Fluoridation by country
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, and is used by 5.7% of people worldwide. 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. Health and dental organizations support water fluoridation in the countries that practice water fluoridation. There has been opposition to water fluoridation whenever it is proposed.
- 1 Africa
- 2 Asia
- 3 Europe
- 4 North America
- 5 Australasia
- 6 South America
- 7 References
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 naturally containing fluoride to the recommended range of 0.3–0.6 ppm, about 62% have fluoride below this range, and the remainder are above this range.
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.
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.
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. As of 2002, there was no water fluoridation in China.
In Hong Kong, rain water from 17 local reservoirs is treated with fluoride in 21 plants. Recent tests showed drinking water to have an average fluoride level of 0.49 mg/L, in a range of less than 0.10 mg/L to 0.74 mg/L.
Water fluoridation is not practiced in India. In 2004 both skeletal and dental fluorosis were endemic in at least 20 states, including Nalgonda, Uttarakhand, Jharkhand and Chhattisgarh. The maximum permissible limit of fluoride in drinking water in India is 1.2 mg/L, and the government has been obligated to install fluoride removal plants of various technologies to reduce fluoride levels from industrial waste and mineral deposits. Now reverse osmosis plants are widely used. Household and public system reverse osmosis plants are common in the market. Alleppey in Kerala is most affected with over-fluoridated water. Government-installed reverse osmosis plants supply free filtered water. Rotary International Club, Saratoga USA, helped to install 3 RO Plants in rural Apply.
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." 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.
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, but after half a year ULA withdrew its petition upon the request of the court.
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. In 2011, the Health and Welfare Committee of the Knesset criticized the Health Ministry for continuation of water fluoridation.
On August 26, 2014, Israel officially stopped adding fluoride to its water supplies.  According to a Ministry of Health press release statement, the reasons it ended the practice of water fluoridation in Israel are: "Only some 1% of the water is used for drinking, while 99% of the water is intended for other uses (industry, agriculture, flushing toilets etc.). There is also scientific evidence that fluoride in large amounts can lead to damage to health. When fluoride is supplied via drinking water, there is no control regarding the amount of fluoride actually consumed, which could lead to excessive consumption. Supply of fluoridated water forces those who do not so wish to also consume water with added fluoride. This approach is therefore not accepted in most countries in the world."
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 water fluoridation at that time. Fluoridation was proposed again in 2012.
In 1998, 66% of Malaysians were getting fluoridated water.
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".
In 1956, Singapore was the first Asian country to institute a water fluoridation program that covered 100% of the population. Water is fluoridated to a typical value of 0.4-0.6 mg per litre.
Many European countries have rejected water fluoridation in general. This includes: Austria, Belgium, Finland, France, Germany, Hungary, Luxembourg, Netherlands, Northern Ireland, Norway, Sweden, Switzerland, Scotland Iceland, and Italy. A 2003 survey of over 500 Europeans from 16 countries concluded that "the vast majority of people opposed water fluoridation".
Austria has never implemented fluoridation.
Belgium does not fluoridate its water supply, although legislation permits it.
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. Fluoridated salt is available.
Croatia does not fluoridate its water.
According to the Danish Ministry of Environment and Energy, "toxic fluorides have never been added to the public water supplies", therefore Denmark does not practice artificial water fluoridation. However there are a number of naturally occurring contaminants in the Danish drinking water, as it can be seen on © HOFOR's website (© HOFOR is Copenhagen's water supply).
Here are the test results for levels of various water contaminants, including fluoride, in the drinking water of some cities in Denmark:
Only one community (with 70,000 people) was ever fluoridated, Kuopio. Kuopio stopped fluoridation in 1992. There was no evidence of additional benefit in children's dental health because of preexisting public health measures, such as promoting toothbrushing. In regions with rapakivi bedrock (small, but densely populated regions), 22% of well waters and 55% of drilled well waters exceed the legal limit of 1.5 mg/l; generally, surface and well waters have 0.5-2.0 mg/l fluoride in affected regions.
Drinking water is not fluoridated in any part of Germany. One experiment, started 1952 in Kassel-Wahlershausen, was discontinued in 1971. The GDR used to fluoridate drinking water in a few cities, but it was discontinued after the German reunification.
There is no water fluoridation in Greece.
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.
In the Republic of Ireland the majority of drinking water is fluoridated; 71% of the population in 2002 resided in fluoridated communities. The fluoridation agent used is hydrofluorosilicic acid (HFSA; H2SiF6). In a 2002 public survey, 45% of respondents expressed some concern about fluoridation.
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 ~50% of the population. This was felt to be a much cheaper way of improving the quality of children's teeth than employing more dentists. 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. This led to the Health (Fluoridation of Water Supplies) Act 1960, which mandated compulsory fluoridation by local authorities. 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. The current regulations date from 2007, and set the level to 0.6–0.8 ppm, with a target value of 0.7 ppm.
Implementation of fluoridation was held up by preliminary dental surveying and water testing, and a court case, Ryan v. Attorney General. 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. By 1965, Greater Dublin's water was fluoridated; by 1973, other urban centers were. Studies from the late 1970s to mid 1990s showed a higher decrease in (and lower incidence of) dental decay in school children living in areas where water was fluoridated than in areas where water was not fluoridated.
A private member's bill to end fluoridation was defeated in the Dáil on 12 November 2013. It was supported by Sinn Féin and some of the technical group and opposed by the Fine Gael-Labour government and Fianna Fáil.
1.5 mg/l of Fluoride is added mainly in Riga, because it's the only city with a large community water supply.
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. Dutch authorities had no legal basis for adding chemicals to drinking water if they would not improve the safety of doing so. Drinking water has not been fluoridated in any part of the Netherlands since 1973.
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.
Around 10% of the population receives fluoridated water.
In 1952, Norrköping in Sweden became one of the first cities in Europe to fluoridate its water supply. It was declared illegal by the Supreme Administrative Court of Sweden in 1961, re-legalized in 1962 and finally prohibited by the parliament in 1971, 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.: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 infringe 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.:29
In Switzerland since 1962 two fluoridation programs 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 programs separate. As a result some of the population of Basel were assumed to use both fluoridated salt and fluoridated water. In order to correct the situation, in April 2003 the State Parliament agreed to cease water fluoridation and officially expand salt fluoridation to Basel.
Around 10% of the population of the United Kingdom receives fluoridated water, about half a million people receive water that is naturally fluoridated with calcium fluoride, and about 6 million total receive fluoridated water. The Water Act 2003 required water suppliers to comply with requests from local health authorities to fluoridate their water.
The following UK water utility companies fluoridate their supply:
- Anglian Water Services Ltd
- Northumbrian Water Ltd
- South Staffordshire Water plc
- Severn Trent plc
- United Utilities Water plc
Earlier plans 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.
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. 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". Fluoridation plans have been particularly controversial in the northwest of England and have been delayed after a large increase on projected costs was revealed.
It was reported in 2007 that the UK Milk Fluoridation Programme, centered in the northwest of England, involved more than 16,000 children.
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.
In 2004, following a public consultation, Scotland's parliament rejected proposals to fluoridate public drinking water.
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. In 1955, Toronto approved water fluoridation, but delayed implementation of the program until 1963 due to a campaign against fluoridation by broadcaster Gordon Sinclair. The city continues to fluoridate its water today. 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. Overall, about 45% of the Canadian population had access to fluoridated water supplies in 2007. A 2008 survey found that about half of Canadian adults knew about fluoridation, and of these, 62% supported the idea.
As of May 2000, 42 of the 50 largest U.S. cities had water fluoridation. In 2010, 66% of all U.S. residents and 74% of U.S. residents with access to community water systems receive fluoridated water. 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]". In response, the U.S. Department of Health and Human Services together with the U.S. Environmental Protection Agency are proposing 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. This could effectively terminate municipal water fluoridation in areas where fluoride levels from mineral deposits and industrial pollution exceed the new recommendation.
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. 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.
The first town to fluoridate the water supply in Australia was Beaconsfield, Tasmania in 1953. Queensland became the last state to formally require the addition of fluoride to public drinking water supplies in December 2008.
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. New Zealand now has fluoridated water supplied to about half of the total population. Of the six main centers, only Christchurch and Tauranga do not have a fluoridated water supply. Wellington's water supply is mostly fluoridated, but the suburbs of Petone and Korokoro receive a non-fluoridated supply. In 2013, a Hamilton City Council committee voted to remove fluoride from late June 2013. A referendum was held during the council elections in October 2013 with approximately 70% of voters voting for fluoride to be added back into the water supply, and in March 2014, the council voted 9 to 1 to re-introduce fluoride into the supply. In a 2007 referendum about half of voters in the Central Otago, South Otago and the Southland Region did not want fluoridation and voters in the Waitaki District were against water fluoridation for all Wards. Ashburton and Greymouth also voted against fluoridation. In 2014, the Prime Minister's Chief Science Advisor and the Royal Society of New Zealand published a report on the health effects of water fluoridation.
Water fluoridation was first adopted in Brazil in the city of Baixo Guandu, ES, in 1953. 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. Between 2005 and 2008, fluoridation became available to 7.6 million people in 503 municipalities. As of 2008, 3,351 municipalities, 60.3% of total, adopted fluoridation, up from 2,466 in 2000. The proportion of the national population affected is greater, because cities with fluoridation tend to be larger.
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