Water fluoridation: Difference between revisions
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'''Water fluoridation''' is the act of adding [[fluoride]] [[ion]]s to [[water]] in order to reduce [[tooth]] decay in the general population. Many [[North American]] and [[Australia]]n municipalities fluoridate their water supplies, citing this practice's effectiveness in reducing tooth decay, the safety of fluoridation, as well as its low cost. The [[American Dental Association]] (ADA), [[World Health Organization]] (WHO), and some other health organizations recommend fluoridation of municipal water supplies to a level between 0.7 and 1.2 [[part per million|ppm]]. |
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{{cleanup-date|May 23, 2006}} |
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'''Water fluoridation''' is the practice of adding [[fluoride]] [[ion]]s to [[water]] with the intended purpose of reducing [[tooth]] decay in the general population. Many [[North American]] and [[Australia|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<ref>http://www.awwa.org/Advocacy/pressroom/fluoride.cfm</ref> |
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Where used in very ''low'' concentrations (on the order of parts per million), fluorides are used in human health applications; specifically, fluorides such as [[sodium fluoride]] ([[Sodium|Na]][[Fluorine|F]]), [[sodium monofluorophosphate]] (SMFP), [[tin(II) fluoride]] ([[Tin|Sn]]F<sub>2</sub>), and [[amine fluorides]] are common ingredients in [[toothpaste]]. Many dentists also give their patients semiannual topical fluoride treatments. |
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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 [[Water fluoridation controversy|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]]. |
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In its earlier days, fluoridation was dogged by an [[urban legend]] declaring it to be a [[Communism|communist]] [[Conspiracy theory|conspiracy]]. This was satirized in [[Stanley Kubrick]]'s ''[[Dr. Strangelove or: How I Learned to Stop Worrying and Love the Bomb]]''. Also, in substantially larger concentrations, fluoride has been used as an active ingredient in rat poison, which has raised some concerns among the general public. Governments in some parts of the world have ceased fluoridation of water supplies, and the practice has [[Water fluoridation controversy|provoked controversy]]. |
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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 [[part per million|ppm]] or mg/L. |
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Currently, there is some fear among dental professionals that the growing use of bottled water may decrease the amount of fluoride exposure people will receive.<ref>Smith, Michael. [http://www.medpagetoday.com/PrimaryCare/DentalHealth/tb/1756 "Bottled Water Cited as Contributing to Cavity Comeback"], from the [http://www.medpagetoday.com/ MedPage Today] website, page accessed 29 April, 2006.</ref> Most companies which sell bottled water do not modify the fluoride levels, and fluoride concentrations are not usually labelled on the bottle. As a result, people who have fluoridated water supplies may receive less than optimal amounts of fluoride if they choose bottled water over tap water. |
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Groups opposing fluoridation have included the [http://www.noforcedfluoride.org/images/Penn.pdf Chapters of the Sierra Club], [http://www.ewg.org/issues/siteindex/issues.php?issueid=5031 Environmental Working Group], [http://www.orgsites.com/ny/nyscof/ New York State Coalition Opposed to Fluoridation (NYSCOF)] |
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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. <ref>Meiers, Peter. [http://www.fluoride-history.de/p-insecticides.htm "Patents on Fluoride Rat Poison and Insecticides"], from the [http://www.fluoride-history.de Fluoride History] website, page accessed 08 May, 2006.</ref> In ''low'' concentrations (on the order of parts per million), fluorides are used in human health applications; specifically, fluorides such as [[sodium fluoride]] ([[Sodium|Na]][[Fluorine|F]]), [[sodium monofluorophosphate]] (SMFP), [[tin(II) fluoride]] ([[Tin|Sn]]F<sub>2</sub>), and [[amine fluorides]] are common ingredients in [[toothpaste]]. Many dentists also give their patients semiannual topical fluoride treatments. |
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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. |
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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.<ref>Smith, Michael. [http://www.medpagetoday.com/PrimaryCare/DentalHealth/tb/1756 "Bottled Water Cited as Contributing to Cavity Comeback"], from the [http://www.medpagetoday.com/ MedPage Today] website, page accessed 29 April, 2006.</ref> 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 [http://www.nofluoride.com/UPI_bottled_water.htm UPI Story]. Some bottlers such as [http://www.dannonwater.com/fluoride.html 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.<ref>Heilman et al.[http://iadr.confex.com/iadr/2006Brisb/techprogram/abstract_79624.htm "Fluoride Content of Bottled Water"] research to be presented at the International Association of Dental Research in June 2006.</ref> |
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==History== |
==History== |
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While the use of fluorides for prevention of dental caries was discussed already in the 19th century in Europe <ref>Meiers, Peter: [http://www.fluoride-history.de/fteeth1.htm "Early Fluoride research in Europe"], from the [http://www.fluoride-history.de Fluoride History] website, page accessed 21 May, 2006.</ref>, 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."<ref name="csdshistory">[http://www.cs-ds.org/history.asp#fluoride History of Dentistry in the Pikes Peak Region],[http://www.cs-ds.org/index.asp Colorado Springs Dental Society] webpage, page accessed 25 February, 2006.</ref> 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. |
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[[Image:Ppeak-s.jpg|right|400px|thumb|Pike's Peak mountain in Colorado from the East.]] |
[[Image:Ppeak-s.jpg|right|400px|thumb|Pike's Peak mountain in Colorado from the East.]] |
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Initial hypotheses for the staining included poor [[nutrition]], overconsumption of [[pork]] or [[milk]], [[radium]] exposure, [[List of childhood diseases|childhood disease]]s, or a [[calcium]] deficiency in the local drinking water.<ref name="csdshistory">[http://www.cs-ds.org/history.asp#fluoride History of Dentistry in the Pikes Peak Region],[http://www.cs-ds.org/index.asp Colorado Springs Dental Society] webpage, page accessed 25 February, 2006.</ref> In 1931, researchers finally concluded that the cause of the Colorado stain was |
Initial hypotheses for the staining included poor [[nutrition]], overconsumption of [[pork]] or [[milk]], [[radium]] exposure, [[List of childhood diseases|childhood disease]]s, or a [[calcium]] deficiency in the local drinking water.<ref name="csdshistory">[http://www.cs-ds.org/history.asp#fluoride History of Dentistry in the Pikes Peak Region],[http://www.cs-ds.org/index.asp Colorado Springs Dental Society] webpage, page accessed 25 February, 2006.</ref> 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 <ref>Meiers, Peter: [http://www.fluoride-history.de/bauxite.htm "The Bauxite Story - A look at ALCOA"], from the [http://www.fluoride-history.de Fluoride History] website, page accessed 12 May, 2006.</ref>. 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. |
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[[Image:McKayandBlackCDC01.jpg|thumb|200px|left|Photograph of Dr. G.V. Black (left) and Dr. McKay (right) studying the "Colorado Brown Stain".]] |
[[Image:McKayandBlackCDC01.jpg|thumb|200px|left|Photograph of Dr. G.V. Black (left) and Dr. McKay (right) studying the "Colorado Brown Stain".]] |
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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. |
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. |
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The classic epidemiological study 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).<ref>Dean, H.T. "Classification of mottled enamel diagnosis." ''Journal of the American Dental Association'', 21, 1421 - 1426, 1934.</ref> <ref>Dean, H.T. "Chronic endemic dental fluorosis." ''Journal of the American Dental Association'', 16, 1269 - 1273, 1936.</ref> In 1939, Dr. Gerald J. Cox conducted laboratory tests on fluoride and released a report |
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).<ref>Dean, H.T. "Classification of mottled enamel diagnosis." ''Journal of the American Dental Association'', 21, 1421 - 1426, 1934.</ref> <ref>Dean, H.T. "Chronic endemic dental fluorosis." ''Journal of the American Dental Association'', 16, 1269 - 1273, 1936.</ref> In 1939, Dr. Gerald J. Cox <ref>Meiers, Peter: [http://www.fluoride-history.de/cox.htm "Gerald Judy Cox"].</ref> conducted laboratory tests on fluoride and released a report suggesting adding fluoride to drinking water in order to improve oral health.<ref>Cox, G.J., M.C. Matuschak, S.F. Dixon, M.L. Dodds, W.E. Walker. "Experimental dental caries IV. Fluorine and its relation to dental caries. Journal of Dental Research, 18, 481-490, 1939. Copy of original paper can be found [http://jdr.iadrjournals.org/cgi/reprint/18/6/481 here].</ref> 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. <ref>Klein H., Palmer C.E.: "Dental caries in American Indian children", Public Health Bulletin, No. 239, Dec. 1937 </ref> 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. |
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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]].<ref name="mntmichigan">[http://www.medicalnewstoday.com/medicalnews.php?newsid=27595 After 60 Years of Success, Water Fluoridation Still Lacking in Many Communities]. [http://www.medicalnewstoday.com Medical News Today] website, accessed 26 February, 2006.</ref> [[Kingston, New York]] was paired with [[Newburgh (city), New York|Newburgh, New York]]. <ref>Ast, D.B., D.J. Smith, B. Wacks, K.T. Cantwell. "Newburgh-Kingston caries-fluorine study XIV. Combined clinical and roentgenographic dental findings after ten years of fluoride experience." ''Journal of the American Dental Association'', 52, 314-25, 1956.</ref> [[Oak Park, Illinois]] was paired with [[Evanston, Illinois]]. [[Sarnia, Ontario]] was paired with [[Brantford, Ontario]], [[Canada]].<ref>Brown, H., M. Poplove. "The Brantford-Sarnia-Stratford Fluoridation Caries Study: Final Survey, 1963." Canadian Journal of Public Health,56, 319–24, 1965.</ref> The research found a decrease in the incidence of tooth decay in cities which had added fluoride to water supplies. |
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]].<ref name="mntmichigan">[http://www.medicalnewstoday.com/medicalnews.php?newsid=27595 After 60 Years of Success, Water Fluoridation Still Lacking in Many Communities]. [http://www.medicalnewstoday.com Medical News Today] website, accessed 26 February, 2006.</ref> [[Kingston, New York]] was paired with [[Newburgh (city), New York|Newburgh, New York]]. <ref>Ast, D.B., D.J. Smith, B. Wacks, K.T. Cantwell. "Newburgh-Kingston caries-fluorine study XIV. Combined clinical and roentgenographic dental findings after ten years of fluoride experience." ''Journal of the American Dental Association'', 52, 314-25, 1956.</ref> [[Oak Park, Illinois]] was paired with [[Evanston, Illinois]]. [[Sarnia, Ontario]] was paired with [[Brantford, Ontario]], [[Canada]].<ref>Brown, H., M. Poplove. "The Brantford-Sarnia-Stratford Fluoridation Caries Study: Final Survey, 1963." Canadian Journal of Public Health,56, 319–24, 1965.</ref> 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. |
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== Common arguments against water fluoridation == |
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==Implementation== |
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===United States=== |
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[[Image:Drinkingwater.JPG|right|200px|thumb|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]] |
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[[Image:MapofUSAfluoridatedStates03-19-06.jpg|right|thumb|250px|Percentage of state population receiving fluoridated water.]] |
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=== Adding fluoride compounds to municipal water supplies takes away individual choice of medication === |
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The history of water fluoridation began in the United States with the investigation into the "Colorado Stain." The first city in the United States, and in the world as well, to modify the fluoride levels in its water supply was [[Grand Rapids, Michigan]], in [[1945]], as part of a ten year evaluation of fluoridation.<ref name="mntmichigan">[http://www.medicalnewstoday.com/medicalnews.php?newsid=27595 After 60 Years of Success, Water Fluoridation Still Lacking in Many Communities]. [http://www.medicalnewstoday.com Medical News Today] website, accessed 26 February, 2006.</ref> As of May 2000, 42 of the 50 largest U.S. cities have water fluoridation.<ref>[http://www.cdc.gov/OralHealth/waterfluoridation/fact_sheets/benefits.htm The Benefits of Fluoride], from the [http://www.cdc.gov/ Centers for Disease Control and Prevention] website, accessed 19 March, 2006.</ref> By 2002, 67% of Americans are receiving optimal amounts of fluoridated water to prevent tooth decay.<ref>[http://www2.cdc.gov/nohss/FluoridationV.asp Fluoridation Status: Percentage of U.S. Population on Public Water Supply Systems Receiving Fluoridated Water], from the [http://www.cdc.gov/ Centers for Disease Control and Prevention] website, accessed 19 March, 2006.</ref> |
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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.<ref>[http://www.fluoridedebate.com/question34.html The Fluoride Debate: Question 34], [http://www.fluoridedebate.com Fluoride Debate] website, accessed 23 February, 2006.</ref> |
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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."<ref>[http://www.iicph.org/docs/fluoride_primer.htm Fluoride Primer: Fluoridation is a serious breach of ethics], [http://www.iicph.org International Institute of Concern for Public Health] website, accessed 22 February, 2006.</ref> |
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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. |
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=== Fluoride is not essential === |
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Some opponents of water fluoridation argue that fluoride is neither a [[vitamin]] nor an [[essential nutrient]].<ref>[http://www.bruha.com/pfpc/html/essential_.html Is Fluoride A Nutrient?],[http://www.bruha.com/pfpc/index.html PFPC The Fluoride Education Project] webpage, page accessed 23 February, 2006.</ref> 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. |
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=== Water fluoridation is not effective === |
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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). <ref>[http://www.nofluoride.com/Fuzzy_Math.htm The "Fuzzy Math" of Fluoride Promotion], [http://www.nofluoride.com No Fluoride] website, Paul Connett, accessed 18 February, 2006.</ref> |
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[[image:FluorideTrays07-05-05.jpg|left|250px|thumb|Some detractors of water fluoridation support concentrated topical methods to deliver fluoride, as seen in these fluoride trays often used in dentistry.]] |
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Opponents also argue that in the instances that fluoride prevents tooth decay, the effects are merely topical.<ref>[http://www.fluoridealert.org/health/teeth/caries/index.html Health Effects: Fluoride & Tooth Decay (Caries)], [http://www.fluoridealert.org Fluoride Alert] website, accessed 18 February, 2006.</ref> Therefore, fluoridating water is unnecessary and ineffective. Instead, they argue, direct applications of fluoride to teeth as done in dental offices and with fluoridated [[toothpaste]]s should be the recommended methods. |
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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.<ref>[http://www.fluoridealert.org/fluoride-facts.htm Facts about Fluoridation], [http://www.fluoridealert.org Fluoride Alert] website, accessed 22 February, 2006.</ref> |
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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.<ref>[http://www.slweb.org/limeback.html Why I am now officially opposed to adding fluoride to drinking water], [http://www.slweb.org Second Look] website, Hardy Limeback, accessed 22 February, 2006.</ref> |
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=== Fluoride causes health problems === |
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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. |
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[[Image:FluorosisFromNIH.jpg|right|200px|thumb|An example of teeth with dental fluorosis.]] |
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These persons point to research which they say supports the notion that fluoride causes chromosomal damage and interferes with DNA repair.<ref>[http://www.fluoridealert.org/health/cancer/mutagen.html Health Effects: Fluoride's Mutagenicity (Genotoxicity)], [http://www.fluoridealert.org Fluoride Alert] website, accessed 18 February, 2006.</ref> 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<ref>[http://www.fluoridealert.org/health/kidney/index.html#animals1ppm Health Effects: Fluoride & the Kidneys], [http://www.fluoridealert.org Fluoride Alert] website, accessed 18 February, 2006.</ref>, an increased uptake of aluminum in the brain, and the formation of beta amyloid deposits, a characteristic of Alzheimers disease.<ref>[http://www.fluoridealert.org/health/brain/index.html Health Effects: Fluoride & the Brain], [http://www.fluoridealert.org Fluoride Alert] website, accessed 18 February, 2006.</ref> Further, it is argued by some opponents that fluoride can weaken the immune system, leaving people vulnerable to the development of cancer and AIDS.<ref>[http://www.fluoridedebate.com/question25.html Diseases: Question 25], [http://www.fluoridedebate.com Fluoride Debate] website, accessed 19 February, 2006.</ref> |
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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.<ref>[http://www.fluoridation.com/sperm.htm The reproductive effects of fluoride intake], [http://www.fluoridation.com Fluoridation.com] website, accessed 18 February, 2006.</ref> Consequently, fluoride is considered dangerous by these groups. |
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=== Reliance on EPA Scientists and Nobel Prize winners who oppose water fluoridation === |
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Many opponents of water fluoridation rely on experts opposing water fluoridation. |
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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.[http://nteu280.org/Issues/Fluoride/NTEU280-Fluoride.htm] |
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"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.[http://www.slweb.org/carlsson.html] |
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== Common Arguments Advocating Water Fluoridation == |
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:''(See [[Water fluoridation controversy#Medical approval|Medical approval]]" for a list of health organizations.)'' |
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[[Image:Dripping faucet 1.jpg|right|200px|thumb|Groups opposing water fluoridation believe that individuals should be able to decide the [[chemicals]] they ingest in their drinking water rather than the [[government|government.]]]] |
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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]].<ref>[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4841a1.htm CDC], website, "Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries," page accessed 4 March, 2006. Overview of list can be found [http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm here].</ref> 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."<ref>[http://profiles.nlm.nih.gov/NN/ListByDate.html Reports of the Surgeon General], hosted by the National Library of Medicine, page accessed 4 March, 2006. The document, "Oral Health in America: A Report of the Surgeon General" can be found [http://profiles.nlm.nih.gov/NN/B/B/J/T/_/nnbbjt.pdf here] (in pdf format).</ref> 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 [[dental caries|tooth decay]].<ref name="whostatement">[http://www.who.int/water_sanitation_health/oralhealth/en/index2.html World Health Organization] website, "World Water Day 2001: Oral health", page 3, page accessed March 3, 2006.</ref> <ref name="iadrstatement">[http://www.dentalresearch.org/about/iadr/policy.html International Association for Dental Research] policy statements, including water fluoridation, page accessed March 3, 2006.</ref> |
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=== Fluoride is part of optimal oral health care === |
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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 [[tooth enamel|enamel]] and makes the enamel more resistant to demineralization by [[acid]]s.<ref>Ross, Michael H., Gordon I. Kaye, and Wojciech Pawlina, ''Histology: a Text and Atlas'', 4th ed. (Baltimore: Lippincott Williams & Wilkins, 2002), p. 453. ISBN 0683302426.</ref> As a result, some organizations, such as the American Dental Hygiene Association, classify fluoride as a [[nutrient]] necessary for proper tooth development.<ref>[http://www.adha.org/CE_courses/course7/nutritional_factors.htm Nutritional Factors in Tooth Development and Maintenance], [http://www.adha.org American Dental Hygiene Association] website, page accessed 4 March, 2006.</ref> In addition, organizations, including the CDC and WHO, promote increasing the accessibility of fluoridated water.<ref>[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5107a2.htm "Populations Receiving Optimally Fluoridated Public Drinking Water"], from the [http://www.cdc.gov CDC] website, page accessed 4 March, 2006.</ref> <ref name="whostatement">[http://www.who.int/water_sanitation_health/oralhealth/en/index2.html World Health Organization] website, "World Water Day 2001: Oral health", page 3, page accessed March 3, 2006.</ref> |
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=== Water fluoridation is effective === |
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[[Image:Suspectedmethmouth09-19-05closeup.jpg|left|200px|thumb|An example of tooth decay.]] |
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<p> |
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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. |
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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 [[Group (sociology)|social group]]s 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.<ref name="whostatement">[http://www.who.int/water_sanitation_health/oralhealth/en/index2.html World Health Organization] website, "World Water Day 2001: Oral health", page 3, page accessed March 3, 2006.</ref> |
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Fluoridation advocates believe that some anti-fluoridation research is published in [[journal]]s, such as "Fluoride", that are deceptively made to appear [[Peer review|peer-reviewed]].<ref name="uwfdeception">[http://www.uwf.edu/rsnyder/reports/fluoride.html "Impact of Fluoridation of the Municipal Drinking Water Supply: Review of the Literature"], hosted on the [http://www.uwf.edu/uwfMain/ University of West Florida] website, page accessed 4 March, 2006.</ref> |
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=== There are safe levels for fluoride use === |
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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.<ref>[http://www.ada.org.au/_FAQFl.asp#Is%20fluoride%20poisonous Is fluoride poisonous?], from the [http://www.ada.org.au/_Home.asp Austrialian Dental Association] website, page accessed 18 March, 2006.</ref> 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.<ref name="adafluoridationfacts">[http://www.ada.org/public/topics/fluoride/facts/fluoridation_facts.pdf Fluoridation Facts] (in pdf format), from the [http://www.ada.org ADA] website, page accessed 18 March, 2006.</ref> As is true for all [[vitamin]]s and [[mineral]]s, recommended dosages for fluoride represent levels which maximize health benefits and minimize adverse effects.<ref>[http://www.scotland.gov.uk/consultations/health/ccoh-06.asp Towards Better Oral Health in Children], from the [http://www.scotland.gov.uk/Home Scottish Executive] website, page accessed 18 March, 2006.</ref> |
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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 [[tooth enamel|enamel]], and makes [[oral hygiene]] more difficult.<ref>[http://www.aapd.org/publications/brochures/fluorosis.asp Enamel Fluorosis], from the [http://www.aapd.org American Academy of Pediatric Dentistry] website, page accessed 18 March, 2006.</ref> Government agencies, such as the Center for Disease Control and Prevention, keep records on the [[prevalence]] of fluorosis in the general public.<ref>[http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5403a1.htm#tab23 Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis --- United States, 1988--1994 and 1999--2002], from the [http://www.cdc.gov CDC] website, page accessed 18 March, 2006.</ref> 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.<ref>[https://www.who.int/water_sanitation_health/diseases/fluorosis/en/ Water-related diseases: Fluorosis], from the [https://www.who.int/en/ World Health Organization] website, page accessed 18 March, 2006.</ref> 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.<ref name="adafluoridationfacts">[http://www.ada.org/public/topics/fluoride/facts/fluoridation_facts.pdf Fluoridation Facts] (in pdf format), from the [http://www.ada.org ADA] website, page accessed 18 March, 2006.</ref> |
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{| cellpadding=10 align=left |
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|- |
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| |
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{| border="BORDER" style="border-collapse:collapse;padding:3px;text-align:center;" |
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! colspan=4 style="background:#ffdead;padding:3px" | Schedule for Fluoride Prescription<ref name="aapdschedule">[http://www.aapd.org/media/Policies_Guidelines/G_FluorideTherapy.pdf Fluoride Therapy] (in pdf format), from the [http://www.aapd.org American Association of Pediatric Dentistry] website, page accessed 18 March, 2006.</ref> |
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|- |
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! style="width:10em" | Age |
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! style="width:5em" colspan=1 | < 0.3 ppm |
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! style="width:5em" colspan=1 | 0.3 - 0.6 ppm |
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! style="width:5em" colspan=1 | >0.6 ppm |
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|- |
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| Birth - 6 months |
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| 0 |
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| 0 |
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| 0 |
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|- |
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| 6 months - 3 years |
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| .25 mg |
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| 0 |
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| 0 |
|||
|- |
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| 3 years - 6 years |
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| .50 mg |
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| .25 mg |
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| 0 |
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|- |
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| 6 years - 16 years |
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| 1.0 mg |
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| .50 mg |
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| 0 |
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|} |
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Dosages are in milligrams F/day; 1.0 ppm = 1 mg/liter. |
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|} |
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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 [[Kilogram|milligram]]s of fluoride per [[Litre|liter]].<ref>[http://www.atsdr.cdc.gov/tfacts11.html ToxFAQs for Fluorine, Hydrogen Fluoride, and Fluorides], from the [http://www.atsdr.cdc.gov/ Agency for Toxic Substances and Disease Registry] (ATSDR) website, page accessed 18 March, 2006.</ref> The [[World Health Organization]] cautions that fluoride levels above 1.5 milligrams per liter leaves the risk for fluorosis.<ref>[http://www.who.int/water_sanitation_health/naturalhazards/en/index2.html Fluoride], from the [http://www.who.int/en/ Agency for World Health Organization] website, page accessed 18 March, 2006.</ref> When there is a fluoride deficiency in water (usually below 0.6 ppm), fluoride [[Dietary supplement|supplement]]s are sometimes needed to encourage healthy dental development. There are accepted recommended guidelines on the amount of fluoride to [[Medical prescription|prescribe]], which depend on the fluoride levels in the drinking water and on the age of the child.<ref name="aapdschedule">[http://www.aapd.org/media/Policies_Guidelines/G_FluorideTherapy.pdf Fluoride Therapy] (in pdf format), from the [http://www.aapd.org American Association of Pediatric Dentistry] website, page accessed 18 March, 2006.</ref> |
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The [[Centers for Disease Control and Prevention]] and the [[National Cancer Institute]] have both issued statements that water fluoridation is not believed to cause [[osteosarcoma]]s.<ref>[http://www.cdc.gov/oralhealth/waterfluoridation/safety/osteosarcoma.htm CDC Statement on Water Fluoridation and Osteosarcoma], from the [http://www.cdc.gov CDC] website, page accessed 18 March, 2006.</ref> <ref name="nciosteosarcomas">[http://www.cancer.gov/cancertopics/factsheet/Risk/fluoridated-water National Cancer Institute] website, "Fluoridated Water: Questions and Answers", page accessed March 3, 2006.</ref> [[Cancer]] in general is not believed to be caused from water fluoridation.<ref>Knox, E.G. [http://www.bopcris.ac.uk/bopall/ref20842.html "Fluoridation of water and cancer: a review of the epidemiological evidence"], hosted on the [http://www.bopcris.ac.uk/ British Official Publications Collaborative Reader Information Service] website, page accessed 18 March, 2006. Full text can be found [http://www.bopcris.ac.uk/imgall/ref20842_1_1.html here]</ref> <ref>[http://www-cie.iarc.fr/htdocs/monographs/vol27/fluorides.html "Inorganic Fluuorides Used In Drinking-water and Dental Preparations"], by the [http://www.iarc.fr International Agency on Research for Cancer] website, page accessed 18 March, 2006.</ref> |
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Fluoridation proponents do not believe there is a link between [[Alzheimer's disease]] and water fluoridation.<ref name="adafluoridationfacts">[http://www.ada.org/public/topics/fluoride/facts/fluoridation_facts.pdf Fluoridation Facts] (in pdf format), from the [http://www.ada.org ADA] website, page accessed 18 March, 2006.</ref> A study in 1998 suggested a possible relationship between fluoride exposure and Alzheimer's disease.<ref>Varner, J.A., K.F. Jensen, W. Horvath, R.L. Isaacson. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9518651&dopt=Citation "Chronic administration of aluminum-fluoride or sodium-fluoride to rats in drinking water: alterations in neuronal and cerebrovascular integrity"], abstract from [http://www.pubmed.gov PubMed] website, page accessed 18 March, 2006.</ref> |
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<p> |
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Fluoridation proponents believe fluoride is not a risk factor for Alzheimer's disease, and instead [[Ageing|age]] and [[Family history (medicine)|family history]] are the most important risk factors.<ref>[http://www.nia.nih.gov/Alzheimers/AlzheimersInformation/Causes/ Causes"], by the [http://www.nia.nih.gov/alzheimers Alzheimer's Disease Education and Referral (ADEAR) Center] website, a division of the National Institue of Aging, page accessed 18 March, 2006.</ref> Moreover, there is some research that suggests Alzheimer's disease can be prevented with water fluoridation because of the competition between [[aluminum]] and fluoride [[Digestion|absorption]].<ref>Kraus, A.S. and W.F. Forbes. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1617567&dopt=Citation "Aluminum, fluoride and the prevention of Alzheimer's disease."], abstract from [http://www.pubmed.gov PubMed] website, page accessed 18 March, 2006.</ref> Nonetheless, this research is also limited by design and no definitive conclusion can be made. |
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Other health concerns, such as [[kidney]] disease, [[Down syndrome]], [[lead poisoning]], [[heart disease]], decreased [[fertility]] rates, and inhibition of biologic [[enzyme]]s, are not believed by fluoride proponents to be attributed to water fluoridation.<ref name="adafluoridationfacts">[http://www.ada.org/public/topics/fluoride/facts/fluoridation_facts.pdf Fluoridation Facts] (in pdf format), from the [http://www.ada.org ADA] website, page accessed 18 March, 2006.</ref> |
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[[Image:Milk glass.jpg|right|150px|thumb|Fluoride proponents suggest that adding fluoride to the water is no different that adding vitamin D to milk.]] |
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=== Ethical questions === |
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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 [[informed consent|consent]] to pursue medical treatment and whether fluoridation should be easily accessable to everyone. |
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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.<ref name="adafluoridationfacts">[http://www.ada.org/public/topics/fluoride/facts/fluoridation_facts.pdf Fluoridation Facts] (in pdf format), from the [http://www.ada.org ADA] website, page accessed 18 March, 2006.</ref> 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 cereal]]s and [[baby food]]s.<ref name="bmastatment">[http://www.bma.org.uk/ap.nsf/Content/Water+fluoridation British Medical Association] website, statement on water fluoridation, page accessed March 3, 2006.</ref> |
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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 [[Socioeconomics|socio-economic]] groups.<ref>[http://www.bfsweb.org/One%20in%20a%20million/10%20ethics.pdf "The Ethics of Water Fluoridation"] publication (in pdf format), from the [http://www.bfsweb.org/index.html British Fluoridation Society] website, page accessed March 19, 2006.</ref> Fluoridation is defended further by its relative low cost. In the United States, the cost can be as low as 31 cents per person.<ref name="RingelbergCost">Ringelberg, M. L., S. J. Allen, L. J. Brown. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1564695&dopt=Citation "Cost of fluoridation: 44 Florida communities."], abstract from [http://www.pubmed.gov PubMed] website, page accessed 19 March, 2006.</ref> As a result, many health organizations defend fluoridation and do not consider it a violation of ethical principles. |
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== Cost of Water Fluoridation == |
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The cost of fluoridating water supplies in the United States has been researched.<ref name="RingelbergCost">Ringelberg, M. L., S. J. Allen, L. J. Brown. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1564695&dopt=Citation "Cost of fluoridation: 44 Florida communities."], abstract from [http://www.pubmed.gov PubMed] website, page accessed 19 March, 2006.</ref> 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. |
The cost of fluoridating water supplies in the United States has been researched.<ref name="RingelbergCost">Ringelberg, M. L., S. J. Allen, L. J. Brown. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1564695&dopt=Citation "Cost of fluoridation: 44 Florida communities."], abstract from [http://www.pubmed.gov PubMed] website, page accessed 19 March, 2006.</ref> 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. |
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== Status of Water Fluoridation Nationally and Internationally == |
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Water fluoridation maintains support among the general public. In 1998, 70% of people polled believed community water should be fluoridated, with 18% disagreeing and the rest undecided. |
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===United States=== |
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As of May 2000, 42 of the 50 largest U.S. cities have water fluoridation.<ref>[http://www.cdc.gov/OralHealth/waterfluoridation/fact_sheets/benefits.htm The Benefits of Fluoride], from the [http://www.cdc.gov/ Centers for Disease Control and Prevention] website, accessed 19 March, 2006.</ref> By 2002, 67% of Americans are living in comunities with fluoridated water.<ref>[http://www2.cdc.gov/nohss/FluoridationV.asp Fluoridation Status: Percentage of U.S. Population on Public Water Supply Systems Receiving Fluoridated Water], from the [http://www.cdc.gov Centers for Disease Control and Prevention] website, accessed 19 March, 2006.</ref> |
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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 initive in 2004 ceased water fluoridation in the city.<ref>Crozier, Stacie. [http://www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=1684 "Michigan town votes to return fluoridation"]. November 30, 2005. Located on the [http://www.ada.org/ American Dental Association] website.</ref> Nonetheless, similar elections in Xenia, Ohio, Springfield, Ohio, Bellingham, Washington and Tooele City, Utah on the same day resulted in rejection of water fluoridation. |
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Water fluoridation remains controversial among the general public. |
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As of 2001, 19 states have at least 75% of their population receiving optimal amounts of fluoridated water.<ref>[http://fluoride.oralhealth.org/papers/2001/astddstatemapfl.htm National Oral Health Surveillance System: Public Water Supply], from the Centers for Disease Control and Prevention.</ref> There is a CDC [http://apps.nccd.cdc.gov/MWF/index.asp database] for researching the water fluoridation status of neighborhood water. |
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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.<ref>Crozier, Stacie. [http://www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=1684 "Michigan town votes to return fluoridation"]</ref>. November 30, 2005. |
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<p>At the same time, voters in Xenia, Ohio, Springfield, Ohio, Bellingham, Washington and Tooele City, Utah all [http://www.noforcedfluoride.org rejected water fluoridation.] |
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As of 2001, 19 states have at least 75% of their population receiving fluoridated water.<ref>[http://fluoride.oralhealth.org/papers/2001/astddstatemapfl.htm National Oral Health Surveillance System: Public Water Supply], from the Centers for Disease Control and Prevention.</ref> There is a CDC [http://apps.nccd.cdc.gov/MWF/index.asp database] for researching the water fluoridation status of neighborhood water. |
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===Canada=== |
===Canada=== |
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Approximately 40% of the Canadian population receives fluoridated water<ref>[http://www.hc-sc.gc.ca/iyh-vsv/environ/fluor_e.html "Fluorides and Human Health"], from the [http://www.hc-sc.gc.ca/index_e.html Health Canada] website, page accessed March 25, 2006.</ref> |
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Canada's position on water fluoridation is that it is beneficial and thus supports a policy to best improve dental health with minimizing the risk of dental fluorosis. 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.<ref>[http://archives.cbc.ca/IDC-1-75-341-1816/science_technology/fluoride/clip4 "Gordon Sinclair's rant"], from the [http://archives.cbc.ca/index.asp?IDLan=1 Canadian Broadcasting Corporation Archives] website, page accessed March 27, 2006.</ref> The city continues to fluoridate its water today.<ref>[http://www.toronto.ca/water/supply/supply_facilities/rlclark/filtration_process.htm "Water supply - R. L. Clark Filtration Plant"], from [http://www.toronto.ca/index.htm Toronto's] website, page accessed March 27, 2006.</ref> Historically, British Columbia has been the province with least percentage of its population receiving fluoridated water.<ref>[http://www.env.gov.bc.ca/wat/wq/BCguidelines/fluoride/fluoridetoo-03.html "Ambient Water Quality Criteria for Fluoride"], from the [http://www.env.gov.bc.ca/epdiv/ Environmental Protection Division] of British Columbia's Ministry of Environment website, page accessed March 27, 2006.</ref> Montreal may be the last major city in Canada which does not fluoridate its water supplies. About 40% of the Canadian population receives fluoridated water<ref>[http://www.hc-sc.gc.ca/iyh-vsv/environ/fluor_e.html "Fluorides and Human Health"], from the [http://www.hc-sc.gc.ca/index_e.html Health Canada] website, page accessed March 25, 2006.</ref> |
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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.<ref>[http://archives.cbc.ca/IDC-1-75-341-1816/science_technology/fluoride/clip4 "Gordon Sinclair's rant"], from the [http://archives.cbc.ca/index.asp?IDLan=1 Canadian Broadcasting Corporation Archives] website, page accessed March 27, 2006.</ref> The city continues to fluoridate its water today.<ref>[http://www.toronto.ca/water/supply/supply_facilities/rlclark/filtration_process.htm "Water supply - R. L. Clark Filtration Plant"], from [http://www.toronto.ca/index.htm Toronto's] website, page accessed March 27, 2006.</ref> Historically, British Columbia has been the province with least percentage of its population receiving fluoridated water.<ref>[http://www.env.gov.bc.ca/wat/wq/BCguidelines/fluoride/fluoridetoo-03.html "Ambient Water Quality Criteria for Fluoride"], from the [http://www.env.gov.bc.ca/epdiv/ Environmental Protection Division] of British Columbia's Ministry of Environment website, page accessed March 27, 2006.</ref> Montreal may be the last major city in Canada which does not fluoridate its water supplies. |
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In 1999, the Public Health Branch of the Ontario Ministry of Health affirmed its support of water fluoridation, while also calling for increased study on other sources of fluoride, such as water, food, breast milk, air, soil and toothpaste.<ref>[http://www.health.gov.on.ca/english/public/pub/ministry_reports/fluoridation/fluor.pdf "Benefits and Risks of Water Fluoridation: An Update of the 1996 Federal-Provincial Sub-committee Report"] (in pdf format), hosted on Ontario's [http://www.health.gov.on.ca/index.html Ministry of Health and Long-term Care] website, page accessed March 25, 2006.</ref> It is believed that cases of dental fluorosis is increased by exposure to fluoride from these other sources. As a result, modifying the recommended levels of fluoride in water may be needed if people are receiving a total intake of fluoride not within the recommendations. |
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===Europe=== |
===Europe=== |
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Most of '''[[Europe]]''' does not fluoridate their water supply.<p> |
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In the [[United Kingdom]], only two major cities, [[Birmingham]] and [[Newcastle]], received fluoridated water in 1982.<ref>Mullen, Joe. [http://www.nature.com/bdj/journal/v199/n7s/full/4812863a.html "History of Water Fluoridation"], British Dental Journal, 2005, page accessed April 29, 2006.</ref> The Water Act of 1985 was the first legislative move to allow water fluoridation and resulted from a complaint toward the Strathclyde Regional Council by an individual who had received fluoridated water.<ref>[http://www.southernwater.co.uk/educationAndEnvironment/drinkingWaterQuality/fluoridation.asp "Fluoridation of drinking water"], from the [http://www.southernwater.co.uk/default.asp Southern Water] website, page accessed April 29, 2006.</ref> Since that time, most of the water companies have avoided fluoridating water supplies for fear of lawsuits by those in the community opposed to fluoride.<ref>[http://news.bbc.co.uk/1/hi/uk_politics/3054519.stm "Lords back water fluoridation"], from the [http://news.bbc.co.uk/ BBC News] website, page accessed April 29, 2006.</ref> The British Dental Association began campaigning for fluoridation of water supplies in 2003.<ref>[http://www.bda-dentistry.org.uk/advice/news.cfm?ContentID=990 "British Dental Association launches campaign on water fluoridation"], hosted on the [http://www.bda-dentistry.org.uk/index.cfm British Dental Association] website, page accessed April 29, 2006.</ref> The Water Act of 2003 was passed, and under section 58 the authority to decide the fluoridation of water supplies was taken from the privatized water companies and given to regional health authorities.<ref>[http://www.opsi.gov.uk/acts/acts2003/30037--d.htm#58 "Water Act 2003"], hosted on the [http://www.opsi.gov.uk/ Office of Public Sector Information] website, page accessed April 29, 2006.</ref> In 2005, the government sent letters to health authorities to remind them of their ability to enforce fluoridation standards on water companies.<ref>[http://news.bbc.co.uk/1/hi/uk_politics/4325908.stm "Government 'pushes fluoridation'"], from the [http://news.bbc.co.uk/ BBC News] website, page accessed April 29, 2006.</ref> This is seen as an effort by the government to increase the number of the British population with access to fluoridated water. |
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In the '''[[United Kingdom]]''', only two major cities, [[Birmingham]] and [[Newcastle]], fluoridate their water supply.<ref>Mullen, Joe. [http://www.nature.com/bdj/journal/v199/n7s/full/4812863a.html "History of Water Fluoridation"], British Dental Journal, 2005, page accessed April 29, 2006.</ref> <p> |
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In [[Switzerland]], only [[Basel]]'s water was fluoridated, and that was stopped in April 2003 on the advice of their Health and Social Commission. Instead, since 1955, beginning with the city of [[Zurich]], fluoridated salt has been used as a substitute for fluoridated water because of the country's few large cities and complex water distribution systems.<ref>Marthaler, Thomas M. [http://www.sso.ch/doc/doc_download.cfm?6D260B3CBCD825C4D8C4C7FDC05E5438 "Overview of salt fluoridation in Switzerland since 1955, a short history"] (in pdf format), from the [www.sso.ch/ Schweizerischen Zahnärzte-Gesellschaft] website, page accessed April 29, 2006.</ref> When Basel replaced its water fluoridation program with that of salt fluoridation, salt containing iodine and fluoride constituted 88% of the market share of all salt sold in the country. |
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After considering the matter, '''[[Scotland]] [http://www.fluoridealert.org/news/2115.html]'''rejected fluoridating their water in November of 2004.<p> |
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Most European countries employ delivery models other than water fluoridation, such as salt and milk fluoridation. |
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'''[[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." ([http://www.fluoridealert.org/france.jpeg Louis Sanchez], Directeur de la Protection de l'Environment, August 25, 2000). <p> |
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'''[[Germany]]''' has consistently rejected water fluoridation. As the German Federal Minster of Health [http://www.fluoridealert.org/germany.jpeg 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 [http://www.fluoridealert.org/germany.jpeg letter] from German Federal Ministry of Health. However, experience shows that opinions change with the official in charge. <p> |
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Basel, '''[[Switzerland]]''', rejected fluoridating their water supply on a [http://www.fluoridealert.org/basel.htm 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.<p> Fluoride was [http://www.fluoridealert.org/basel.htm removed] from the last city in Switzerland in April of 2003. |
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=== Other === |
=== Other === |
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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%.<ref>[http://www.funasa.gov.br/Web%20Funasa/san/Fluoreta/Fluoretacao.htm Fluoretação da Água em Sistema Público de Abastecimento], page accessed April 29, 2006.</ref> [[Chile]] rejected fluoridation in [[1977]]. |
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%.<ref>[http://www.funasa.gov.br/Web%20Funasa/san/Fluoreta/Fluoretacao.htm Fluoretação da Água em Sistema Público de Abastecimento], page accessed April 29, 2006.</ref> [[Chile]] rejected fluoridation in [[1977]]. |
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[[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. |
[[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 in Australia|1953]].<ref>{{cite book | editor = Editors: Graham Aplin, S.G. Foster and Michael McKernan | title = Australians:Events and Places | year = 1987 | publisher = Fairfax, Syme & Weldon Associates | location = Sydney, NSW, Australia | id = ISBN 0-521-34073-X | pages = page 366 | chapter = Tasmania}} </ref> |
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== Acute Poisoning resulting from malfunctions in water fluoridation equipment == |
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[[India]] and [[Egypt]] have naturally occurring fluoride in the water. |
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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. |
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==Controversy== |
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''See main article [[Water fluoridation controversy]]'' |
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There have been a number of instances in the United States in which water fluoridation equipment has malfunctioned and poisoned water users. |
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Water fluoridation by public authorities has occassionally provoked controversy, though opposition to fluoridation is a minority viewpoint. Advocates of water fluoridation say that fluoridation is similar to fortifying [[salt]] with [[iodine]], [[milk]] with [[vitamin D]] and [[orange juice]] with [[vitamin C]] and say it is an effective way to prevent [[dental caries|tooth decay]] and improve oral health over a lifetime, for both [[child|children]] and [[adult]]s. Those opposed to public fluoridation of drinking water say that water fluoridation can have negative health effects such as [[dental fluorosis]] which outweighs the purported benefits of water fluoridation. Some opponents claim that releasing fluoride compunds into a municipal water takes away individual choice as to the substances a person ingests and amounts to mass medication. Some suggest water fluoridation is part of a scheme to dispose of a toxic [[industry|industrial]] byproduct. |
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<p> |
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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, "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8259189 296 people were poisoned; 1 person died."] (Division of Field Epidemiology, Centers for Disease Control and Prevention, Atlanta.(1994)) |
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==Groups Opposing Water Fluoridation== |
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*[http://www.ewg.org/issues/siteindex/issues.php?issueid=5031 Environmental Working Group] |
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*[http://www.orgsites.com/ny/nyscof/ New York State Coalition Opposed to Fluoridation (NYSCOF)] |
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*[http://www.fluoridealert.org Fluoride Action Network] |
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*[http://www.ewg.org/issues/siteindex/issues.php?issueid=5031 Environmental Working Group] |
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*[http://www.skagitcleanwater.com Skagit County Clean Water (Washington)] |
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== Groups Advocating Water Fluoridation == |
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*[http://www.who.int/water_sanitation_health/oralhealth/en/index2.html World Health Organization] |
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*[http://www.ada.org/ American Dental Association] |
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*[http://www.dentalhealthwestmidlands.nhs.uk/keyfacts2004/keyfacts.htm U.K. National Health Service] |
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*[http://www.phaa.net.au/Advocacy_Issues/letterbeattie.html Public Health Association of Australia] |
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*[http://www.pha.org.nz/Advocacy.html Public Health Association of New Zealand] |
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== References == |
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==Notes and references== |
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<references /> |
<references /> |
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==External links== |
==External links== |
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* [http://apps.nccd.cdc.gov/MWF/index.asp CDC] database for the fluoridation status of neighborhood water |
* [http://apps.nccd.cdc.gov/MWF/index.asp CDC] database for the fluoridation status of neighborhood water |
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* [http://www.ada.org/public/media/presskits/fluoridation/epa_flouoridation_letter_on_thesis.pdf Letter on fluoridation from EPA] (PDF) hosted by ADA |
* [http://www.ada.org/public/media/presskits/fluoridation/epa_flouoridation_letter_on_thesis.pdf Letter on fluoridation from EPA] (PDF) supporting fluoridation hosted by ADA |
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* [http://www.nature.com/bdj/journal/v199/n7s/full/4812863a.html History of Water Fluoridation] |
* [http://www.nature.com/bdj/journal/v199/n7s/full/4812863a.html History of Water Fluoridation] |
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* [http://archives.cbc.ca/IDC-1-75-341-1829/science_technology/fluoride/clip5 1970s discussion on fluoridation] |
* [http://archives.cbc.ca/IDC-1-75-341-1829/science_technology/fluoride/clip5 1970s discussion on fluoridation] |
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</ref> |
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[[Category:Dentistry]] |
[[Category:Dentistry]] |
Revision as of 21:19, 27 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.
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.
![](http://upload.wikimedia.org/wikipedia/commons/thumb/a/ac/McKayandBlackCDC01.jpg/200px-McKayandBlackCDC01.jpg)
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
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]
![](http://upload.wikimedia.org/wikipedia/commons/thumb/f/fb/FluorideTrays07-05-05.jpg/250px-FluorideTrays07-05-05.jpg)
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.
![](http://upload.wikimedia.org/wikipedia/commons/thumb/1/1d/FluorosisFromNIH.jpg/200px-FluorosisFromNIH.jpg)
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.)
![](http://upload.wikimedia.org/wikipedia/commons/thumb/5/58/Dripping_faucet_1.jpg/200px-Dripping_faucet_1.jpg)
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
![](http://upload.wikimedia.org/wikipedia/commons/thumb/e/e4/Suspectedmethmouth09-19-05closeup.jpg/200px-Suspectedmethmouth09-19-05closeup.jpg)
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]
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]
![](http://upload.wikimedia.org/wikipedia/commons/thumb/0/0e/Milk_glass.jpg/150px-Milk_glass.jpg)
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
- ^ http://www.awwa.org/Advocacy/pressroom/fluoride.cfm
- ^ Meiers, Peter. "Patents on Fluoride Rat Poison and Insecticides", from the Fluoride History website, page accessed 08 May, 2006.
- ^ Smith, Michael. "Bottled Water Cited as Contributing to Cavity Comeback", from the MedPage Today website, page accessed 29 April, 2006.
- ^ Heilman et al."Fluoride Content of Bottled Water" research to be presented at the International Association of Dental Research in June 2006.
- ^ Meiers, Peter: "Early Fluoride research in Europe", from the Fluoride History website, page accessed 21 May, 2006.
- ^ a b History of Dentistry in the Pikes Peak Region,Colorado Springs Dental Society webpage, page accessed 25 February, 2006.
- ^ Meiers, Peter: "The Bauxite Story - A look at ALCOA", from the Fluoride History website, page accessed 12 May, 2006.
- ^ Dean, H.T. "Classification of mottled enamel diagnosis." Journal of the American Dental Association, 21, 1421 - 1426, 1934.
- ^ Dean, H.T. "Chronic endemic dental fluorosis." Journal of the American Dental Association, 16, 1269 - 1273, 1936.
- ^ Meiers, Peter: "Gerald Judy Cox".
- ^ Cox, G.J., M.C. Matuschak, S.F. Dixon, M.L. Dodds, W.E. Walker. "Experimental dental caries IV. Fluorine and its relation to dental caries. Journal of Dental Research, 18, 481-490, 1939. Copy of original paper can be found here.
- ^ Klein H., Palmer C.E.: "Dental caries in American Indian children", Public Health Bulletin, No. 239, Dec. 1937
- ^ After 60 Years of Success, Water Fluoridation Still Lacking in Many Communities. Medical News Today website, accessed 26 February, 2006.
- ^ Ast, D.B., D.J. Smith, B. Wacks, K.T. Cantwell. "Newburgh-Kingston caries-fluorine study XIV. Combined clinical and roentgenographic dental findings after ten years of fluoride experience." Journal of the American Dental Association, 52, 314-25, 1956.
- ^ Brown, H., M. Poplove. "The Brantford-Sarnia-Stratford Fluoridation Caries Study: Final Survey, 1963." Canadian Journal of Public Health,56, 319–24, 1965.
- ^ The Fluoride Debate: Question 34, Fluoride Debate website, accessed 23 February, 2006.
- ^ Fluoride Primer: Fluoridation is a serious breach of ethics, International Institute of Concern for Public Health website, accessed 22 February, 2006.
- ^ Is Fluoride A Nutrient?,PFPC The Fluoride Education Project webpage, page accessed 23 February, 2006.
- ^ The "Fuzzy Math" of Fluoride Promotion, No Fluoride website, Paul Connett, accessed 18 February, 2006.
- ^ Health Effects: Fluoride & Tooth Decay (Caries), Fluoride Alert website, accessed 18 February, 2006.
- ^ Facts about Fluoridation, Fluoride Alert website, accessed 22 February, 2006.
- ^ Why I am now officially opposed to adding fluoride to drinking water, Second Look website, Hardy Limeback, accessed 22 February, 2006.
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- ^ The reproductive effects of fluoride intake, Fluoridation.com website, accessed 18 February, 2006.
- ^ CDC, website, "Achievements in Public Health, 1900-1999: Fluoridation of Drinking Water to Prevent Dental Caries," page accessed 4 March, 2006. Overview of list can be found here.
- ^ Reports of the Surgeon General, hosted by the National Library of Medicine, page accessed 4 March, 2006. The document, "Oral Health in America: A Report of the Surgeon General" can be found here (in pdf format).
- ^ a b c World Health Organization website, "World Water Day 2001: Oral health", page 3, page accessed March 3, 2006.
- ^ International Association for Dental Research policy statements, including water fluoridation, page accessed March 3, 2006.
- ^ Ross, Michael H., Gordon I. Kaye, and Wojciech Pawlina, Histology: a Text and Atlas, 4th ed. (Baltimore: Lippincott Williams & Wilkins, 2002), p. 453. ISBN 0683302426.
- ^ Nutritional Factors in Tooth Development and Maintenance, American Dental Hygiene Association website, page accessed 4 March, 2006.
- ^ "Populations Receiving Optimally Fluoridated Public Drinking Water", from the CDC website, page accessed 4 March, 2006.
- ^ 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.
- ^ "Impact of Fluoridation of the Municipal Drinking Water Supply: Review of the Literature", hosted on the University of West Florida website, page accessed 4 March, 2006.
- ^ Is fluoride poisonous?, from the Austrialian Dental Association website, page accessed 18 March, 2006.
- ^ a b c d e Fluoridation Facts (in pdf format), from the ADA website, page accessed 18 March, 2006.
- ^ Towards Better Oral Health in Children, from the Scottish Executive website, page accessed 18 March, 2006.
- ^ Enamel Fluorosis, from the American Academy of Pediatric Dentistry website, page accessed 18 March, 2006.
- ^ Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis --- United States, 1988--1994 and 1999--2002, from the CDC website, page accessed 18 March, 2006.
- ^ Water-related diseases: Fluorosis, from the World Health Organization website, page accessed 18 March, 2006.
- ^ a b Fluoride Therapy (in pdf format), from the American Association of Pediatric Dentistry website, page accessed 18 March, 2006.
- ^ ToxFAQs for Fluorine, Hydrogen Fluoride, and Fluorides, from the Agency for Toxic Substances and Disease Registry (ATSDR) website, page accessed 18 March, 2006.
- ^ Fluoride, from the Agency for World Health Organization website, page accessed 18 March, 2006.
- ^ CDC Statement on Water Fluoridation and Osteosarcoma, from the CDC website, page accessed 18 March, 2006.
- ^ National Cancer Institute website, "Fluoridated Water: Questions and Answers", page accessed March 3, 2006.
- ^ Knox, E.G. "Fluoridation of water and cancer: a review of the epidemiological evidence", hosted on the British Official Publications Collaborative Reader Information Service website, page accessed 18 March, 2006. Full text can be found here
- ^ "Inorganic Fluuorides Used In Drinking-water and Dental Preparations", by the International Agency on Research for Cancer website, page accessed 18 March, 2006.
- ^ Varner, J.A., K.F. Jensen, W. Horvath, R.L. Isaacson. "Chronic administration of aluminum-fluoride or sodium-fluoride to rats in drinking water: alterations in neuronal and cerebrovascular integrity", abstract from PubMed website, page accessed 18 March, 2006.
- ^ Causes", by the Alzheimer's Disease Education and Referral (ADEAR) Center website, a division of the National Institue of Aging, page accessed 18 March, 2006.
- ^ Kraus, A.S. and W.F. Forbes. "Aluminum, fluoride and the prevention of Alzheimer's disease.", abstract from PubMed website, page accessed 18 March, 2006.
- ^ British Medical Association website, statement on water fluoridation, page accessed March 3, 2006.
- ^ "The Ethics of Water Fluoridation" publication (in pdf format), from the British Fluoridation Society website, page accessed March 19, 2006.
- ^ a b Ringelberg, M. L., S. J. Allen, L. J. Brown. "Cost of fluoridation: 44 Florida communities.", abstract from PubMed website, page accessed 19 March, 2006.
- ^ The Benefits of Fluoride, from the Centers for Disease Control and Prevention website, accessed 19 March, 2006.
- ^ Fluoridation Status: Percentage of U.S. Population on Public Water Supply Systems Receiving Fluoridated Water, from the Centers for Disease Control and Prevention website, accessed 19 March, 2006.
- ^ Crozier, Stacie. "Michigan town votes to return fluoridation"
- ^ National Oral Health Surveillance System: Public Water Supply, from the Centers for Disease Control and Prevention.
- ^ "Fluorides and Human Health", from the Health Canada website, page accessed March 25, 2006.
- ^ "Gordon Sinclair's rant", from the Canadian Broadcasting Corporation Archives website, page accessed March 27, 2006.
- ^ "Water supply - R. L. Clark Filtration Plant", from Toronto's website, page accessed March 27, 2006.
- ^ "Ambient Water Quality Criteria for Fluoride", from the Environmental Protection Division of British Columbia's Ministry of Environment website, page accessed March 27, 2006.
- ^ Mullen, Joe. "History of Water Fluoridation", British Dental Journal, 2005, page accessed April 29, 2006.
- ^ "Water Fluoridation - The Facts", from South Africa's Department of Health website, page accessed April 29, 2006.
- ^ Fluoretação da Água em Sistema Público de Abastecimento, page accessed April 29, 2006.
- ^ 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.
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See also
External links
- CDC database for the fluoridation status of neighborhood water
- Letter on fluoridation from EPA (PDF) supporting fluoridation hosted by ADA
- History of Water Fluoridation
- 1970s discussion on fluoridation
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