Water fluoridation in the United States
As with some other countries, water fluoridation in the United States is a contentious issue. As of May 2000, 42 of the 50 largest U.S. cities had water fluoridation. On January 25, 1945, Grand Rapids, Michigan, became the first community in the United States to fluoridate its drinking water to prevent tooth decay.
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. 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. Near the end of 2012, 67.1% of the U.S. population were getting water from community water systems (CWS) supplying water that had fluoride at or above recommended levels. Those included the 3.5% of the population that were on CWS with naturally occurring fluoride at or above recommended levels. 74.6% of those on CWS were receiving water with fluoride at or above recommended levels.
U.S. regulations for bottled water do not require disclosing fluoride content. A survey of bottled water in Cleveland and in Iowa, published in 2000, found that most had fluoride levels well below the 1 mg/L level common in tap waters.
Community water fluoridation in the United States is partly due to the research of Dr. Frederick McKay, who pressed the dental community for an investigation into what was then known as "Colorado Brown Stain." The condition, now known as dental fluorosis, when in its severe form is characterized by cracking and pitting of the teeth. Of 2,945 children examined in 1909 by Dr. McKay, 87.5% had some degree of stain or mottling. All the affected children were from the Pikes Peak region. Despite the negative impact on the physical appearance of their teeth, the children with stained, mottled and pitted teeth also had fewer cavities than other children. McKay brought this to the attention of Greene Vardiman Black, and Black's interest was followed by greater interest within 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. In 1931, researchers from the Aluminum Company of America (ALCOA) concluded that the cause of the Colorado stain was a high concentration of fluoride ions in the region's drinking water (ranging from 2 to 13.7 mg/L) and areas with lower concentrations had no staining (1 mg/L or less). Pikes Peak's rock formations contained the mineral cryolite, one of whose constituents is fluorine. As the rain and snow fell, the resulting runoff water dissolved fluoride which made its way into the water supply.
Dental and aluminum researchers then moved toward determining a relatively safe level of fluoride to be added to 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 reduce incidences of fluorosis, and (2) to encourage communities with a low concentration of fluoride in drinking water to add fluoride in order to help prevent tooth decay. 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.
In April 2015, fluoride levels in the United States were lowered for the first time in 50 years, to the minimum recommended levels of 0.7ppm, because too much fluoride exposure has become a common issue for children teeth, visible in the form of white splotches. The basis were the results of two national surveys (1999–2004 NHANES) which assessed the prevalence of dental fluorosis, and found that two out of five adolescents had tooth streaking or spottiness on their teeth - an increase of mostly very mild or mild forms.
A study of varying amounts of fluoride in water was led by Dr. H. Trendley Dean, a dental officer of the U.S. Public Health Service. In 1936 and 1937, Dr. Dean and other dentists compared statistics from Amarillo, which had 2.8 – 3.9 mg/L fluoride content, and low fluoride Wichita Falls. The data is alleged to show fewer cavities in Amarillo children, but the studies were never published. Dr. Dean's research on the fluoride-dental caries relationship, published in 1942, included 7,000 children from 21 cities in Colorado, Illinois, Indiana, and Ohio. The study concluded that the optimal amount of fluoride which minimized the risk of severe fluorosis but had positive benefits for tooth decay was 1 mg per day, per adult. Although fluoride is more abundant in the environment today, this was estimated to correlate with the concentration of 1 mg/L.
In 1937, 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 Native American children. 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 1939, Dr. Gerald J. Cox conducted laboratory tests using rats that were fed aluminum and fluoride. Dr. Cox suggested adding fluoride to drinking water (or other media such as milk or bottled water) in order to improve oral health.
In the mid-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 add fluoride to its drinking water to try to benefit dental health on January 25, 1945. Kingston, New York was paired with Newburgh, New York. Oak Park, Illinois was paired with Evanston, Illinois. Sarnia, Ontario was paired with Brantford, Ontario, Canada.
In 1952 Nebraska Representative A.L. Miller complained that there had been no studies carried out to assess the potential adverse health risk to senior citizens, pregnant women, or people with chronic diseases from exposure to the fluoridation. A decrease in the incidence of tooth decay was found in some of the cities which had added fluoride to water supplies. The early comparison studies would later be criticized as, "primitive," with a, "virtual absence of quantitative, statistical methods...nonrandom method of selecting data and...high sensitivity of the results to the way in which the study populations were grouped..." in the journal Nature.
The U.S. Centers for Disease Control has identified community water fluoridation as one of ten great public health achievements of the 20th century. The CDC recommends water fluoridation at a level of 0.7–1.2 mg/L, depending on climate. The CDC also advises parents to monitor use of fluoride toothpaste, and use of water with fluoride concentrations above 2 mg/L, in children up to age 8. There is a CDC database for researching the water fluoridation status of neighborhood water.
In 1998, 70% of people polled in a survey conducted by the American Dental Association (ADA) believed community water should be fluoridated, with 18% disagreeing and the rest undecided. In November 2006, the ADA began recommending to parents that infants from 0 through 12 months of age should have their formula prepared with water that is fluoride-free or contains low levels of fluoride to reduce the risk of fluorosis.
The issue of whether or not to fluoridate water 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 2004 ballot initiative ceased water fluoridation in the city. At the same time, voters in Xenia, Ohio; Springfield, Ohio; Bellingham, Washington; and Tooele City, Utah all rejected water fluoridation.
In Skagit County in the state of Washington, the county commissioners in 2007 voted 2 to 1 to order the local public utility district to begin fluoridating the public water supply by Jan. 2009. $1.2 million was to be provided by the privately funded Washington Dental Service Foundation to begin building the equipment needed to add fluoride to the Judy Reservoir, which supplies the majority of Skagit Valley's water customers. The source and type of fluoride to be added to the drinking water of more than 70,000 citizens had not been disclosed. However, in February 2009, Skagit County commissioners rescinded the 2007 order, citing costs and possible lawsuits.
The cost of adding fluoridation to the water of 44 Florida communities has been researched by the State Health Office in Tallahassee. In communities with a population of over 50,000 people, fluoridation costs were estimated at 31 cents per person per year. The estimated cost rises to $2.12 per person in areas with a population below 10,000. Unintended consequences, such as equipment malfunction, can substantially raise the financial burden, as well as the health risks, to the consumer.
In the U.S., Hispanic and Latino Americans are significantly more likely to consume bottled instead of tap water, and the use of bottled and filtered water grew dramatically in the late 1990s and early 2000s.
Decisions about water fluoridation
Fluoridation has been the subject of many court cases wherein activists have sued municipalities, asserting that their rights to consent to medical treatment and due process are infringed by mandatory water fluoridation. Individuals have sued municipalities for a number of illnesses that they believe were caused by fluoridation of the city's water supply. In most of these cases, the courts have held in favor of cities, finding no or only a tenuous connection between health problems and widespread water fluoridation. To date, no federal appellate court or state court of last resort (i.e., state supreme court) has found water fluoridation to be unlawful.
A flurry of cases were heard in numerous state courts across the U.S. in the 1950s during the early years of water fluoridation. State courts consistently held in favor of allowing fluoridation to continue, analogizing fluoridation to mandatory vaccination and the use of other chemicals to clean the public water supply, both of which had a long-standing history of acceptance by courts.
In 1952, a Federal Regulation was adopted that stated in part, "The Federal Security Agency will regard water supplies containing fluorine, within the limitations recommended by the Public Health Service, as not actionable under the Federal Food, Drug, and Cosmetic Act."
The Supreme Court of Oklahoma analogized water fluoridation to mandatory vaccination in a 1954 case. The court noted, "we think the weight of well-reasoned modern precedent sustains the right of municipalities to adopt such reasonable and undiscriminating measures to improve their water supplies as are necessary to protect and improve the public health, even though no epidemic is imminent and no contagious disease or virus is directly involved .... To us it seems ridiculous and of no consequence in considering the public health phase of the case that the substance to be added to the water may be classed as a mineral rather than a drug, antiseptic or germ killer; just as it is of little, if any, consequence whether fluoridation accomplishes its beneficial result to the public health by killing germs in the water, or by hardening the teeth or building up immunity in them to the bacteria that causes caries or tooth decay. If the latter, there can be no distinction on principle between it and compulsory vaccination or inoculation, which, for many years, has been well-established as a valid exercise of police power."
In the 1955 case Froncek v. City of Milwaukee, the Wisconsin Supreme Court affirmed the ruling of a circuit court which held that "the fluoridation is not the practice of medicine, dentistry, or pharmacy, by the City" and that "the legislation is a public health measure, bearing a real, substantial, and reasonable relation to the health of the city."
The Supreme Court of Ohio, in 1955's Kraus v. City of Cleveland, said, "Plaintiff's argument that fluoridation constitutes mass medication, the unlawful practice of medicine and adulteration may be answered as a whole. Clearly, the addition of fluorides to the water supply does not violate such principles any more than the chlorination of water, which has been held valid many times."
In 1973, as cases continued to be brought in state courts, a consensus developed that fluoridation, at least from a legal standpoint, was acceptable. In 1973's Beck v. City Council of Beverly Hills, the California Court of Appeal, Second District, said, "Courts through the United States have uniformly held that fluoridation of water is a reasonable and proper exercise of the police power in the interest of public health. The matter is no longer an open question."
Much of the contemporary debate on water fluoridation revolves around questions of how consumer demand for fluoride is determined and processed, which fluoridation costs and benefits are considered, how conflicts over its provision and production are addressed or resolved, and how the merits of relevant health policies can be equally recast in terms of their presumed demerits.
Advocates continue to make contemporary challenges to the spread of fluoridation. For instance, in 2002, the city of Watsonville, California, chose to disregard a California law mandating fluoridation of water systems with 10,000 or more hookups, and the dispute between the city and the state ended up in court. The trial court and the intermediate appellate court ruled in favor of the state and its fluoridation mandate, and the Supreme Court of California declined to hear the case in February 2006. Since 2000, courts in Washington, Maryland, and Texas have reached similar conclusions.
San Diego, California began water fluoridation in February 2011, despite its Municipal Code Section 67.0101, which prohibits the city from fluoridating. The local ordinance was preempted by California law that requires fluoridation when an outside funding source is available. In 2008, First 5 Commission of San Diego County, a state-funded child advocacy organization, provided nearly $4 million to San Diego, for fluoridation equipment and operating costs for the first two years of fluoridation. That organization is funded with tobacco taxes instituted by California Proposition 10 (1998). San Diego raises the fluoride level of its water to 0.7 mg/L, as recommended by CDC.
In 2012, New Hampshire began requiring public water systems that fluoridate to post the following notice in their consumer confidence reports: "Your public water supply is fluoridated. According to the Centers for Disease Control and Prevention, if your child under the age of 6 months is exclusively consuming infant formula reconstituted with fluoridated water, there may be an increased chance of dental fluorosis. Consult your child's health care provider for more information." The law was passed with overwhelming majorities in the legislature and took effect August 4.
In 2011 the Pinellas County, Florida commissioners voted to stop adding fluoride to the county's public drinking water. Tampa Bay Times editor Tim Nickens and columnist Daniel Ruth then published a joint series of ten editorials challenging the decision in 2012, and two of the commissioners who had voted to stop fluoridation were voted out of office and replaced with candidates who had pledged to add it back. In March 2013, after a 6–1 vote, the county resumed the addition of fluoride, which the Times characterized as being "long considered the most effective method to prevent tooth decay". Nickens and Ruth were awarded the 2013 Pulitzer Prize for Editorial Writing for their series.
On May 21, 2013, voters in Portland, Oregon decided 61–39% not to commence fluoridation of Portland's water, which is supplied to 900,000 people. It was the fourth defeat of fluoridation proposals in Portland, the first being in 1956. On September 12, 2012, the Portland City Council unanimously passed Ordinance No. 185612, authorizing and directing the Portland Water Bureau to begin fluoridating. Those opposing the ordinance immediately began a petition process to hold a referendum that could reverse the ordinance. In October, it was revealed that four city council members had had undisclosed meetings with pro-fluoridation lobbyists. Public calendars of those four did not mention the meetings, except that one meeting was mentioned with a vague title. This was in violation of a city ordinance requiring the disclosure of such meetings. Over 33,000 signatures were gathered for the petition, which led to the referendum that defeated fluoridation. In the campaign, the pro-fluoridation side out-raised opponents $850,000 to $270,000.
- Klein RJ (February 7, 2008). "Healthy People 2010 Progress Review, Focus Area 21—Oral Health". National Center for Health Statistics. Retrieved December 14, 2009.
- Lennon MA (September 2006). "One in a million: the first community trial of water fluoridation". Bulletin of the World Health Organization. 84 (9): 759–60. doi:10.2471/BLT.05.028209. PMC 2627472. PMID 17128347.
- Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion, CDC (September 17, 2008). "Water fluoridation statistics for 2006". Retrieved December 22, 2008.CS1 maint: Multiple names: authors list (link)
- "Community Water Fluoridation --- 2012 Water Fluoridation Statistics". www.cdc.gov. Retrieved January 21, 2015.
- Hobson WL, Knochel ML, Byington CL, Young PC, Hoff CJ, Buchi KF (2007). "Bottled, filtered, and tap water use in Latino and non-Latino children". Arch Pediatr Adolesc Med. 161 (5): 457–61. doi:10.1001/archpedi.161.5.457. PMID 17485621.
- Lalumandier JA, Ayers LW (March 2000). "Fluoride and bacterial content of bottled water vs tap water". Archives of Family Medicine. 9 (3): 246–50. doi:10.1001/archfami.9.3.246. PMID 10728111.
- "Study Finds Some Bottled Water Has More Bacteria And Less Fluoride Than Tap Water". www.sciencedaily.com. March 22, 2000. Retrieved July 29, 2012.
- Douglas, William A. (1959). History of Dentistry in Colorado, 1859–1959. Denver: Colorado State Dental Assn. p. 199. hdl:2027/mdp.39015055618535.
- History of Dentistry in the Pikes Peak Region, Colorado Springs Dental Society webpage, page accessed February 25, 2006.
- McGraw-Hill's AccessScience
- Report Judges Allowable Fluoride Levels in Water : NPR
- Meiers, Peter: "The Bauxite Story – A look at ALCOA", from the Fluoride History website, page accessed May 12, 2006.
- "US lowers fluoride levels in drinking water for first time in over 50 years". The Guardian. 27 April 2015.
- "U.S. Public Health Service Recommendation for Fluoride Concentration in Drinking Water for the Prevention of Dental Caries". CDC. Retrieved 18 May 2017.
- Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion, CDC (1999). "Achievements in public health, 1900–1999: Fluoridation of drinking water to prevent dental caries". MMWR Morb Mortal Wkly Rep. 48 (41): 933–40.CS1 maint: Multiple names: authors list (link) Contains H. Trendley Dean, D.D.S. Reprinted in: "From the Centers for Disease Control and Prevention. Achievements in public health, 1900–1999: fluoridation of drinking water to prevent dental caries". JAMA. 283 (10): 1283–6. 2000. doi:10.1001/jama.283.10.1283. PMID 10714718.
- 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.
- Questionable Fluoride Safety Studies: Bartlett – Cameron, Newburgh – Kingston
- Klein H., Palmer C.E.: "Dental caries in American Indian children", Public Health Bulletin, No. 239, Dec. 1937
- 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.
- After 60 Years of Success, Water Fluoridation Still Lacking in Many Communities. Medical News Today website, accessed February 26, 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.
- Diesendorf, Mark, "The mystery of declining tooth decay" Nature, July 10, 1986
- The Benefits of Fluoride, from the Centers for Disease Control and Prevention website, accessed March 19, 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 March 19, 2006.
- Community Water Fluoridation
- Community Water Fluoridation FAQ
- "Oral Health Data Systems --- My Water's Fluoride". www.cdc.gov. Retrieved January 22, 2015.
- American Dental Association Survey Center. 1998 consumers' opinions regarding community water fluoridation. Chicago, Illinois: American Dental Association, 1998
- What is the ADA’s interim guidance on infant formula and fluoride? American Dental Association Website accessed May 28, 2008 
- Crozier, Stacie. "Michigan town votes to return fluoridation" November 30, 2005.
- No Forced Fluoride in Bellingham, Washington (Fluoride)
- Staff. "Commissioners vote to halt fluoride program". Skagit Valley Herald. Retrieved April 10, 2011.
- Ringelberg ML, Allen SJ, Brown LJ (1992). "Cost of fluoridation: 44 Florida communities". Journal of Public Health Dentistry. 52 (2): 75–80. doi:10.1111/j.1752-7325.1992.tb02247.x. PMID 1564695.
- Flanders RA, Marques L (1993). "Fluoride overfeeds in public water supplies". Illinois Dental Journal. 62 (3): 165–9. PMID 8244437.
- ^ Gessner, B. D.; Beller, M.; Middaugh, J. P.; Whitford, G. M. (January 1994). "Acute fluoride poisoning from a public water system". New England Journal of Medicine 330 (2): 95–99.
- Sidhu KS, Kimmer RO (October 2002). "Fluoride overfeed at a well site near an elementary school in Michigan". Journal of Environmental Health. 65 (3): 16–21, 38. PMID 12369244.
- Penman AD, Brackin BT, Embrey R (1997). "Outbreak of acute fluoride poisoning caused by a fluoride overfeed, Mississippi, 1993". Public Health Reports. 112 (5): 403–9. PMC 1381948. PMID 9323392.
- CHICAGO SUN-TIMES, July 31, 1993, Fluoride Blamed in 3 Deaths: Traces found in Blood of U. of C. Dialysis Patients Gary Wieby
- EVENING CAPITAL (Annapolis, Maryland), November 29, 1979, Fluoride Linked to Death, Mary Ann Kryzankowicz
- Williams BL, Florez Y, Pettygrove S (2001). "Inter- and intra-ethnic variation in water intake, contact, and source estimates among Tucson residents: Implications for exposure analysis". J Expo Anal Environ Epidemiol. 11 (6): 510–21. doi:10.1038/sj.jea.7500192. PMID 11791167.
- Cross DW, Carton RJ (2003). "Fluoridation: a violation of medical ethics and human rights". International Journal of Occupational and Environmental Health. 9 (1): 24–9. doi:10.1179/107735203800328830. PMID 12749628.
- Beck v. City Council of Beverly Hills, 30 Cal. App. 3d 112, 115 (Cal. App. 2d Dist. 1973) (citations omitted).
- Pratt E, Rawson RD, Rubin M (2002). "Fluoridation at fifty: what have we learned?". The Journal of Law, Medicine & Ethics. 30 (3 Suppl): 117–21. PMID 12508513.
- 17 Fed. Reg. 6743 (July 23, 1952).
- 273 P.2d 859, 862–63 (Okl. 1954) (available at FindLaw for Legal Professionals)
- 69 N.W.2d 242, 252 (Wis. 1955)
- 127 N.E.2d 609, 613 (Ohio 1955)
- Roger Lee Mendoza (2011). Fluoride-treated water and the problem of merit goods. Water Policy Journal, 13 (1): 38–52, http://www.iwaponline.com/wp/01301/wp013010038.htm.
- Roger Lee Mendoza (2009). Promoting Social Welfare Through Oral Health: New Jersey's Fluoridation Experience. Social Work in Public Health, 24 (6): 584-599, http://www.tandfonline.com/doi/abs/10.1080/19371910902911321#%2EVEvmpovF8VE%2E.
- Jones, Donna "Supreme Court turns down Watsonville's appeal to keep fluoride out of its water." Santa Cruz Sentinel. February 10, 2006.
- Parkland Light & Water Co. v. Tacoma-Pierce County Bd. of Health, 90 P.3d 37 (Wash. 2004)
- Pure Water Committee of W. MD., Inc. v. Mayor and City Council of Pure Water Comm. of W. MD., Inc. v. Mayor and City Council of Cumberland, MD. Not Reported in F.Supp.2d, 2003 WL 22095654 (D.Md. 2003)
- Espronceda v. City of San Antonio, Not Reported in S.W.3d, 2003 WL 21203878 (Tex. App.-San Antonio 2003)
- "Water Fluoridation". www.sandiego.gov. Retrieved December 27, 2014.
- "About First 5 San Diego". first5sandiego.org. Retrieved December 27, 2014.
- "New Hampshire Passes First State-Wide Fluoride Warning Law". June 20, 2012. Retrieved January 18, 2015.
- "CHAPTER 122, HB 1416-LOCAL – FINAL VERSION". www.gencourt.state.nh.us. Retrieved January 18, 2015.
- "City Council Meeting Summary (Sept. 22)". blog.cstx.gov. 2011-09-23. Retrieved December 25, 2014.
- "College Station Council Votes to End Fluoridation". Retrieved December 25, 2014.
- Deggans, Eric (April 15, 2013). "Times' Tim Nickens, Daniel Ruth win Pulitzer Prize for editorial writing". Tampa Bay Times.
- Michael D. Bates (February 25, 2014). "Hernando commissioners say no to fluoridation". hernandotoday.com. Retrieved December 25, 2014.
- Aaron Mesh. "Portland Voters Soundly Reject Fluoride". Willamette Week. Retrieved December 25, 2014.
- "2013 Referendum Petition Log, Measure 26-151". City of Portland. Retrieved December 25, 2014.
- Brad Schmidt (October 19, 2012). "Portland City Council calendars don't show meetings reported by fluoride lobbyists: Portland City Hall roundup". The Oregonian. Retrieved December 25, 2014.
- Peter Weber (May 22, 2013). "Why Portland refuses to fluoridate its drinking water". The Week. Retrieved December 25, 2014.
- My Water's Fluoride: CDC data on Fluoride levels in water systems in the U.S.
- Water Fluoridation Reporting System (WFRS) Fact Sheet: describes the CDC system for gathering information about water fluoridation from CWS officials, coordinated with the Safe Drinking Water Information System of the EPA.
- (Historical) Reference Statistics on Water Fluoridation Status