sodium silico-fluoride. It was resumed only in the Fangcun district of the city, due to objections, and was halted in 1983. The fluoridation reduced the number of cavities, but increased dental fluorosis; the fluoride levels could have been set too high, and low-quality equipment led to inconsistent, and often excessive, fluoride concentrations.[9] As of 2002, there was no water fluoridation in China.[10]

Hong Kong[edit]

In Hong Kong, water is totally fluoridated,[11] at an average level of 0.49 mg/L[12]

India[edit]

Water fluoridation is not practiced in India.[13][14] In 2004 both skeletal and dental fluorosis were endemic in at least 20 states, including Nalgonda, Uttarakhand, Jharkhand and Chhattisgarh.[15] The maximum permissible limit of fluoride in drinking water in India is 1.2 mg/L,[16] and the government has been obligated to install fluoride removal plants of various technologies to reduce fluoride levels from industrial waste and mineral deposits.

Israel[edit]

Mekorot, Israel's national water company states, "In the South of the country, it is unnecessary to add fluoride because it is found naturally in the water."[17] Water fluoridation was introduced in Israel's large cities in 1981, and a national effort to fluoridate all the country's water was approved in 1988.[18]

In 2002, the Union of Local Authorities (ULA) and others petitioned Israel's High Court to stop the Health Ministry from forcing cities to implement water fluoridation. The court soon issued a restraining order,[19][20] but after half a year ULA withdrew its petition upon the request of the court.[21]

By 2011, about 65% of the municipalities and local authorities in Israel had agreed to allow fluoridation, and there was active opposition to the spread of fluoridation to the towns where it has not yet been instituted.[18] In 2011, the Health and Welfare Committee of the Knesset criticized the Health Ministry for continuation of water fluoridation.[22]

In 2013 the new Minister of Health Yael German has signed a new regulation setting water quality and not requiring fluoridation, that will take effect in the following year. She has insisted that it was better to provide fluoride in other ways to “target audiences” such as poor children, who were unlikely to brush their teeth regularly with fluoride toothpaste. “It must be known to you that fluoridation can cause harm to the health of the chronically ill and pregnant women,” German wrote in the letter.She argued that only 2% of water is used for drinking by the population, with the rest used for dishwashing, bathing, industry and other uses."[23][24]

Japan[edit]

Less than 1% of Japan practices water fluoridation.[25]

South Korea[edit]

In 2005, the ruling Uri Party proposed legislation for compulsory water fluoridation for municipalities. The legislation failed, and only 29 out of around 250 municipal governments had introduced the water fluoridation project at that time.[26][27] Fluoridation was proposed again in 2012.[28]

Malaysia[edit]

In 1998, 66% of Malaysians were getting fluoridated water.[29]

In 2010, Bernama reported, "Principal Director (Oral Health) in the Health Ministry, Datuk Dr Norain Abu Taib said that only 75.5% of the country’s population are enjoying the benefits of water fluoridation".[30]

Singapore[edit]

In 1956, Singapore was the first asian country to institute a water fluoridation program that covered 100% of the population.[31][32] Water is fluoridated to a typical value of 0.4-0.6 mg per litre.[33]

Vietnam[edit]

About 4% of the population of Vietnam has water fluoridation, whereas only 70% get their water from public supplies.[34]

Europe[edit]

Many European countries have rejected water fluoridation in general. This includes: Austria, Belgium, Denmark, Finland, France, Germany, Hungary, Luxembourg, Netherlands, Northern Ireland, Norway, Sweden, Switzerland,[35] Scotland[36] Iceland, and Italy.[citation needed] A 2003 survey of over 500 Europeans from 16 countries concluded that "the vast majority of people opposed water fluoridation".[37]

Austria[edit]

Austria has never implemented fluoridation.[25]

Belgium[edit]

Belgium does not fluoridate its water supply, although legislation permits it.[25]

Czech Republic[edit]

Czech Republic (previously Czechoslovakia) started water fluoridation in 1958 in Tábor. In Prague fluoridation started in 1975. It was stopped in Prague in 1988 and subsequently in the whole country. Since 2008 no water has been fluoridated.[38] Fluoridated salt is available.[39]

Croatia[edit]

Croatia does not fluoridate its water.[40]

Denmark[edit]

Denmark does not fluoridate its water, although the National Health Board is in favour.[25]

Finland[edit]

The Finnish government supports fluoridation, although only one community of 70 000 people was fluoridated, Kuopio.[25] Kuopio stopped fluoridation in 1992.[41]

France[edit]

Fluoridated salt is available in France,[25] and 3% of the population uses naturally fluoridated water,[34] but the water is not artificially fluoridated.[34][35]

Germany[edit]

Drinking water is not fluoridated in any part of Germany. One experiment, started 1952 in Kassel-Wahlershausen, was discontinued in 1971.[42] The GDR used to fluoridate drinking water in a few cities, but it was discontinued after the German reunification.[1] Fluoridated salt is available since 1992 with steadily increasing market share.

Greece[edit]

There is no water fluoridation in Greece.[43]

Hungary[edit]

In the early 1960s the city of Szolnok briefly fluoridated its water. The program was discontinued due to technical problems and a view that fluoridation did not seem reasonable.[clarification needed] Hungary has not used artificially fluoridated water since then.[citation needed]

Ireland[edit]

In the Republic of Ireland the majority of drinking water is fluoridated; 71% of the population in 2002 resided in fluoridated communities.[44] The fluoridation agent used is hydrofluosilicic acid (HFSA; H2SiF6).[45] In a 2002 public survey, 45% of respondents expressed some concern about fluoridation.[46]

In 1957, the Department of Health established a Fluorine Consultative Council which recommended fluoridation at 1.0 ppm of public water supplies, then accessed by c.50% of the population.[47] This was felt to be a much cheaper way of improving the quality of children's teeth than employing more dentists.[48] The ethical approval for this was given by the "Guild of Saints Luke, Cosmas and Damian", established by Catholic Archbishop of Dublin, John Charles McQuaid.[47] This led to the Health (Fluoridation of Water Supplies) Act 1960, which mandated compulsory fluoridation by local authorities.[48][49] The statutory instruments made in 1962–65 under the 1960 Act were separate for each local authority, setting the level of fluoride in drinking water to 0.8–1.0 ppm.[50][51] The current regulations date from 2007, and set the level to 0.6–0.8 ppm, with a target value of 0.7 ppm.[52]

Implementation of fluoridation was held up by preliminary dental surveying and water testing,[53] and a court case, Ryan v. Attorney General.[54] In 1965, the Supreme Court rejected Gladys Ryan's claim that the Act violated the Constitution of Ireland's guarantee of the right to bodily integrity.[54][55] By 1965, Greater Dublin's water was fluoridated; by 1973, other urban centres were.[56] Dental surveys of children from the 1950s to the 1990s showed marked reductions in cavities parallel to the spread of fluoridation.[57]

Netherlands[edit]

Water was fluoridated in large parts of the Netherlands from 1960 to 1973, when the High Council of The Netherlands declared fluoridation of drinking water unauthorized.[58] Dutch authorities had no legal basis adding chemicals to drinking water if they will not improve the safety as such.[4] Drinking water has not been fluoridated in any part of the Netherlands since 1973.

Norway[edit]

In 2000, representatives of the Norwegian National Institute for Public Health reported that no cities in Norway were practicing water fluoridation. There had been intense discussion of the issue around 1980, but no ongoing political discussion in 2000.[59]

Spain[edit]

Around 10% of the population receives fluoridated water.[60]

Sweden[edit]

In 1952, Norrköping in Sweden became one of the first cities in Europe to fluoridate its water supply.[61] It was declared illegal by the Supreme Administrative Court of Sweden in 1961, re-legalized in 1962[62] and finally prohibited by the parliament in 1971,[63] after considerable debate. The parliament majority said that there were other and better ways of reducing tooth decay than water fluoridation. Four cities received permission to fluoridate tap water when it was legal.[61]:56-57 An official commission was formed, which published its final report in 1981. They recommended other ways of reducing tooth decay (improving food and oral hygiene habits) instead of fluoridating tap water. They also found that many people found fluoridation to impinge upon personal liberty/freedom of choice by forcing them to be medicated, and that the long-term effects of fluoridation were insufficiently acknowledged. They also lacked a proper study on the effects of fluoridation on formula-fed infants.[61]:29

Switzerland[edit]

In Switzerland since 1962 two fluoridation programmes had operated in tandem: water fluoridation in the City of Basel, and salt fluoridation in the rest of Switzerland (around 83% of domestic salt sold had fluoride added). However it became increasingly difficult to keep the two programmes separate. As a result some of the population of Basel were assumed to use both fluoridated salt and fluoridated water. In order to correct that situation, in April 2003 the State Parliament agreed to cease water fluoridation and officially expand salt fluoridation to Basel.[64][65]

United Kingdom[edit]

Around 10% of the population of the United Kingdom receives fluoridated water[60] about half a million people receive water that is naturally fluoridated with calcium fluoride which is different to sodium fluoride, and about 6 million total receive fluoridated water.[66] The All Party Parliamentary Group on Primary Care and Public Health recommended in April 2003 that fluoridation be introduced "as a legitimate and effective means of tackling dental health inequalities".[citation needed] The Water Act 2003 required water suppliers to comply with requests from local health authorities to fluoridate their water.[66]

The following UK water utility companies fluoridate their supply:

Earlier schemes were undertaken in the Health Authority areas of Bedfordshire, Hertfordshire, Birmingham, Black Country, Cheshire, Merseyside, County Durham, Tees Valley, Cumbria, Lancashire, North, East Yorkshire, Northern Lincolnshire, Northumberland, Tyne and Wear, Shropshire, Staffordshire, Trent and West Midlands South whereby fluoridation was introduced progressively in the years between 1964 and 1988.[67]

The South Central Strategic Health Authority carried out the first public consultation under the Water Act 2003, and in 2009 its board voted to fluoridate water supplies in the Southampton area to address the high incidence of tooth decay in children there.[66] Surveys had found that the majority of surveyed Southampton residents opposed the plan, but the Southampton City Primary Care Trust decided that "public vote could not be the deciding factor". A judicial review has been initiated.[68] Fluoridation plans have been particularly controversial in the North West of England and have been delayed after a large increase on projected costs was revealed.[69]

It was reported in 2007 that the UK Milk Fluoridation Programme, centered in the North west of England, involved more than 16,000 children.[70]

The water supply in Northern Ireland has never been artificially fluoridated except in two small localities where fluoride was added to the water for about 30 years. By 1999, fluoridation ceased in those two areas, as well.[citation needed]

In 2004, following a public consultation, Scotland's parliament rejected proposals to fluoridate public drinking water.[36]

North America[edit]

U.S. residents served with community water fluoridation, 1992 and 2006. The percentages are the proportions of the resident population served by public water supplies who are receiving fluoridated water.[71]

Canada[edit]

The decision whether to fluoridate lies with local governments, with guidelines set by provincial, territorial, and federal governments. Brantford, Ontario became the first city in Canada to fluoridate its water supplies in 1945.[72] In 1955, Toronto approved water fluoridation, but delayed implementation of the program until 1963 due to a campaign against fluoridation by broadcaster Gordon Sinclair.[73] The city continues to fluoridate its water today.[74] In 2008 the recommended fluoride levels in Canada were reduced from 0.8–1.0 mg/L to 0.7 mg/L to minimize the risk of dental fluorosis. Ontario, Alberta, and Manitoba have the highest rates of fluoridation, about 70–75%. The lowest rates are in Quebec (about 6%), British Columbia (about 4%), and Newfoundland and Labrador (1.5%), with Nunavut and the Yukon having no fluoridation at all.[72] Overall, about 45% of the Canadian population had access to fluoridated water supplies in 2007.[72] A 2008 survey found that about half of Canadian adults knew about fluoridation, and of these, 62% supported the idea.[75]

In 2010, the Region of Waterloo held a referendum for residents to decide if water fluoridation should continue.[76][77] The result of the vote was 50.3% voting against fluoridation.[77][78]

In 2011, Calgary city council voted 10-3 to stop adding fluoride to the city's drinking water, having started water fluoridation in 1991.[79][80]

United States[edit]

Main article: Water fluoridation in the United States

As of May 2000, 42 of the 50 largest U.S. cities had water fluoridation.[81] In 2010, 66% of all U.S. residents and 74% of U.S. residents with access to community water systems receive fluoridated water.[82] In 2010, a U.S. Centers for Disease Control and Prevention study determined that "40.7% of adolescents aged 12–15 had dental fluorosis [in 1999–2004]".[83] In response, the U.S. Department of Health and Human Services together with the U.S. Environmental Protection Agency are proposing[84] to reduce the recommended level of fluoride in drinking water to the lowest end of the current range, 0.7 milligrams per liter of water (mg/L), from the previous recommended maximum of 1.2 mg/L.[85] This could effectively terminate municipal water fluoridation in areas where fluoride levels from mineral deposits and industrial pollution exceed the new recommendation.[86]

Australasia[edit]

Australia[edit]

Australian residents served with community water fluoridation, 2005[87] and 2012. The percentages are the proportions of the resident population served by public water supplies who are receiving fluoridated water.
Main article: Water fluoridation in Australia

Australia now provides fluoridated water for 70% or more of the population in all states and territories. Many of Australia's drinking water supplies began fluoridation in the 1960s and 1970s. By 1984 almost 66% of the Australian population had access to fluoridated drinking water, represented by 850 towns and cities.[88][89] Some areas within Australia have natural fluoride levels in the groundwater, which was estimated in 1991 to provide drinking water to approximately 0.9% of the population.[88]

The first town to fluoridate the water supply in Australia was Beaconsfield, Tasmania in 1953.[90] Queensland became the last state to formally require the addition of fluoride to public drinking water supplies in December 2008.[91]

New Zealand[edit]

New Zealand has fluoridated water supplied to about half of the total population.[92] Of the six main centres only Christchurch[93] and Tauranga[94] do not to have a fluoridated water supply, with Hamilton to remove fluoride from late June 2013.[95] The use of water fluoridation first began in New Zealand in Hastings in 1954. A Commission of Inquiry was held in 1957 and then its use rapidly expanded in the mid 1960s.[96] In a 2007 referendum about half of voters in the Central Otago, South Otago and the Southland Region did not want fluoridation[97] and voters in the Waitaki District were against water fluoridation for all Wards.[98] Ashburton and Greymouth also voted against fluoridation.[99]

South America[edit]

Brazil[edit]

Water fluoridation was first adopted in Brazil in the city of Baixo Guandu, ES, in 1953.[100] A 1974 federal law required new or enlarged water treatment plants to have fluoridation, and its availability was greatly expanded in the 1980s, with optimum fluoridation levels set at 0.8 mg/L. Today, the expansion of fluoridation in Brazil is a governmental priority; state-sponsored research points to a sharp correlation between the availability of fluoridation and benefits to human health.[101] Between 2005 and 2008, fluoridation became available to 7.6 million people in 503 municipalities.[101] As of 2008, 3,351 municipalities, 60.3% of total, adopted fluoridation, up from 2,466 in 2000.[102] The proportion of the national population affected is greater, because cities with fluoridation tend to be larger.

Chile[edit]

In Chile 70.5% of the population receives fluoridated water (10.1 million added by chemical means, 604,000 naturally occurring).[103]

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  96. ^ New Zealand Ministry of Health
  97. ^ "Voters say no to water fluoridation". The Southland Times. 3 November 2007. Retrieved 29 January 2011. 
  98. ^ "Waitaki District Council: all Wards with referendum vote NO to fluoridation". 18 October 2007. 
  99. ^ Keast, John (12 March 2007). "Ashburton fluoride bid fails". The Press. Retrieved 29 January 2011. 
  100. ^ [1]
  101. ^ a b [2]
  102. ^ [3]
  103. ^ Information from the Oral Health Department of the Chilean Ministry of Health. December 2004.
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