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Water fluoridation

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File:DrinkingWater 155px.jpg
Drinking water taken from a faucet. Fluoridation does not affect water's appearance, taste, or smell.[1]

Water fluoridation is the controlled addition of fluoride to a public water supply to reduce tooth decay.[2] Drinking fluoridated water creates low levels of fluoride in saliva, and this reduces the rate at which tooth enamel demineralizes and increases the rate at which it remineralizes in the early stages of cavities.[3] A recommended level of fluoridation is 0.6 to 1.1 mg/L (milligrams per liter), depending on climate.[4] Typically a fluoridated compound is added to drinking water, a process that costs about $0.72 per person per year (range $0.17–$7.62, in 1999 U.S. dollars).[2] Defluoridation is needed when the naturally occurring fluoride level exceeds recommended limits.[5] Bottled water typically has unknown fluoride levels, and some more-expensive household water filters remove some or all fluoride.[6]

Water fluoridation prevents cavities in both children[4] and adults.[7] Although it can cause dental fluorosis, which can alter the appearance of developing teeth, most of this is mild and usually not considered to be of aesthetic concern.[4] There is no clear evidence of other adverse effects. However, little high-quality fluoridation research has been done.[8] Other methods of fluoride therapy include fluoridation of toothpaste, salt, and milk.[9] Water fluoridation, when feasible and culturally acceptable, has substantial advantages over toothpaste, especially for subgroups at high risk.[10] In the U.S., water fluoridation was listed as one of the ten great public health achievements of the 20th century;[11] in Europe, most countries experienced substantial declines in tooth decay by using fluoride toothpaste and other products instead.[3] Fluoridation may be more justified in the U.S. for reasons that include lack of access to dental care.[12]

Water fluoridation's goal is to prevent a chronic disease whose burdens particularly fall on children and on the poor.[13] Its use presents a conflict between the common good and individual rights.[14] Opposition to water fluoridation has been based on ethical, legal, safety, and efficacy grounds. Almost all major public health and dental organizations support water fluoridation, or consider it safe.[15] Its use in the U.S. began in the 1940s, following studies of children in a region where higher levels of fluoride occur naturally in the water. U.S. researchers discovered that moderate fluoridation prevents cavities,[16] and it is now used by 61.5% of the U.S. population[17] and by 5.7% of people worldwide.[18]

Motivation

A cavity starts in a tooth's outer enamel and spreads to the dentin and pulp inside.

Water fluoridation's goal is to prevent tooth decay (dental caries), one of the most prevalent chronic diseases worldwide, and one which greatly affects the quality of life of children, particularly those of low socioeconomic status.[13] In the U.S., minorities and the poor both have higher rates of decayed and missing teeth,[19] and their children have less dental care.[20] The motivation for fluoridation of salt or water is similar to that of iodized salt for the prevention of mental retardation and goiter.[21]

Alternative methods

Methods effective in preventing tooth decay include dental sealants and fluoride therapies[13] that also include fluoridation of toothpaste, salt, and milk.[9] Other public-health strategies to control tooth decay, such as education to change behavior and diet, have lacked impressive results.[22]

Fluoride toothpaste is effective, but the underprivileged are less likely to use it.[9]

Fluoride toothpaste is the most widely used and rigorously evaluated fluoride treatment.[9] It is the only realistic fluoride strategy in many low-income countries, where lack of infrastructure renders water or salt fluoridation infeasible.[23] However, it relies on individual and family behavior, and its use is less likely among the underprivileged;[9] in low-income countries it is unaffordable for the poor.[23] The strong evidence for toothpaste in clinical trials does not easily generalize to community settings: a large 1985 U.S. study[24] found that school-based toothbrushing programs did not substantially reduce tooth decay.[22] Water fluoridation, when it is culturally acceptable and technically feasible, has substantial advantages over toothpaste, especially for subgroups at high risk.[10]

The effectiveness of salt fluoridation is about the same as water fluoridation, if most salt for human consumption is fluoridated. Fluoridated salt reaches the consumer in salt at home, in meals at school and at large kitchens, and in bread. For example, Jamaica has just one salt producer, but a complex public water supply; it fluoridated all salt starting in 1987, resulting in a notable decline in cavities. Universal salt fluoridation is also practiced in Columbia, Jamaica, and the Canton of Vaud in Switzerland; in France and Germany fluoridated salt is widely used in households but unfluoridated salt is also available. Concentrations of fluoride in salt range from 90 to 350 mg/kg, with studies suggesting an optimal concentration of around 250 mg/kg.[9]

Milk fluoridation is being practiced by the Borrow Foundation in some parts of Bulgaria, Chile, Peru, Russia, Thailand and the United Kingdom. For example, milk-powder fluoridation is used in Chilean rural areas where water fluoridation is not technically feasible.[25] These programs are aimed at children, and have neither targeted nor been evaluated for adults.[9] A 2005 systematic review found insufficient evidence to support the practice, but also concluded that studies suggest that fluoridated milk benefits schoolchildren, especially their permanent teeth.[26]

Implementation

Fluoride monitor (at left) in a community water tower pumphouse, Minnesota, 1987.

Fluoridation is normally accomplished by adding one of three compounds to drinking water: sodium fluoride, fluorosilicic acid, or sodium fluorosilicate.

  • Sodium fluoride (NaF) was the first compound used and is the reference standard.[27] It is a white odorless powder or crystal; the crystalline form is preferred if manual handling is used, as it minimizes dust.[28] It is more expensive, but is easily handled and is usually used by smaller utility companies.[29]
  • Fluorosilicic acid (H2SiF6) is a cheap liquid byproduct of phosphate fertilizer manufacture.[27] It comes in varying strengths, typically 23–25%; because it contains so much water, shipping can be expensive.[28] It is also known as hexafluorosilicic, hexafluosilicic, hydrofluosilicic, and silicofluoric acid.[27]
  • Sodium fluorosilicate (Na2SiF6) is a powder or very fine crystal that is easier to ship than fluorosilicic acid. It is also known as sodium silicofluoride.[28]

These compounds were chosen for their solubility, safety, availability, and low cost.[27] A 1992 census found that, for U.S. public water supply systems reporting the type of compound used, 63% of the population received water fluoridated with fluorosilicic acid, 28% with sodium fluorosilicate, and 9% with sodium fluoride.[30] The estimated cost of fluoridation in the U.S., in 1999 dollars, is $0.72 per person per year (range: $0.17–$7.62); larger water systems have lower per capita cost, and the cost is also affected by the number of fluoride injection points in the water system, the type of feeder and monitoring equipment, the fluoride chemical and its transportation and storage, and water plant personnel expertise.[2] In the U.S., the Centers for Disease Control and Prevention has developed recommendations for water fluoridation that specify requirements for personnel, reporting, training, inspection, monitoring, surveillance, and actions in case of overfeed, along with technical requirements for each major compound used.[31]

In southern Arizona, numerous areas (in darker blues) have groundwater with naturally occurring fluoride above optimal levels.

The U.S. specifies the optimal level of fluoridation to range from 0.7 to 1.2 mg/L (milligrams per liter, equivalent to parts per million), depending on the average maximum daily air temperature; the optimal level is lower in warmer climates, where people drink more water, and is higher in cooler climates.[32] In Australia the recommended range is from 0.6 to 1.1 mg/L.[4] Fluoridation levels in naturally occurring water supplies can be above, below or at recommended levels. Rivers and lakes generally contain less than 0.5 mg/L, but groundwater, particularly in volcanic or mountainous areas, can contain as much as 50 mg/L.[33] Defluoridation is needed when the naturally occurring fluoride level exceeds recommended limits. It can be accomplished by percolating water through granular beds of activated alumina, bone meal, bone char, or tricalcium phosphate; by coagulation with alum; or by precipitation with lime.[5]

U.S. regulations for bottled water do not require disclosing fluoride content, so the effect of always drinking it is not known.[6] Surveys of bottled water in Cleveland and in Iowa found that most contained well below optimal fluoride levels;[34] a survey in São Paulo, Brazil, found large variations of fluoride, with many bottles exceeding recommended limits and disagreeing with their labels.[35] Pitcher or faucet-mounted water filters do not alter fluoride; the more-expensive reverse osmosis filters remove 65–95% of fluoride, and distillation filters remove all fluoride.[6]

Mechanism

Water fluoridation operates by creating low levels (about 0.04 mg/L) of fluoride in saliva and plaque fluid. This in turn reduces the rate of tooth enamel demineralization, and increases the rate of remineralization of the early stages of cavities.[3] Demineralization and remineralization is how fluoride exerts its major effect. Fluoride also affects the physiology of dental bacteria,[36] although its effect on bacterial growth does not seem to be relevant to cavity prevention.[37] Technically, fluoride does not prevent cavities but rather controls the rate at which they develop;[38] although it is the only well-documented agent with this property, it has been suggested that also adding some calcium to the water would reduce cavities further.[39] Water fluoridation does not affect the appearance, taste, or smell of water.[1]

Evidence basis

Existing evidence strongly suggests that water fluoridation reduces tooth decay. There is also consistent evidence that it causes fluorosis, most of which is mild and not usually of aesthetic concern.[4] There is no clear evidence of other adverse effects. Moderate-quality research exists as to water fluoridation's effectiveness and its potential association with cancer; research into other potential adverse effects has been almost all of low quality. Little high-quality research has been performed.[8]

Effectiveness

Water fluoridation is the most effective and socially equitable way to achieve wide exposure to fluoride's cavity-prevention effects,[4] and has contributed to the dental health of children and adults worldwide.[2] A 2000 systematic review found that fluoridation was statistically associated with a decreased proportion of children with cavities (the median of mean decreases was 14.6%, the range −5 to 64%), and with a decrease in decayed, missing, and filled primary teeth (the median of mean decreases was 2.25 teeth, the range 0.5 to 4.4 teeth),[8] which is roughly equivalent to preventing 40% of cavities.[40] The review found that the evidence was of moderate quality: many studies did not attempt to reduce observer bias, control for confounding factors, or use appropriate analysis.[8] Fluoride also prevents cavities in adults of all ages;[40] a 2007 meta-analysis found that water fluoridation prevented an estimated 27% of cavities in adults (95% confidence interval [CI] 19–34%).[7]

Water fluoridation has been listed as one of the ten great public health achievements of the 20th century in the U.S.[11][41] Initial studies showed that water fluoridation led to reductions of 50–60% in childhood cavities; more recent estimates are lower (18–50%[42]), likely due to increasing use of fluoride from other sources, notably toothpaste, and also the halo effect of food and drink made in fluoridated areas and consumed in unfluoridated ones.[2] The introduction of fluoride toothpaste in the early 1970s has been the main reason for the decline in tooth decay since then in industrialized countries.[3]

Most countries in Europe have experienced substantial declines in cavities without the use of water fluoridation, indicating that water fluoridation may be unnecessary in industrialized countries.[3] For example, in Finland and Germany, tooth decay rates remained stable or continued to decline after water fluoridation stopped. Fluoridation may be more justified in the U.S. because unlike most European countries, the U.S. does not have school-based dental care, many children do not visit a dentist regularly, and for many U.S. children water fluoridation is the prime source of exposure to fluoride.[12]

Although a 1989 workshop on cost-effectiveness of caries prevention concluded that water fluoridation is one of the few public health measures that saves more money than it costs, little high-quality research has been done on the cost-effectiveness and solid data are scarce.[2][32] Some studies suggest that fluoridation reduces oral health inequalities between the rich and poor, but the evidence is limited.[3] There is anecdotal but not scientific evidence that fluoridation allows more time for dental treatment by slowing the progression of tooth decay, and that it simplifies treatment by causing most cavities to occur in pits and fissures of teeth.[22]

Safety

At the commonly recommended dosage, the only clear adverse effect is dental fluorosis, which can alter the appearance of children's teeth during tooth development; this is mostly mild and not usually of aesthetic concern. Compared to unfluoridated water, fluoridation to 1 mg/L is estimated to cause fluorosis in one of every 6 people (95% CI 4–21 people), and to cause fluorosis of aesthetic concern in one of every 22 people (95% CI 13.6–∞ people). Here, aesthetic concern is a term used in a standardized scale based on what adolescents would find unacceptable, as measured by a 1996 study of British 14-year-olds.[8] In many industrialized countries the prevalence of fluorosis is increasing, mostly due to fluoride from swallowed toothpaste; the total cost of treatment is unknown.[43] Fluorosis might also be caused by fluoride in infant formula or in water added to reconstitute the formula, though the evidence here may be distorted by publication bias or confounding factors.[4] In the U.S. the decline in tooth decay was accompanied by increased fluorosis in both fluoridated and unfluoridated communities; accordingly, fluoride has been reduced in various ways worldwide in infant formulas, children's toothpaste, water, and fluoride-supplement schedules.[22]

Fluoridation has little effect on risk of bone fracture (broken bones); it may result in slightly lower fracture risk than either excessively high levels of fluoridation or no fluoridation.[4] There is no clear association between fluoridation and cancer or deaths due to cancer, both for cancer in general and also specifically for bone cancer and osteosarcoma.[4] A 1997 study found that people who thought they were receiving fluoridated water reported the same symptoms regardless of whether they were actually receiving it, suggesting that the symptoms came from psychological effects.[1]

Fluoride can occur naturally in water in concentrations well above recommended levels, which can have several adverse effects, including severe dental fluorosis, skeletal fluorosis, and weakened bones. In 2006 the U.S. National Research Council recommended lowering the Maximum Contaminant Level Goal for fluoride, or known safe level independent of cost and feasibility, from its current value of 4 mg/L.[44] In rare cases improper implementation of water fluoridation can result in overfluoridation, resulting in fluoride poisoning. For example, in Hooper Bay, Alaska, in 1992, a combination of equipment and human errors resulted in one of the two village wells being overfluoridated, causing one death and an estimated 295 nonfatal cases of fluoride intoxication.[45]

Some adverse effects lack sufficient evidence to reach a scientific conclusion.[4] Like other common water additives such as chlorine, hydrofluosilicic acid and sodium silicofluoride decrease pH, and cause a small increase of corrosivity; this can easily be resolved by adjusting the pH upward.[46] Some reports have linked hydrofluosilicic acid and sodium silicofluoride to increased human lead uptake;[47] these have been criticized as providing no credible evidence.[46] Arsenic and lead may be present in fluoride compounds added to water, but there is no credible evidence that this is of concern: concentrations are below measurement limits.[46]

The effect of water fluoridation on the environment has been investigated, and no adverse effects have been established. Issues studied have included fluoride concentrations in groundwater and downstream rivers; lawns, gardens, and plants; consumption of plants grown in fluoridated water; air emissions; and equipment noise.[46]

Ethics and politics

Further information: Water fluoridation controversy

Like vaccination and food fortification, fluoridation presents a conflict between benefiting the common good and infringing on individual rights.[14] Fluoridation can be viewed as a violation of ethical or legal rules that prohibit medical treatment without medical supervision or informed consent, and that prohibit administration of unlicensed medical substances.[3] It can also be viewed as a public intervention to replicate the benefits of naturally fluoridated water in order to free people from the misery of toothache and dental work, with greatest benefit to those least able to help themselves, and where it would be unethical to withhold such treatment.[48]

Almost all major health and dental organizations support water fluoridation, or have found no association between fluoridation and adverse effects.[15][49] These organizations include the World Health Organization,[10][50] the Centers for Disease Control and Prevention,[2] the U.S. Surgeon General,[51] and the national dental associations of Australia,[52] Canada,[53] and the U.S.[54]

Despite support by public health organizations and authorities, efforts to introduce water fluoridation meet considerable opposition whenever it is proposed.[15] Since fluoridation's inception, proponents have argued for scientific optimism and faith in experts, while opponents have drawn on distrust of experts and unease about medicine and science.[55] Controversies include disputes over fluoridation's benefits and the strength of the evidence basis for these benefits, the difficulty of identifying harms, legal issues over whether water fluoridation is a medicine, and the ethics of mass intervention.[18] Opposition campaigns involve newspaper articles, talk radio, and public forums. Media reporters are often poorly equipped to explain the scientific issues, and are motivated to present controversy regardless of the underlying scientific merits. Internet websites, which are increasingly used by the public for health information, contain a wide range of material about fluoridation ranging from factual to fraudulent, with a disproportionate percentage opposed to fluoridation. Conspiracy theories involving fluoridation are common, and include claims that fluoridation was motivated by protecting the U.S. atomic bomb program from litigation, that it is part of a Communist or New World Order plot to take over the world, that it was pioneered by a German chemical company to make people submissive to those in power, that it is backed by the sugar or aluminum or phosphate industries, or that it is a smokescreen to cover failure to provide dental care to the poor.[15] Specific antifluoridation arguments change to match the spirit of the time.[56]

Opponents of fluoridation include individual researchers, dental and medical professionals, alternative medical practitioners such as chiropractors, health food enthusiasts, a few religious objectors (mostly Christian Scientists), and occasionally consumer groups and environmentalists.[57] Political opposition has come from right-wing groups such as the John Birch Society, and more recently from left-wing groups like the Green Party.[58] Many people do not know that fluoridation is meant to prevent tooth decay, or that natural or bottled water can contain fluoride; as the general public does not have a particular view on fluoridation, the debate may reflect an argument between two relatively small lobbies. A 2003 study of focus groups from 16 European countries found that a majority opposed fluoridation, apart from countries where it was practiced.[59] In contrast, a 1999 UK survey found that 62% supported and 31% opposed fluoridation, with opponents registering greater intensity.[60] Every year in the U.S., pro- and anti-fluoridationists face off in referenda or other public decision-making processes: in most of them, fluoridation is rejected.[57] In the U.S., rejection is more likely when the decision is made by a public referendum; in Europe, most decisions against fluoridation have been made administratively.[61] Neither side of the dispute appears to be weakening or willing to concede.[57]

Use around the world

U.S. residents served with community water fluoridation, 1992 and 2006. In darker-colored states, fluoridated water was received by larger percentages of residents served by public water supplies.[62]
Main article: Fluoridation by country

About 5.7% of people worldwide drink fluoridated water;[18] this includes 61.5% of the U.S. population.[17] In the U.S., Hispanic and Latino Americans are significantly more likely to consume bottled instead of tap water,[63] and the use of bottled and filtered water grew dramatically in the late 1990s and early 2000s.[6]

Fluoridated water is used by 12 million people in Western Europe, mainly in parts of the United Kingdom, Spain, and Ireland. Fluoridation has been introduced to varying degrees in many other countries, including Argentina, Australia, Brazil, Canada, Chile, Columbia, Hong Kong, Israel, Korea, Malaysia, New Zealand, the Phillippines, Singapore, and Vietnam.[64] In addition, at least 50 million people worldwide drink water that is naturally fluoridated to optimal levels; in some locations (notably parts of Africa, China, and India), natural fluoridation exceeds recommended levels.[64] Locations have discontinued water fluoridation in some other countries, including Finland, Germany, Japan, the Netherlands, Sweden, and Switzerland.[18] The use of fluoride in its various forms is the foundation of tooth decay prevention throughout Europe; for example, France, Germany, and many other European countries use fluoridated salt.[64]

History

Main article: History of water fluoridation
1909 photograph by Frederick McKay of G.V. Black (left), Isaac Burton and F.Y. Wilson, studying the Colorado Brown Stain.[65]

The history of water fluoridation can be divided into three periods. The first (c. 1901–33) was research into the cause of a form of mottled tooth enamel called the Colorado Brown Stain, which later became known as fluorosis. The second (c. 1933–45) focused on the relationship between fluoride concentrations, fluorosis, and tooth decay. The third period, from 1945 on, focused on adding fluoride to community water supplies.[16]

The foundation of water fluoridation in the U.S. was the research of the dentist Frederick McKay. McKay spent thirty years investigating the cause of what was then known as the Colorado Brown Stain, which produced mottled but also cavity-free teeth; with the help of G.V. Black and other researchers, he established that the cause was fluoride.[66] The first report of a statistical association between the stain and lack of tooth decay was done by UK dentist Norman Ainsworth in 1925. In 1931, an Alcoa chemist, H.V. Churchill, concerned about a possible link between aluminum and staining, analyzed water from several areas where the staining was common and found that fluoride was the common factor.[67]

H. Trendley Dean set out in 1931 to study fluoride's harm, but by 1950 had demonstrated the benefits of small amounts.[41]

In the 1930s and early 1940s, H. Trendley Dean and colleagues at the U.S. National Institutes of Health published several epidemiological studies suggesting that a fluoride concentration of about 1 mg/L was associated with substantially fewer cavities in temperate climates, and that it increased fluorosis but only to a level that was of no medical or aesthetic concern. Other studies found no other significant adverse effects even in areas with fluoride levels as high as 8 mg/L.[68] To test the hypothesis that adding fluoride would prevent cavities, Dean and his colleagues conducted a controlled experiment by fluoridating the water in Grand Rapids, Michigan, starting on January 29, 1945. The results, published in 1950, showed significant reduction of cavities.[69] By present-day standards this and other pioneering studies were crude, but the large reductions in cavities convinced public health professionals of the benefits of fluoridation.[12]

Fluoridation became an official policy of the U.S. Public Health Service by 1951, and by 1960 water fluoridation had become widely used in the U.S., reaching about 50 million people.[68] By 2006, 69.2% of the U.S. population on public water systems were receiving fluoridated water, amounting to 61.5% of the total U.S. population; 3.0% of the population on public water systems were receiving naturally occurring fluoride.[17] In some other countries the pattern was similar. Fluoridation was introduced into Brazil in 1953, was regulated by federal law starting in 1974, and by 2004 was used by 71% of the population.[70] In other locations, fluoridation was used and then discontinued; for example, in Kuopio, Finland, fluoridation was used for decades but was discontinued because the school dental service provided significant fluoride programs and the cavity risk was low.[67]

McKay's work had established that fluorosis occurred before tooth eruption. Dean and his colleagues assumed that fluoride's protection against cavities was also pre-eruptive, and this incorrect assumption was accepted for years. By 2000, however, the topical effects of fluoride (in both water and toothpaste) was well understood, and it had become known that a constant low level of fluoride in the mouth works best to prevent cavities.[12]

References

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