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=== Water fluoridation is effective ===
=== Water fluoridation is effective ===


[[Image:Suspectedmethmouth09-19-05closeup.jpg|left|200px|thumb|An example of tooth decay. The amount of benefits fluoride provides is disputed.]]
[[Image:Suspectedmethmouth09-19-05closeup.jpg|left|200px|thumb|An example of tooth decay.]]
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The Centers for Disease Control and Prevention published in its Morbidity and Mortality Weekly Report (MMWR) that starting or continuing water fluoridation decreased the [[Incidence (epidemiology)|incidence]] of [[dental caries|tooth decay]] by 29%, and that stopping water fluoridation increased the incidence of tooth decay in some communities.<ref>[http://www.cdc.gov/mmwr/PDF/rr/rr5021.pdf Promoting Oral Health: Interventions for Preventing Dental Caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries: A Report on Recommendations of the Task Force on Community Preventive Services] (in pdf format), from the Morbidity and Mortality Weekly Report (MMWR) produced by the CDC, page accessed 4 March, 2006.</ref> Other organizations also see a clear link between desired fluoride levels in water and a decrease in tooth decay.
The Centers for Disease Control and Prevention published in its Morbidity and Mortality Weekly Report (MMWR) that starting or continuing water fluoridation decreased the [[Incidence (epidemiology)|incidence]] of [[dental caries|tooth decay]] by 29%, and that stopping water fluoridation increased the incidence of tooth decay in some communities.<ref>[http://www.cdc.gov/mmwr/PDF/rr/rr5021.pdf Promoting Oral Health: Interventions for Preventing Dental Caries, Oral and Pharyngeal Cancers, and Sports-Related Craniofacial Injuries: A Report on Recommendations of the Task Force on Community Preventive Services] (in pdf format), from the Morbidity and Mortality Weekly Report (MMWR) produced by the CDC, page accessed 4 March, 2006.</ref> Other organizations also see a clear link between desired fluoride levels in water and a decrease in tooth decay.

Revision as of 23:00, 26 May 2006

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Water fluoridation is the practice of adding fluoride ions to water with the intended purpose of reducing tooth decay in the general population. Many North American and Australian municipalities fluoridate their water supplies, believing that this practice will reduce tooth decay at a low cost. In the United States, fluoridation is usually accomplished by the addition of Dihydrogen hexafluorosilicate or sodium hexafluorosilicate, which decompose in water, forming fluoride ions. Currently 66% of United States residents in urban areas have fluoridated water[1]

However, many cities in the US have chosen to keep fluoride out of the water supply. Many European countries and Canadian provinces have likewise removed fluoride from their water supplies. Some countries offer fluoride in salt or milk. Water fluoridation has attracted controversy for a number of reasons, ranging from the right to choose one's own medication to concern about undesirable health effects such as dental fluorosis.

Groups supporting water fluoridation include The American Dental Association (ADA), World Health Organization (WHO), and some other health organizations which recommend raising the fluoride level of municipal water supplies to a level between 0.7 and 1.2 ppm or mg/L.

Groups opposing fluoridation have included the Chapters of the Sierra Club, Environmental Working Group, New York State Coalition Opposed to Fluoridation (NYSCOF)

Concerns among the general public were also raised by the fact that fluoride (sodium fluoride and certain fluorosilicates) has been used as an active ingredient in rat poison and insecticides. [2] In low concentrations (on the order of parts per million), fluorides are used in human health applications; specifically, fluorides such as sodium fluoride (NaF), sodium monofluorophosphate (SMFP), tin(II) fluoride (SnF2), and amine fluorides are common ingredients in toothpaste. Many dentists also give their patients semiannual topical fluoride treatments.

Toothpaste is a major source of ingested fluoride. The safety of the recommended fluoride levels in drinking water was originally based on the assumption that people brushed their teeth once each day, and that non-fluoride toothpaste was available for people who brushed more frequently. Today, although most people now brush several times each day, non-fluoride toothpaste is available only through specialized outlets. This may be causing a much greater fluoride exposure than existed at the time fluoridation was introduced.

Currently, there is some concern among dental professionals that the growing use of bottled water may decrease the amount of fluoride exposure people will receive.[3] However, there is no scientific evdience to support the theory that drinking non-fluoridated bottled water leads to more tooth decay. [Bottled water not affecting tooth decay], from UPI Story. Some bottlers such as Dannon have begun adding fluoride to their water. Still, most companies that sell bottled water do not add fluoride, and fluoride concentrations are not usually labelled on the bottle. As a result, people who have fluoridated water supplies may receive less than amounts of fluoride that fluoride proponents recommend if they choose bottled water over tap water. However, many bottled water tested do have a fluoride content even when it's not on the label.[4]

History

While the use of fluorides for prevention of dental caries was discussed already in the 19th century in Europe [5], community water fluoridation owes its origin in part to the research of Dr. Frederick McKay, who pressed the dental community for an investigation into what was then known as "Colorado stain."[6] In 1909, of the 2,945 children seen by Dr. McKay, 87.5% had some degree of stain or mottling. All the affected children were from the Pikes Peak region. Despite having a negative impact on the physical appearance of their teeth, the children with stained or mottled teeth also were believed to have fewer cavities than other children. McKay brought the problem to the attention of Dr. G.V. Black, who later became known as the father of modern dentistry, and Black's interest into the Colorado stain led to greater interest throughout the dental profession.

File:Ppeak-s.jpg
Pike's Peak mountain in Colorado from the East.

Initial hypotheses for the staining included poor nutrition, overconsumption of pork or milk, radium exposure, childhood diseases, or a calcium deficiency in the local drinking water.[6] In 1931, researchers finally concluded that the cause of the Colorado stain was the presence of fluoride ions (above 1 ppm) in the region's drinking water [7]. Pikes Peak's rock formations contained the mineral cryolite, one of whose constituents is fluoride. As the rain and snow fell, the resulting runoff water picked up the fluoride as it migrated to the water supply.

Photograph of Dr. G.V. Black (left) and Dr. McKay (right) studying the "Colorado Brown Stain".

Dental research then moved toward determining a safe level for fluoride in water supplies. The research had two goals: (1) to warn communities with a high concentration of fluoride of the danger, initiating a reduction of the fluoride levels in order to prevent the Colorado stain, currently known as dental fluorosis, and (2) to encourage communities with a low concentration of fluoride in drinking water to increase the fluoride levels in order to help prevent tooth decay.

The classic epidemiological study to attempt to determine the optimal level of fluoride in water was led by Dr. H. Trendley Dean, a dental officer of the U.S. Public Health Service, in 1934. His research included 7,000 children from 21 cities in Colorado, Illinois, Indiana, and Ohio. The study concluded that the optimal level of fluoride which minimized the risk of severe fluorosis but had positive benefits for tooth decay was 1 part per million (ppm).[8] [9] In 1939, Dr. Gerald J. Cox [10] conducted laboratory tests on fluoride and released a report suggesting adding fluoride to drinking water in order to improve oral health.[11] In 1937 already, dentists Henry Klein and Carroll E. Palmer had considered the possibility of fluoridation to prevent cavities, after their evaluation of data gathered by a Public Health Service team at dental examinations of American indian children. [12] In a series of papers published afterwards (1937-1941), yet disregarded by his colleagues within the U.S.P.H.S., Klein summarized his findings on tooth development in children and related problems in epidemiological investigations on caries prevalence.

In the 1940s, four widely-cited studies were conducted. The researchers investigated cities that had both fluoridated and unfluoridated water. The first pair was Muskegon, Michigan and Grand Rapids, Michigan, making Grand Rapids the first community in the world to modify its fluoride levels in drinking water to benefit dental health on January 25, 1945.[13] Kingston, New York was paired with Newburgh, New York. [14] Oak Park, Illinois was paired with Evanston, Illinois. Sarnia, Ontario was paired with Brantford, Ontario, Canada.[15] The research found a decrease in the incidence of tooth decay in cities which had added fluoride to water supplies. Fluoride proponents believe these studies support their position to fluoridate municipal water supplies.

Common arguments against water fluoridation

File:Drinkingwater.JPG
Tap water in cities may have fluoride compounds added in an effort to reduce dental decay. However, opponents object to being forced to ingest these compounds based on freedom of choice and health concerns

Adding fluoride compounds to municipal water supplies takes away individual choice of medication

Some opponents of water fluoridation object to adding fluoride to the water supply because it takes away individual choice as cities usually only have one source of water. Thus, they do not approve of the social or political implications of adding fluoride to the public's water supplies. Even though water fluoridation may improve dental health of the general public, these people value an individual's choice to pursue medical treatment and argue that water fluoridation is "compulsory mass medication" because it does not allow proper consent.[16]

On the other hand, other commentators argue that because of the negative health effects of fluoride exposure, mandatory fluoridation of public water supplies is a "breach of ethics" and a "human rights violation."[17]

Many groups oppose adding fluoride compounds to municipal water supplies primarily on health concerns and a general objection about being forced to ingest a substance introduced in the water supply.

Fluoride is not essential

Some opponents of water fluoridation argue that fluoride is neither a vitamin nor an essential nutrient.[18] They state that overall health does not rely on fluoride and that dental health can be improved through other methods, such as modifying diet. Consequently, they argue, there is no need to promote fluoride as important to healthy growth and development.


Water fluoridation is not effective

Opponents point to a study by the National Institute of Dental Research showing little difference in tooth decay rates among children in fluoridated and non-fluoridated communities. In the study's results, the difference between the children exposed to water fluoridation and those who were not was very small, between 0.12 and 0.30 DMFS (Decayed Missing and Filled Surfaces). [19]

Some detractors of water fluoridation support concentrated topical methods to deliver fluoride, as seen in these fluoride trays often used in dentistry.

Opponents also argue that in the instances that fluoride prevents tooth decay, the effects are merely topical.[20] Therefore, fluoridating water is unnecessary and ineffective. Instead, they argue, direct applications of fluoride to teeth as done in dental offices and with fluoridated toothpastes should be the recommended methods.

Opponents point out that dental decay continues to exist in water fluoridated communities. They reason that if fluoride is effective, then there would be no more tooth decay. While, in theory, the poorest members of society would be aided the most by fluoridinated water, baby bottle tooth decay (BBTD) and tooth decay in general is still prevalent in those social groups. Opponents conclude that, in light of the continuing dental health problem, water fluoridation is unable to successfully increase health standards and thus should not be used.[21]

Finally, opponents argue that the general decline of tooth decay is the result of factors beside water fluoridation, including toothpaste with fluoride, improved diets, and overall improved general and dental health.[22]

Fluoride causes health problems

There are some opponents of fluoridation who believe fluoride causes negative health effects such as dental fluorosis and other problems. They argue that having a lethal chemical in the water is reckless and leads to many health problems in the general public.

Teeth as seen in dental fluorosis caused by excessive fluoride.

These persons point to research which they say supports the notion that fluoride causes chromosomal damage and interferes with DNA repair.[23] They point to animal studies that they say demonstrate that rats fed for one year with 1 ppm fluoride in their water had detrimental changes to their kidneys and brains[24], an increased uptake of aluminum in the brain, and the formation of beta amyloid deposits, a characteristic of Alzheimers disease.[25] Further, it is argued by some opponents that fluoride can weaken the immune system, leaving people vulnerable to the development of cancer and AIDS.[26]

At high doses, fluoride has many side effects. Animal studies demonstrate that fluoride can damage the male reproductive system in a various number of species.[27] Consequently, fluoride is considered dangerous by these groups.

Reliance on EPA Scientists and Nobel Prize winners who oppose water fluoridation

Many opponents of water fluoridation rely on experts opposing water fluoridation.

On April 1998 Chapter 280 of the National Treasury Employees Union, the EPA union of scientists voted to oppose water fluoridation of drinking water supplies. The union is comprised of and represents the approximately 1500 scientists, lawyers, engineers and other professional employees at EPA Headquarters in Washington, D.C.[1]

"I would advise against fluoridation. Individual prophylaxis (treatment) is preferable on principle grounds and is as equally effective," says Dr. Arvid Carlsson of Sweden, co-winner of the 2000 year's Nobel Prize for medicine.[2]


Common Arguments Advocating Water Fluoridation

(See Medical approval" for a list of health organizations.)
Groups opposing water fluoridation believe that individuals should be able to decide the chemicals they ingest in their drinking water rather than the government.

Advocates for water fluoridation argue that any risks posed by water fluoridation are outweighed by the benefits. The Centers for Disease Control and Prevention (CDC) has listed water fluoridation as one of the ten greatest achievements in public health of the 20th century.[28] In 2000, a report by the Surgeon General of the United States titled "Oral Health in America" stated, "Community water fluoridation remains one of the great achievements of public health in the twentieth century."[29] Various international groups, including the World Health Organization (WHO) and the International Association for Dental Research (IADR) support water fluoridation as a safe and effective method to fight tooth decay.[30] [31]

Fluoride is part of optimal oral health care

Fluoridation proponents believe that research has shown that fluoride has a positive effect on overall dental health. During tooth development, fluoride binds to the hydroxyapatite crystals present in enamel and makes the enamel more resistant to demineralization by acids.[32] As a result, some organizations, such as the American Dental Hygiene Association, classify fluoride as a nutrient necessary for proper tooth development.[33] In addition, organizations, including the CDC and WHO, promote increasing the accessibility of fluoridated water.[34] [30]


Water fluoridation is effective

An example of tooth decay.

The Centers for Disease Control and Prevention published in its Morbidity and Mortality Weekly Report (MMWR) that starting or continuing water fluoridation decreased the incidence of tooth decay by 29%, and that stopping water fluoridation increased the incidence of tooth decay in some communities.[35] Other organizations also see a clear link between desired fluoride levels in water and a decrease in tooth decay. In addition, since oral health is affected by many factors, fluoride alone would be unable, nor would it be expected, to eradicate the disease. The social groups that would be more likely to benefit from water fluoridation are those living in poorer conditions, and an important factor to decrease dental health disparities may be water fluoridation programs.[30] Fluoridation advocates believe that some anti-fluoridation research is published in journals, such as "Fluoride", that are deceptively made to appear peer-reviewed.[36]

There are safe levels for fluoride use

Advocates of water fluoridation concede that fluoride in high concentrations produces harmful effects to the body. Nonetheless, they argue that almost any substance is harmful because toxicity is based on the amount of exposure.[37] In defending water fluoridation, the American Dental Association points out that vitamin A, vitamin D, iron, iodine, aspirin, and water are potentially harmful if given in certain amounts.[38] As is true for all vitamins and minerals, recommended dosages for fluoride represent levels which maximize health benefits and minimize adverse effects.[39]

Fluoride proponents believe the greatest concern with fluoride overexposure is dental fluorosis. Fluorosis is undesireable because, in severe cases, it discolors teeth, causes surface changes to the enamel, and makes oral hygiene more difficult.[40] Government agencies, such as the Center for Disease Control and Prevention, keep records on the prevalence of fluorosis in the general public.[41] Also a concern, skeletal fluorosis is a disease in which fluoride deposits into bone, causing joint stiffness, joint pain, and sometimes changes in bone shape.[42] A mild form of skeletal fluorosis, osteosclerosis, is seen when levels of fluoride reach 5 parts per million (ppm) and the time of exposure lasts for 10 years.[38]

Schedule for Fluoride Prescription[43]
Age < 0.3 ppm 0.3 - 0.6 ppm >0.6 ppm
Birth - 6 months 0 0 0
6 months - 3 years .25 mg 0 0
3 years - 6 years .50 mg .25 mg 0
6 years - 16 years 1.0 mg .50 mg 0

Dosages are in milligrams F/day; 1.0 ppm = 1 mg/liter.

In order to best reduce fluorosis, health organizations have created guidelines restricting the amount of fluoride exposure. The Environmental Protection Agency limits the maximum amount of fluoride in drinking water to 4.0 milligrams per liter of water and recommends water supplies to contain between 0.7 and 1.2 milligrams of fluoride per liter.[44] The World Health Organization cautions that fluoride levels above 1.5 milligrams per liter leaves the risk for fluorosis.[45] When there is a fluoride deficiency in water (usually below 0.6 ppm), fluoride supplements are sometimes needed to encourage healthy dental development. There are accepted recommended guidelines on the amount of fluoride to prescribe, which depend on the fluoride levels in the drinking water and on the age of the child.[43]

The Centers for Disease Control and Prevention and the National Cancer Institute have both issued statements that water fluoridation is not believed to cause osteosarcomas.[46] [47] Cancer in general is not believed to be caused from water fluoridation.[48] [49]

Fluoridation proponents do not believe there is a link between Alzheimer's disease and water fluoridation.[38] A study in 1998 suggested a possible relationship between fluoride exposure and Alzheimer's disease.[50]

Fluoridation proponents believe fluoride is not a risk factor for Alzheimer's disease, and instead age and family history are the most important risk factors.[51] Moreover, there is some research that suggests Alzheimer's disease can be prevented with water fluoridation because of the competition between aluminum and fluoride absorption.[52] Nonetheless, this research is also limited by design and no definitive conclusion can be made. Other health concerns, such as kidney disease, Down syndrome, lead poisoning, heart disease, decreased fertility rates, and inhibition of biologic enzymes, are not believed by fluoride proponents to be attributed to water fluoridation.[38]

Fluoride proponents suggest that adding fluoride to the water is no different that adding vitamin D to milk.

Ethical questions

Frequently, health agencies confront the ethics of water fluoridation along the lines of two topics. They address the issues of whether fluoridation violates people's consent to pursue medical treatment and whether fluoridation should be easily accessable to everyone.

Many advocates of fluoridation do not consider it a violation of people's right to consent to medical treatment. They usually argue that fluoridation is not a form of mass medication because fluoride is naturally present in all water systems.[38] In their view, fluoridation is a modification of a naturally present substance in water that helps resist dental decay. Frequently, the comparison is made to the fortication of other types of foods, such as adding vitamins to breakfast cereals and baby foods.[53]

In addition, they propose that preventing broad, easy access to fluoride is unethical. Since the populations which benefit most from water fluoridation are children and those in poorer communities, fluoridation is considered an avenue to relieve some of the health disparities between socio-economic groups.[54] Fluoridation is defended further by its relative low cost. In the United States, the cost can be as low as 31 cents per person.[55] As a result, many health organizations defend fluoridation and do not consider it a violation of ethical principles.

Cost of Water Fluoridation

The cost of fluoridating water supplies in the United States has been researched.[55] In cities with a population of over 50,000 people, fluoridation costs 31 cents per person. The cost rises to $2.12 per person in cities with a population below 10,000.

Status of Water Fluoridation Nationally and Internationally

United States

As of May 2000, 42 of the 50 largest U.S. cities have water fluoridation.[56] By 2002, 67% of Americans are living in comunities with fluoridated water.[57]

Water fluoridation remains controversial among the general public.

The issue of whether or not to fluoridate waters supplies frequently arises in local governments. For example, on November 8, 2005, citizens of Mt. Pleasant, Michigan voted 63% to 37% in favor of reinstating fluoridation in public drinking water after a "clean water" ballot initiave in 2004 ceased water fluoridation in the city.[58]. November 30, 2005.

At the same time, voters in Xenia, Ohio, Springfield, Ohio, Bellingham, Washington and Tooele City, Utah all rejected water fluoridation. As of 2001, 19 states have at least 75% of their population receiving fluoridated water.[59] There is a CDC database for researching the water fluoridation status of neighborhood water.

Canada

Approximately 40% of the Canadian population receives fluoridated water[60]

Implementation of fluoridation usually lies with provincial or city 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.[61] The city continues to fluoridate its water today.[62] Historically, British Columbia has been the province with least percentage of its population receiving fluoridated water.[63] Montreal may be the last major city in Canada which does not fluoridate its water supplies.

Europe

Most of Europe does not fluoridate their water supply.

In the United Kingdom, only two major cities, Birmingham and Newcastle, fluoridate their water supply.[64]

After considering the matter, Scotland [3]rejected fluoridating their water in November of 2004.

France does not fluoridate their water supply. As "[f]luoride chemicals are not included in the list [of 'chemicals for drinking water treatment']. This is due to ethical as well as medical considerations." (Louis Sanchez, Directeur de la Protection de l'Environment, August 25, 2000).

Germany has consistently rejected water fluoridation. As the German Federal Minster of Health explained "[g]enerally, in Germany fluoridation of drinking water is forbidden. The relevant German law allows exceptions to the fluoridation ban on application (as was the case in the Kassel-Wahlershausen experiment in the 1950´s). The argumentation, in 1999, of the Federal Ministry of Health against a general permission of fluoridation of drinking water is the problematic nature of compuls[ory] medication." (Gerda Hankel-Khan, Embassy of Federal Republic of Germany, September 16, 1999). See the letter from German Federal Ministry of Health. However, experience shows that opinions change with the official in charge.

Basel, Switzerland, rejected fluoridating their water supply on a vote of 73 to 23 by their City Parliment in 2003 after conducting a re-examination of fluoridation's merits by the Health and Social Commission.

Fluoride was removed from the last city in Switzerland in April of 2003.

Other

The government of South Africa supports the fluoridation of water supplies.[65]

In Brazil, about 45% of the cities have a fluoridated water supply. Government studies reported a decrease in cavities on the affected population between 40% and 80%.[66] Chile rejected fluoridation in 1977.

Australia has fluoridation in all but one state, Queensland, in which water fluoridation is under local government control. Many regional centres in Queensland do fluoridate their water supply, however Brisbane, the state capital, currently does not add fluoride to its drinking water. The first town to fluoridate the water supply in Australia was Beaconsfield, Tasmania in 1953.[67]

Acute Poisoning resulting from malfunctions in water fluoridation equipment

In addition to the health risks asserted by fluoridation opponents, water fluoridation opponents also point to the harm that has occurred from acute poisoning when water fluoridation equipment has not functioned as designed.

There have been a number of instances in the United States in which water fluoridation equipment has malfunctioned and poisoned water users.

Perhaps the worst incident in U.S. history occurred in Hooper, Alaska in 1992. Here, when the fluoridation equipment failed, a large amount of fluoride was released into the drinking water supply, "296 people were poisoned; 1 person died." (Division of Field Epidemiology, Centers for Disease Control and Prevention, Atlanta.(1994))

Groups Opposing Water Fluoridation

Groups Advocating Water Fluoridation

References

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  63. ^ "Ambient Water Quality Criteria for Fluoride", from the Environmental Protection Division of British Columbia's Ministry of Environment website, page accessed March 27, 2006.
  64. ^ Mullen, Joe. "History of Water Fluoridation", British Dental Journal, 2005, page accessed April 29, 2006.
  65. ^ "Water Fluoridation - The Facts", from South Africa's Department of Health website, page accessed April 29, 2006.
  66. ^ Fluoretação da Água em Sistema Público de Abastecimento, page accessed April 29, 2006.
  67. ^ Editors: Graham Aplin, S.G. Foster and Michael McKernan, ed. (1987). "Tasmania". Australians:Events and Places. Sydney, NSW, Australia: Fairfax, Syme & Weldon Associates. pp. page 366. ISBN 0-521-34073-X. {{cite book}}: |editor= has generic name (help); |pages= has extra text (help)

See also

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